GOVERNING BODY/COMMITTEE
Report Title: Continuing Healthcare Response to Report Author and Title: Pam Kaur
Healthwatch Sandwell- ‘The CHC Maze’
Head of Continuing Healthcare
Date of Governing Body/ Committee:
Contact Details: 0121 612 1409
Agenda item:
Date:
Supporting Documents/further Reading: (Highlight any documents or further reading for members
which supports this report)
Summary of purpose and scope of the report:
A report was published by Healthwatch Sandwell in which concerns were raised regarding patient
experience of Continuing Healthcare Assessment process in Sandwell.
The submitted report is a response to the issues highlighted and addresses in particular the
recommendations made by Healthwatch Sandwell.
Recommendations:

Governing Body/Committee are requested to:
Decision
Assurance
Action
Approve
X
Previous Decision (Inform the Governing Body/Committee if the paper has been reviewed or monitored by
another committee and their recommendation or decision)
Summary of Strategic Priorities:
Quality & Safety
Finance & Performance
Partnership
Implications:
Financial
Assurance Framework
Risks and legal obligations
Equality and Diversity
Statutory and External Influences
Further implications not stated
Consultation : X
Patients
Staff
Committees
X
Strategic Commissioning & Redesign
Organisational Development
Collaborative Commissioning
State any financial implications for the CCG
Detail any links to the Assurance Framework
State any risks or legal implications related to
this document. Ensure the risk entered on the
CCG risk register?
Detail any further implications including
resources and training.
Public
Partners
Sponsored By: (Chief Officer or
Committee Chair)
Date Received for Committee:
Claire Parker
1.
INTRODUCTION (BACKGROUND AND CONTEXT)
On 22nd July 2015 Healthwatch Sandwell published a report ‘The Continuing Healthcare
Maze’ on its website. The CCG were notified of the publication on 21st July 2015 and invited
to make a response to the issues raised by the report.
The CCG has over 135 full multidisciplinary assessments per month; this does not include
Free Nursing Care reviews. The ratification panel ratifies between 20 to 40 cases per week.
The conversion rate of checklist to full CHC award is approximately 45% and the assessors for
physical health hold on average 30 40 cases each. The CCG also manages CHC for Learning
Disabilities, Organic Mental Health and Children for it population across Sandwell and West
Birmingham (530,000).
This is the CCGs response.
1.1 To enable a full appraisal of the issues and concerns arising as a result of the Healthwatch
Sandwell Report on Continuing Healthcare this paper aims to address those matters raised.
Healthwatch Sandwell also made a number of recommendations in their report.

(i) CCG to undertake a thorough review of process and resources in the assessment
process
This year, in January 2015, a repeat review and audit of processes within the CHC
service was carried out by CW Audit which demonstrated improvements in service
processes and pathways from moderate to significant assurance. However, the CCG
does acknowledge that further improvements are to be made, especially with regard
to ensuring the assessment process is as user-friendly as possible. From an
operational perspective the CHC team are consistently looking at ways to develop
working practices to improve efficiency for patients and their carers, for example, all
patient and carers have access to the CCG Time2Talk team.

(ii) That there should be recognition of the personal and human cost in the assessment
CHC works to a National framework and the process itself is not easy to navigate. It is
imperative that all involved, including patients and their carers, understand that the
process can have time implications as it is a complex and lengthy process; however
the assessors will always provide support and explain to the service user the process if
they do not fully understand it. Further support can be offered from the Time 2 Talk
team who provide expert customer care.

(iii) Support for service users and carers: advice and advocacy
The CCG undertook an exercise to jointly appoint CHC Advocacy Services to support
the CHC assessment process with Sandwell MBC. The process was halted, however it
will be revisited by the CCG either with the MBC or by the CCG as a single agency.
Currently the Time 2 Talk team give customer support and clinical professionals can
explain the process and support patients at any stage of the process.

(iv) Support for service users and carers: enforcement of rights
Should it be deemed that an individual does not meet the eligibility criteria for CHC,
the opportunity exists for a second assessment with different assessors to be
undertaken to ensure impartiality (enforcement of rights).
2. DISCUSSION
2.1 The report highlighted that there was instances where service users did not understand
the process. ‘NHS Continuing Healthcare and NHS-funded Nursing Care’ Public information
Leaflets are distributed prior to the assessment date and again with the decision of eligibility
letter. At any time the patient can contact the assessor for information and advice or more
recently, the Time2Talk team.
As part of the assessment process the assessor explains the process and reinforces that a
second assessment is available if service users feel their views and opinions have not been
fully taken into consideration.
In respect of communication concerns, the service is patient centred, so every attempt will
be made to include the service user and their family, if they wish, in the process, and to
make them feel comfortable and believed, to prevent any emotional distress. If the service
user is unable to be involved due to capacity issues or wishes not to be involved, the assessor
would involve and engage with a relative or advocate on their behalf and in their best
interests.
The service user or their representative may have a lack of understanding of process, either
due to not being given enough information or not understanding the information. In order to
address the on-going concerns regarding the complexity of the process, it has been identified
that a review and reflection of the patient information leaflet is needed, and also the way
assessors are explaining the process. Patient materials are currently being developed with
the Time2talk, CHC and Communications teams.
Any change of circumstances due to ill health can be an emotionally distressing period for all
and the CCG recognises that introducing a continuing healthcare assessment is an additional
stress, due to the complex nature of the assessment. Training for assessors has been adapted
to make every effort to ensure patients and their carers are supported through every part of
the process.
The report makes comment that an independent panel may be required to review the
process. In reality within the Continuing Healthcare process an element of independent
review of the initial assessment is already built in at the end of the CHC appeal process in
accordance with the statutory framework. (Reference: National Framework, revised 2012).
A recommendation within the report was made to use a ‘blank sheet’ approach to
redesigning CHC practices. Although the CCG appreciates that many of its services are led by
design through patient focus groups and actively encourages participation and engagement,
Continuing Healthcare is bound by national guidelines therefore it is not possible to
undertake a blank sheet approach as the guidelines are determined by the Department of
Health Framework for NHS CHC revised 2012. The CCG continuously reviews processes in line
with the Framework to ensure that efficient application of the Framework is applied and
patients and their carers get prompt responses. The CCG recognises that this doesn’t happen
in every single case but its aim and intention would be that every patient would receive the
highest standard of service including in cases where CHC funding is not awarded.
The report identified concerns regarding the assessment process and the Decision Support
meeting, in which it was stated that the process ‘ignores common sense and prioritises box
ticking’. It was further highlighted that a common sense approach was omitted during the
assessment, and assessors would ask questions to which the answers were evident.
The documentation used in the process is predetermined by the Department of Health and
needs to be completed as a part of the process and clinicians are professionally bound to
record all information no matter how small the detail and how trivial it may seem to ensure a
complete picture of the patient is represented appropriately and fairly.
References to ‘no human aspect’ and ‘asking questions about the obvious’ were additional
issues raised in the report. To inform a complete assessment of care needs, asking questions
is part of the process, because not everything is obvious, and something may be missed if this
process it not followed and recorded. To ensure assessments are accurate and reflect the
patients’ health needs at the time of the assessment, the assessor may need to further
explain the scoring process, and explain that they are not able to make assumptions and not
follow the correct procedures and this is why obvious questions may be need to be asked.
With regard to review and reassessment, the National Framework for Continuing Healthcare
sets out as a minimum that all patients should be reviewed initially within 3 months and
annually, thereafter. If the service user has a progressive condition it is vital for their safety
for them to be reassessed in line with the national guidance. Progressive conditions can
rapidly change and service users can be subject to an assessment if significant changes to
their care needs identify a need for reassessment to ensure patients continued safety
therefore assessments can occur more often. It is usual that reassessments are done by a
case holder that knows the patient and only in exceptional circumstances would this change.
The report noted that funding was wasted on two members of staff carrying out an
assessment. The assessment is a multidisciplinary assessment and therefore it is imperative
to have at least two people, but sometimes more, to follow the multi-disciplinary approach
for the assessment as recommended by Department of Health. For example this may be two
nurses with different clinical specialties i.e. Registered Mental Health Nurse or Registered
General Nurse.
There are nationally set timescales, for non-Fast Track patients (patients unlikely to be at the
end of life stage of care). The National Framework allows a 28 day timescale for the whole
process from Checklist to Decision. However, the majority of the decisions are made well
within these time scales and all (100%) acute inpatients are managed within 7 days.
From a clinical perspective Sandwell & West Birmingham CCG have a 100% success rate at
meeting this target, all assessments are completed within the 28 day deadline, and only in
complex cases where more in-depth evidence is required would a decision potentially exceed
the 28 days. However, due to administration capacity issues within the CHC team there have
been times when the input of the ratified cases has not been uploaded onto the database
and this has impacted upon CHC data and as a result there are discrepancies in reported
figures. This process does not affect the clinical processes, but has created timing issues for
letters for patients in some cases.
Local guidelines recommend decision outcome letters should be forwarded within 5 working
days following ratification, this timescale is not being met. As of 10/08/15 there was a
backlog of 79 cases to be input. The CHC team is currently undergoing a workforce review
with particular attention being paid to the administration team.
In regards to data, reports can be run but unless the data input is up-to-date any information
within the database will show inaccurate reports compared to real-time events.
There are agreed protocols between health and social care including managing
disagreements and disputes. If there is a disagreement between professionals or family, this
is recorded and sent to a ratification panel as per normal process. Healthwatch Sandwell’s
report commented that that there have been incidents where ‘disagreements became
territorial spats’. The CCG and the Local Authorities have worked very hard to ensure there is
much better partnership working between social care and health professionals. Through this
joint working, regular weekly meetings have been set up between operational managers to
pick up front line queries and disagreements to immediately resolve any issues in the very
early stages. Joint training and regular meetings between front line staff has been established
to achieve a seamless approach for assessments and care planning for the population of
Sandwell & West Birmingham CCG. Patients who see poor professional behaviour should
relay their concerns to the customer support teams of either organisation so that any issues
can be immediately addressed and resolved.
The report highlighted recognition of the personal and human cost in the assessment –
Whilst the CCG is bound by the Department of Health process under the National
Framework, which is auditable the CCG also prides itself on delivering the best care possible
on what can be a difficult process. CHC can be contentious as not every patient will be
eligible. However, we will take on board the comments and ensure that all our staff makes
the process as user friendly as possible. The clinical staff have to present the clinical picture
from factual health evidence available at the time of the assessment so that the CCG can
meet its statutory obligations under the framework. All patients eligible for Continuing
Healthcare will have their funding provided for their healthcare needs to be met.
In response to the patient issues raised in the report the CCG is reviewing and updating our
information leaflets to ensure they are easier to understand. Staff have been advised to
further clarify the process prior to the assessment taking place such as the time involved in
an assessment. At any time that a patient feels they do not understand, they can ask for the
assessment to be paused until further explanation is given during the assessment. At any
time the patient or relatives does not consider they are receiving the appropriate support
from the assessor they can contact the Time2Talk team and request further support or
assistance with any of the Continuing Healthcare processes ie. assessments, care planning or
appeal.
3.SUMMARY
To place some context to the report, the Healthwatch Sandwell paper was based on the
experiences of seven service users that had undergone the assessment process in early 2015.
During 2014/15 Sandwell & West Birmingham CCG funded 1,014 Continuing Healthcare
eligible patients.
The CCG appreciates that not every patient experience is as seamless as National Framework
dictates, and that not every patient or carer contact meets the high expectations of quality
that the CCG expects and this can be for a variety of reasons including: miscommunication
between assessor and patient or health and social care professionals; lack of understanding
of processes; delays due to complexities of the case. It is clear that improvements to the
local application of the process have been made following the CW audit and the increase in
cases being reviewed and ratified. The CCG Continuing Healthcare team actively welcomes
engagement with service users. As with every service we can always do better and all the
comments within the report from the seven users of the service will be reflected in the
review of the processes and information provided.
Additionally, any comments, concerns or complaints made directly to the CCG in relation to
Continuing Healthcare are responded to and acted upon in line with CCG Policy.
We hope the response to this report gives the CCG Governing Body assurance and
Healthwatch Sandwell a better understanding of the national and local processes in the CCG
for , give assurance of the way in which the CCG has worked to ensure processes have been
improved as demonstrated by the annual audit and to make them patient and carer focused
by working with service users to address concerns.
4. RECOMMENDATIONS
Members of the Governing Board are asked to discuss and acknowledge the content of this
report.
Contact Officer with contact telephone number
am Kaur, Head of Continuing Healthcare. 0121 612 1409