Guidance

Reintroduction of NHS continuing healthcare (NHS CHC): guidance

Published 21 August 2020

This guidance was withdrawn on 19 November 2021

This guidance was published on 21 August 2020 to support the reintroduction of NHS continuing healthcare processes from 1 September 2020. All deferred assessments have been completed, so this guidance is for reference only.

For up-to-date information on the discharge to assess approach and funding, please see this guidance on hospital discharge and community support.

Applies to England

1. Summary

This document sets out:

• how NHS clinical commissioning groups (CCGs) will restart NHS continuing healthcare (NHS CHC) assessment processes from 1 September 2020
• how this aligns to the introduction of a maximum of 6 weeks of funded health and care recovery and support services after discharge from hospital

The Department of Health and Social Care (DHSC) and NHS England and NHS Improvement request that local health and social care systems:

• reintroduce the NHS CHC processes from 1 September 2020
• introduce (from 1 September 2020) a change of process to implement their responsibilities under the discharge to assess approach in line with the hospital discharge service: policy and operating model (August 2020). This ensures that NHS CHC and Care Act assessments have been carried out and eligibility decisions have been confirmed within the 6 weeks following a discharge from hospital
• undertake the NHS CHC referrals, reviews and assessments, that have been received between 19 March and 31 August 2020, and any that have been deferred as a result of the COVID-19 hospital discharge service requirements (March 2020).

2. Restart of NHS CHC processes

From 1 September 2020, the government has decided that NHS CHC assessments in the community, 3 and 12 month reviews, and individual requests to review eligibility decisions (local resolution and independent review) will restart. CCGs and local authorities will have to manage 2 streams of work:

• NHS CHC work deferred between 19 March and 31 August 2020
• routine NHS CHC referrals, starting from 1 September 2020

Local health and social care systems will need to establish efficient processes to manage these two pieces of work, which includes extending the use of the Trusted Assessor Model and digital assessments.

Local health and social care systems should, where appropriate, consider aligning Care Act and NHS CHC assessments, so that there is a single ‘collation’ of relevant information to support a joint approach to a (health and social care) recommendation for long-term funding, by either the local authority or the NHS. This approach should not, however, cause any further delays. It should be legally compliant and have regard to the national framework for NHS continuing healthcare and NHS-funded nursing care.

The principles below should be adopted to support joint health and social care system recovery.

Workforce

CCGs and local authorities should secure sufficient staff to deal with the NHS CHC and Care Act deferred work (from 19 March and 31 August 2020) and business as usual activity. This may require securing additional temporary health and/or social care professionals^{[footnote 1]}.

Local health and social care systems should ensure that they use their workforce efficiently and effectively by:

• using well-trained non-clinical staff, wherever possible, to release clinical or professional staff time to focus on robust eligibility recommendations
• ensuring good training programmes and supervision

Communication

Good local communication with individuals and families is key to ensuring they have clarity around possible future funding arrangements for long-term care.

To ensure effective communication and a clear understanding, the Accessible Information Standard should be applied to the information and communication support needs of patients, service users, carers and parents with a disability, impairment or sensory loss.

Where care has been NHS-funded during the COVID-19 period (since 19 March 2020) particular focus should be on explaining how the local authority Care Act Assessment and subsequent means testing could lead to some individuals having to contribute to, or fully fund their future care should they be identified as not eligible for NHS CHC funding.

Efficient and effective referrals

To ensure that the right people are referred, there needs to be an agreement between CCGs and local authorities on the appropriate use of the NHS CHC checklist, consistent with the national framework. See section 5: when it is not necessary to complete an NHS CHC checklist below.

The following needs to be in place:

• formal arrangements to confirm who is ‘checklisting’ on behalf of the CCG
• ‘checklisting’ training programme

CCGs may have used an NHS CHC checklist as part of their process to monitor actions taken during the COVID-19 period, for those individuals that may need longer term care. However, it is possible to use a second NHS CHC checklist if the individual’s needs reduce in the time frame between a positive NHS CHC checklist and a full assessment (see paragraph 115 of the national framework). Individuals should be fully informed of this position.

Assurance and governance

Local assurance and governance processes will need to be in place to ensure the delivery of high-quality assessments, and appropriate decision-making regarding eligibility for NHS CHC. This includes local audit and peer reviews, and CCGs should have a system in place to monitor the use, quality and source of the NHS CHC checklist.

NHS CHC staff that were re-deployed to other roles in March 2020 need to be brought back to their roles in CCG teams to start from no later than 1 September 2020. This process needs to be planned and managed carefully, to ensure the teams and services that, NHS CHC staff are currently working in, are not negatively affected. Special care and attention should be made in re-introducing staff back into NHS CHC teams, ensuring staff are supported throughout the process and are able to take their annual leave. Additional staff will also be required in order to manage the deferred work.

There will be a regular NHS CHC situation report (SITREP) data collection to monitor the completion of NHS CHC assessments that were deferred between 19 March and 31 August 2020. This regular data collection will begin in August 2020 and last until decisions have been made on all deferred assessments.

3. Change of process under the discharge to assess arrangements

The hospital discharge service: policy and operating model (August 2020) introduces a change of process for the discharge to assess approach. From 1 September 2020, for those individuals being discharged from hospital, an assessment of the individual’s longer-term care needs, including Care Act and NHS CHC assessments, should be undertaken during the individual’s period of funded recovery services (which can be up to a maximum of 6 weeks).

NHS CHC teams must work closely with community health and social care staff in supporting people on discharge pathways 1, 2 and 3, to ensure appropriate discussions and planning concerning a person’s long-term care options happen as early as possible during the 6-week discharge pathway. This close working and communication will also ensure time is allowed for the CCG to undertake the full NHS CHC assessment and for local authority staff to undertake Care Act assessments where it is needed.

The funding of new care and support on discharge from hospital is intended to support individuals to recover and rehabilitate. CCGs and local authorities need to have processes in place to ensure that, where required, NHS CHC and Care Act assessments are completed, and the eligibility decisions have been confirmed by the end of the discharge pathway (up to 6 weeks following discharge from hospital or any ‘Pathway 2’ facility).

It is expected that an assessment for ongoing health and care needs takes place within 6 weeks of discharge and that a decision is made about how this care will be funded by this date. CCGs will not be able to draw down from the discharge support funding after the end of the 6th week to fund any care package beyond this date. On the rare occasion that a decision is not reached within this time frame, the parties paying for the care should continue to do so until the relevant ongoing care assessments are complete. Whatever arrangements are agreed, costs from week 7 cannot be charged to the discharge support fund and must be met from existing budgets. CCGs and local authorities should agree an approach to funding of care from the 7th week.

Where an existing local arrangement is in place to agree who funds care while assessments are taking place, then the local authority and the CCG, if they both agree and it is affordable within existing envelopes, may choose to continue with this local funding arrangement from week 7 rather than following the arrangements in the paragraph below.

In the absence of an existing locally agreed approach for funding (see the 2 paragraphs immediately above) from week 7 onwards, it is suggested as a default that the following approach is adopted.

The costs are allocated according to what point in the assessment process has been reached by the end of the 6 weeks of care, as follows:

• where the NHS CHC or NHS funded-nursing care (FNC) assessments are delayed, the CCG remains responsible for paying until NHS CHC/FNC assessment is done
• after this, where the individual is assessed as not eligible for NHS CHC, responsibility for funding will sit with the local authority in line with existing procedures until the Care Act assessment is completed, after which normal funding routes will apply

4. Funding arrangements

From 19 March to 31 August 2020 the government, via the NHS, paid for new or extensions of existing packages of care and support for patients discharged from hospital or who would otherwise have been admitted to hospital. This approach was funded through a COVID-19 budget which supplemented CCG and local authority usual expenditure on discharge and rehabilitation and reablement services.

CCGs should assume that anyone discharged from hospital on discharge to assess pathways 1, 2 and 3, who needed a new (or enhanced) package of support upon discharge or admission avoidance, will have received care funded from the CCG, local authority and/or COVID-19 discharge funding for as long as they required care (and may still be receiving this).

Individuals discharged from, or who would have been admitted to, hospital between 19 March and 31 August 2020

The COVID-19 discharge and recovery service budget will not be used to fund any new packages of support on discharge from hospital from 1 September 2020 onwards.

People funded though the COVID-19 Discharge funding arrangements which commenced on 19 March 2020, who entered a care package between 19 March and 31 August 2020, will continue to be funded through those arrangements. Relevant assessments should be completed for these individuals as soon as is practical to ensure transition to normal funding arrangements.

CCGs are expected to carry out assessments in a timely manner, and the speed of completing the deferred assessments will be monitored regularly, as set out above in the paragraph on NHS CHC SITREP data collection.

If an individual was funded during this period using the COVID-19 budget and is assessed as eligible for NHS CHC funding, the payment of their care costs will transfer from the COVID-19 budget to core CCG CHC budgets at the end of the NHS CHC assessment process.

If an individual was funded during this period using the COVID-19 budget, and is not eligible for NHS CHC funding, the payment of their care costs will transfer from the COVID-19 budget to local authority responsibility, following the end date of the NHS CHC assessment process. Local authorities will need to determine if individuals continue to be eligible for support under the Care Act or are responsible for the costs of their own care.

Where individuals are assessed and found eligible for NHS CHC and they, or the local authority, funded any part of their care while awaiting an NHS CHC assessment, then CCGs should arrange for refunds to take place directly to the individual or the local authority, as long as that funding arrangement is consistent with the national framework.

CCGs should make appropriate reimbursements following the principles listed below:

• where an NHS CHC checklist has been used, the costs of the services from day 29 of the CCG receiving the NHS CHC checklist should be reimbursed (see Annex E, paragraph 9 of the national framework)
• where an NHS CHC checklist has been used and the individual’s needs have changed by the time the full assessment is completed (due to the time passed), then the CCG will need to reimburse back to the point in time from which the individual was determined to have a primary health need
• if, during the period above only, no NHS CHC checklist was used then the CCG will need to reimburse back to the point in time from which the individual was determined to have a primary health need.

It’s essential that, under the new arrangements, there is clarity about which CCG is responsible for assessing each person’s needs and paying the relevant organisation for any healthcare services provided to the individual. NHS England is publishing updated Who Pays? rules to provide this clarity.

5. When it is not necessary to complete an NHS CHC checklist

The circumstances when it is not necessary to complete an NHS CHC checklist are set out in paragraph 91 of the national framework. There will be many situations where it is not necessary to complete a checklist. These include where:

• it is clear to practitioners working in the health and care system that there is no need for NHS CHC at this point in time. Where appropriate/relevant this decision and its reasons should be recorded
• the individual has short-term health care needs or is recovering from a temporary condition, and has not yet reached their optimum potential
• it has been agreed by the CCG that the individual should be referred directly for full assessment of eligibility for NHS CHC
• the individual has a rapidly deteriorating condition and may be entering a terminal phase. In these situations the fast-track pathway tool should be used instead of the checklist
• an individual is receiving services under section 117 of the Mental Health Act that are meeting all their assessed needs
• it has previously been decided that the individual is not eligible for NHS CHC and it is clear that there has been no change in needs

1. Funding from the 19 March 2020 Hospital Discharge Programme will be made available to CCGs/local authorities to recruit extra health or social care staff to support the deferred assessment work. Further details of this additional funding and how this is to be used by CCGs is to follow. ↩