Feature / A sharper focus
Continuing healthcare costs are a major pressure for the NHS and clinical commissioning groups. The increase in costs in recent years has outstripped the growth in NHS spending overall. And with an ageing population, if no action is taken, costs are expected to keep on rising. Against this backdrop – and with significant variation across the country in spending and eligibility rates – NHS England has set ambitious targets to slow down the rate of increase.
Continuing healthcare (CHC) is a package of care for adults with ongoing healthcare needs that can be provided in a nursing home or at an individual’s own home. Once an individual is assessed as being eligible for CHC, defined as having a primary health need (assessed under a fast-track or standard process), the NHS pays for a package of care for all healthcare and associated social care needs.
Individuals not eligible for CHC funding may still be entitled to NHS-funded nursing care or local authority (means-tested) social care services. For someone living in a nursing home, this would mean a flat weekly rate paid to the care home.
A report from the National Audit Office over the summer said that spending on CHC rose from £2,647m in 2013/14 to £3,062m in 2015/16. This £415m difference represents a 16% increase, well ahead of the overall growth in NHS spending over the same period of just 6%. The costs of NHS-funded nursing care stayed relatively static during this period (at just under £500m).
Factors at play
There are a number of factors in play. The number of people receiving or being assessed as eligible for CHC funding increased by 12% over the three years to 2015/16, says the NAO. However, snapshot data suggests a fall in the numbers on CHC at the ends of 2015 and 2016, perhaps indicating people are receiving CHC funding for shorter periods. The average annualised cost of CHC per person has also risen over the same period by 9% – from £45,850 to £50,000.
These pressures are digging deep into commissioning budgets. CCGs are already averaging 4% of their total spending in 2015/16 on CHC. In addition, NHS England is meeting costs for previously unassessed periods of care (PUPOC), relating to periods before April 2013, when primary care trusts were responsible for CHC.
But NHS England estimates CCG spending on CHC and NHS-funded nursing care and assessment costs will increase by a further £1.64bn from £3.607bn in 2015/16 to £5.247bn in 2020/21 if things are left as they are and current trends continue. This would represent a huge 45% increase – well above general NHS growth. To counter this, it plans to deliver £855m of savings compared with this ‘no action’ forecast.
According to the NAO, it plans to do this by ‘increasing standardisation, reducing variation between CCGs and adopting best practice, including in conducting assessments and in procurement’. If successful, this would leave spending in 2020/21 at £4.392bn. However, the NAO pointed out that NHS England does not have a costed breakdown and CCGs do not have spending plans to achieve this.
NHS England says that ‘draft plans are now in place’ and these are currently being reviewed at CCG level. And it insists the £855m figure has been modelled taking account of the need to provide fair access to CHC.
With no plans to change the eligibility for CHC, as this is mandated in legislation, the broad thrust of the plan is to improve consistency, ensure more patients are assessed after being discharged from hospital and improve the commissioning of care packages. NHS England’s assumption is that these measures will temper the predicted growth in eligibility and cost in coming years.
In April, it launched a two-year CHC Strategic Improvement Programme. This is about more than costs. It also aims to improve outcomes and patient experience – but better use of resources is very much on the agenda.
Understanding variation and addressing this where it is unwarranted are high on its ‘to do’ list. And there is a lot of it for the programme to get its teeth into. According to the NAO, the numbers of people receiving or eligible for funding in 2015/16 ranged from 28 to 356 per 50,000 population. The proportion of people assessed as eligible, having been referred for a fast-track assessment or identified as needing a full assessment, ranged from 41% to 86%. And CCGs are spending 2%-7% of total spending on CHC (excluding the 5% of CCGs with the highest and lowest percentages).
There is also a question mark over the number of screenings being undertaken. Although the process sets out to ensure anyone who might be eligible for CHC is properly assessed, just 18% of screenings actually lead to someone being assessed as eligible for full CHC. This means multidisciplinary teams spend most of their time carrying out assessments that do not lead to people being assessed as eligible. The low thresholds between screening and full assessment can also raise people’s expectations about eligibility.
Alison Henley-Jones, NHS England’s finance lead for the Strategic Improvement Programme, says analysis to date suggests that demographics only go so far in explaining the variation. ‘We are doing further work to understand the age drivers in CHC, but we’ve also been sense checking what we’ve done and our assumptions at a national level out in the system. The lack of correlation could be telling us: we’re missing a key driver we haven’t considered; our data isn’t as good as we’d like; or variation is driven by so many local level factors that we can’t identify correlations at a national level.’
Alternatively, it could represent different local interpretations of existing guidance in the national framework for CHC.
Savings interventions
A number of interventions are seen as key to delivering savings over the next four years:
- Increase regular case management for existing care packages
- Improve CHC processes and invest in CHC workforce
- Encourage active market management and implement e-procurement
- Encourage the uptake of personalised health budgets.
With a number of work streams in place, some measures are already in operation to improve processes – using the quality premium mechanisms to incentivise timely assessments and more assessments outside of hospital, for example. While this latter measure should support a reduction in delayed transfers of care and increase acute capacity, by cutting the numbers of patients waiting in hospital until an assessment can be undertaken, it could also have an impact on CHC costs.
NHS England reminded CCGs of the required standards in an August letter and identified the poorest performers, which need to take action to get back on track.
Ensuring less than 15% of all full assessments take place in an acute setting is about allowing individuals more time to recover before their assessment. This can often provide a far better indication of long-term care needs.
One CCG Healthcare Finance spoke to commissions discharge-to-assess beds specifically for this purpose, enabling patients to recover more before screening using a checklist to indicate if someone is entitled to be considered for CHC eligibility. It suggests it has led to more accurate assessment of real ongoing care needs and is considering expanding the model to enable discharge for assessment at home.
The quality premium also links to getting decisions on CHC eligibility within 28 days of a positive checklist in 80% of cases. NHS England’s newly appointed national director for the CHC Strategic Improvement Programme, Jim Connolly, believes this will have multiple benefits. ‘Delivering a decision for CHC eligibility within 28 days is good practice and will benefit the person, their family and the NHS as a whole,’ he says.
Some CCGs have looked at direct ways to balance patient choice with overall cost-effectiveness – looking at whether there should be any limits on meeting individual patient requests, perhaps involving being cared for at home however complex the condition. While many CCGs currently have no official policy in this area, the Disability United charity earlier this year highlighted growing numbers of CCGs operating caps some set as low as 10% and up to 40% above the most cost-effective package of care. In some areas, proposals to change this cap – from a pre-existing 25% to 10% in one case – have met stiff local resistance and, for some of the CCGs involved, a postponement of the decision.
CCGs would like to see central guidance on how to balance out these pressures, clarifying what patients should expect at a national level for example.
Asked about the issue, NHS England says only that ‘decisions on buying appropriate care are for CCGs. This has to be balanced on the needs of an individual and requirements for CCGs to balance their budgets’.
The national framework, which is overseen by the Department of Health and sets out
the process for establishing eligibility for CHC and the dispute process, is currently being reviewed.
It is not completely clear what the scope of this review is although the NAO report said that the ‘Department has been working with NHS England, local authority representatives and charity groups to understand the impact of the national framework on delivery of CHC and where there might be scope for improvements’.
Market management is another area where NHS England sees opportunities for spreading best practice. This could look at the benefits of different types of contract but also look at how contracts are subsequently managed. ‘If a CCG is paying for a high level of nursing care for a patient – one-to-one care, for example – it needs to have assurance that that care is being delivered,’ says Ms Henley-Jones.
It is clear that NHS England is serious about getting a more consistent and equitable approach to CHC assessment and funding across the country. Having set it as a national improvement priority, CCGs should expect both more support and more scrutiny of local provision and costs over the next two years.
Local action
Sunderland CCG deputy chief finance officer Tarryn Lake (pictured) says detailed plans are being developed to identify where savings will come from locally. The CCG – targeting the delivery of more services in the community as part of its multi-specialty community provider vanguard – has seen a rise in CHC numbers and costs. This may be as a result of some of its transformation work. ‘As you try to help more people in the community, inevitably more of the frail elderly population may become eligible for CHC and the packages of care that go with it,’ she says.
She adds that with people living longer, there are increased challenges with bed capacity in care homes too, as numbers rise. And care homes face some significant cost pressures themselves. Some homes across the country claim that public sector rates cover only 75% of the cost of care, leaving private payers cross-subsidising taxpayer-funded residents. Those homes in more deprived areas have fewer self-funders and so less ability to compensate for the shortfall in income from public funding. And recent increases in the national living wage – which is paid to many care home staff – have also created pressures in this sector.
Mirroring the NHS, care homes also have their own struggles recruiting nursing staff and are also having to use more expensive agencies to fill vacancies. Nationally there have been reports of care homes closing their doors to NHS and local authority residents unless there is a top-up to basic rates.
The flat national rate for funded nursing care is in many cases added to locally agreed residential care rates in setting standard CHC rates. Enhancements for more complex cases, perhaps requiring one-to-one care, can then be negotiated.
Ms Lake says the process is difficult, with a lack of a national price structure and little transparency about the cost structure and profitability of different homes.
She wonders whether different contracting arrangements – perhaps offering homes block contract arrangements, giving greater stability on income – might offer opportunities for homes to reduce costs and improve sustainability.
There are other issues with direct costs. For example, providing care in someone’s own home can be more expensive than provision in a nursing home – particularly for complex cases.
Sunderland is developing a policy around CHC – balancing patient choice with a desire to maximise the number of people it can support. This will involve making an offer to a client and their family that provides the best quality service and gets the best outcomes, while still being cost-effective. This will not set a cap on cost and will allow opportunities to appeal against the offer.
This is not new, but the policy aims to improve the consistency of approach and staff are currently being trained to support them in discussions with patients and their families in what are often sensitive circumstances.
‘There may also be opportunities for new care models to get a grip on this,’ says Ms Lake. ‘Special purpose vehicles within foundation trusts could perhaps own homes and run care. I don’t think this has been explored enough yet.’
In terms of the process, Ms Lake believes Sunderland has some challenges meeting the requirement to review CHC cases three months after the initial eligibility decision to reassess care needs and eligibility. She suggests that, recognising people’s care needs change as they recover more from any acute incidents, improving performance in this area could lead to some efficiencies.
Applying the framework
Much greater rigour in the application of the primary health need test at Telford and Wrekin Clinical Commissioning Group has led to a significant drop in both the numbers of people assessed as eligible for continuing healthcare and the associated costs.
Back in 2009, the CCG’s predecessor primary care trust had more than 100 CHC clients per 50,000 population – well above the national average at the time. This fell to about a quarter of that figure before increasing a small amount again in recent years. Compared with expenditure of more than £12m on all continuing care in 2009, it is now closer to £5m.
According to head of complex care Colin Evans (pictures), the big difference relates to two issues: a bar set too low pre-2009 with a poor review process; and subsequent rigorous understanding and adherence to the national framework alongside good housekeeping of ongoing cases and costs.
‘We have a clear understanding of what CHC looks like,’ he says. ‘All our nurse assessors are clear on the threshold, backed up with training, and we ensure a consistent application of the assessment criteria to ensure equity to all across all client groups.’
Countering suggestions that the CCG’s assessment process is overly robust, he says that local work suggests it is getting the right results. Reviews in 2012 and 2016, undertaken to reassure the local authority that eligibility was being correctly assessed, resulted in just one case being changed from ineligible to eligible out of 86 cases that had been assessed as ‘not eligible’.
Consistency and clarity are key to the whole process – which is run by an in-house complex care team – along with proactive case management. All cases are reviewed at least annually and whenever there is any indication of a change of need.
The team also keeps track of changes to the caseload each month, looking at the numbers and the costs of new CHC clients (standard and fast-tracks), joint funded clients and those eligible for funded nursing care. These are looked at alongside cases no longer eligible for the various forms of continuing care support. We ensure the team know the financial position,’ says Mr Evans. ‘It doesn’t change clinical decisions, but they can’t work in a vacuum.’
Good housekeeping at team level is mirrored at board meetings, with detailed statistics covering referrals, eligibility assessments and outstanding reviews all reported monthly.
Mr Evans says the provider market is closely managed. It is moving towards a benchmarked cost for all ‘typical’ cases and challenges every cost that is different to expectations. Requests for additional money are reviewed, and the homes all know that the CCG could drop in at any point to ensure care delivered matches what is being paid for – for example, in one-to-one care cases.
There is less control over fast-track cases, where numbers are rising annually. However, these cases are subject to ongoing review in the early weeks, with a full assessment undertaken by week 12.
The CCG also undertakes no standard assessments in an acute setting. Instead, potential patients who are medically fit for discharge are subject to a pre-checklist fact-finding assessment to understand rehabilitation needs. This matches the patient to one of four discharge-to-assess pathways. This could involve being discharged to their own home (48% of cases), a residential care home (29%), nursing home (23%) or requiring a checklist screening on the ward.
In the first three pathways, patients are given enablement support involving occupational therapy, physiotherapy and district nursing. This is provided by the community healthcare trust and funded using the Better Care Fund. Mr Evans says this means that when the checklist or CHC assessment is undertaken, it has a much better chance of identifying the ongoing care needs from the outset.
‘Overall the process needs rigorous application in a consistent and equitable way,’ he says. ‘Everyone needs to understand the eligibility criteria and be supported in their decision-making. And there needs to be a high level of challenge.’
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