BMA response to Department of Health consultation: National framework for NHS continuing healthcare and NHS nursing care in England
20 September 2006
Dear Simon Medcalf,
Introduction
The British Medical Association (BMA) welcomes the opportunity to respond to much needed guidelines for a national framework for NHS continuing healthcare and NHS funded nursing care in England.
Download the consultation document in pdf format here (145 K)
The BMA’s Committee on Community Care has been examining government policy with regard to the assessment and delivery of continuing NHS care and has previously met with Government officials to express our views and concerns. Much of this work is summarised in the BMA discussion paper published in 2003, which concluded that the Department of Health should produce guidelines for those wishing to commission continuing NHS care. Read more here.
Members from the Association’s Committee on Community Care have provided their comments to each of the Department of Health’s 13 consultation questions below:
Question 1:
There is some concern that ‘continuing NHS healthcare’ can be confused with intermediate care. The issue is compounded by the fact that there are NHS wards which provide this care in some areas and that NHS funds are used to provide care in nursing homes or at home. The whole area seems to be a minefield of muddled terminology.
The phrase ‘continuing NHS care’ emphasises that we have a responsibility in the NHS for the overall care of some patients, not solely their health needs. The phrase ‘long term NHS care’ was in some ways clearer, but is hard to apply now as many of these patients have such limited prognoses that ‘long term’ is a misnomer. ‘Continuing NHS care’ embodies the WHO definition of health as being about social and psychological well-being as well as physical health but is less clear than spelling out the inclusion of health and social care.
‘Health and social care joint package’ does not clarify to the public the different ways in which the package is funded, so might more accurately be described by the use of the words ‘state’ and ‘means-tested’, i.e. “state health and means-tested social care package’.
‘NHS-funded nursing care’ could be replaced by state-funded nursing care or state nursing care as opposed to private nursing care analogous to state and private education which the public are familiar with.
Question 2:
There is a lack of confidence in the ability of current PCTs, especially (but not solely) those with historic deficits, to commission continuing NHS healthcare. Would PCTs be able to both commission and provide continuing NHS healthcare? It was felt that PCTs who commission NHS healthcare might choose the cheapest provider of the social care element and that this would not drive up the quality of continuous NHS care. Thus PCTs could fail to prioritise continuing NHS care in any way.
In a target-led NHS culture with multiple providers, we have major doubts whether PCTs would ensure adequate commissioning. The only advantage we could see is that PCTs might have a better understanding of local resources and facilities. The standards of care and minimum resource allocation levels that any commissioner would have to abide by are more important than who does the commissioning. i.e. if there are clear ‘rules’ about how to commission this care and what per capita resources at minimum have to be allocated to it, assuring the right resourcing would not be as dependent on who does it.
If such standards were devised and adequate resources identified, a Practice Based Commissioning Consortium could commission continuing NHS healthcare, but again the provider and the commissioning arms must be separated to avoid the possibility of the consortium becoming a cartel.
We wonder if there is a role for the voluntary sector or expert patient groups in commissioning continuing NHS healthcare at a local level. Alternatively the ten strategic health authorities can consult with local patient, professional and voluntary groups to inform their commissioning.
Question 3:
We cannot fault any process which is predicated absolutely on a global assessment of need. However, the allocation of continuing NHS care will always partly be based on available resources and in our opinion it is time to be explicit about that.
The Association welcomes the National Framework’s stated aim to assess individuals on the basis of their need for care, rather than their condition or where care is required. This consultation is an opportunity for public debate and shared understanding that the threshold for and availability of funded health and social care is limited by available resources, and that we need to look at different models for funding continuing NHS care, including the arguments for funded social care or the Wanless-partnership model. We should also have a public debate about what a civilised society should provide as continuing NHS care and ways to drive up standards, such as valuing formal and informal carers.
Question 4:
We welcome the statement that assessment must include consideration of the individual’s physical, mental, psychological and emotional needs, to which could also be added ‘social’ because of the problem of isolation, and perhaps also ‘cultural’, to take account of diversity within the target population. A clear statement that assessment is independent of age, but needs-based would be welcome.
It was felt that ‘limited prognosis’ should be added to this list. It cannot be right that some patients who are dying be denied NHS care because the assessment process takes too long to happen. They could be fast-tracked in a similar way to the current DS1500. This comes back to need: two patients with current identical care needs may have very different prognoses; the one who is going to die in the very near future could arguably be more deserving of NHS care.
Question 5:
The key indicators were well described but still open to some interpretation.
Question 6:
The list met with some approval, although there was some puzzlement as to why seizures/altered consciousness were included; it was suspected that this applied to younger chronic disabled/learning disabled with severe epilepsy who sometimes have special needs.
Psychological and emotional needs should be more clearly defined, perhaps explicitly stating that a depression screening tool should be used.
Question 7:
The flow diagram (figure 2) quite accurately describes the current process . The key is the number of steps in that process, the time over which it happens and any appeal mechanism where care is not deemed to be worthy of NHS funding. In many ways the process, as outlined, will be much less important than how the responsible individuals perform it and how they communicate with each other. One of the key things which will dictate whether or not it is a success is, of course, how health and local authorities communicate. There perhaps needs to be clear guidance on how that happens and how any potential disagreements are dealt with. It is felt that disputes between health and social professionals about the funding or type of care after the assessments have been undertaken are far more likely to snarl up the process than the assessment itself.
Successful implementation relies on the individuals undertaking assessments communicating with those who are being assessed and all those involved in their care, including both informal carers and professionals. It is felt that successful assessment might be aided by an integrated health and social care primary care team, with a team member who has both a health and social care background and skills, such as a medical social worker, or perhaps an appropriately trained health visitor. This professional can make use of the knowledge held by the registered GP of the individual being assessed, in the context of their family and social circumstances. Information might then be shared at a primary care team meeting.
Question 8:
‘Yes’, as long as it is a clear tool that is used consistently across local authority areas and helps prevent health inequalities and postcode lotteries.
Question 9:
This was felt to be a good idea, so long as it is not a completely rigid tool. Given the complexity of this area, reducing decision-making solely to the use of an algorithm is impossible, and would, ultimately, be unhelpful. Thus there will always be a need to make ‘judgement calls’ in grey areas. We would therefore like to see more detail.
The use of an impersonal (objective) algorithm can also be augmented by making use of all the professionals involved in the care of an individual communicating their knowledge of that particular individual, and sharing the responsibility of the subjective areas in, for example, primary care team meetings, and shared record keeping, and even patient held shared records.
Question 10:
Yes, as long as that care planning process is thorough, comprehensive and truly multidisciplinary.
Question 11:
Abolishing banding would be a step towards simplifying the process and as such is to be welcomed, as long as it is seen as fair and transparent. However, how will the 'average weekly cost of care' be calculated? How will it take account of local market forces factors? Presumably there will be winners and losers in this arrangement. And what mechanism, if any, is there for this weekly cost to be reviewed in line with inflation and other economic factors?
Question 12:
Members will need to consider these issues further.
Question 13:
We have nothing further to add: key points about looking at other methods are made above.
The BMA looks forward to receiving a copy of the Department’s response to this important consultation exercise. For further information and queries, please contact Rachel Craine, Council Secretariat, on 020 7383 6611 or e-mail rcraine@bma.org.uk..
Yours sincerely,
Sally Watson
Director of Representational and Political Activities
British Medical Association