A clinical commissioning group has been accused of blocking potentially eligible patients from receiving continuing healthcare funding under a programme supported by NHS England.
West Norfolk CCG has been using a locally-devised screening process, called the “5Qs test”, which effectively means a higher proportion of patients do not receive an official assessment for NHS funded continuing healthcare.
By law, patients with complex long term conditions are entitled to free social care funded by the NHS, so long as they are assessed as having a primary medical care need under the official CHC process.
An expert in CHC cases told Health Service Journal that West Norfolk’s test is “significantly flawed”, because it screens out some patients who should be eligible for an official assessment.
Dan Harbour, managing director of Beacon, a company which specialises in CHC cases, said ward nurses have raised concerns to his organisation.
The CHC process involves two steps. Patients are initially screened using an official Department of Health & Social Care checklist to identify those who may be eligible. Patients who pass through this screening receive CHC funding until their full assessment decides if this funding should continue.
National guidance published by the DHSC says the initial screening checklist “is the only screening tool that can be used” to identify patients who should receive a full assessment.
West Norfolk’s 5Qs test takes place before either of those steps and decides if a person needs nursing care or social care. If it’s the latter, they are referred to means-tested local authority services and not offered a CHC checklist unless the individual requests one or their case is “subsequently triggered”.
If more patients are discharged straight to social care without an initial CHC screening, there is a saving to the CCG.
The 5Q test was first devised in 2016 as part of a pilot project supported by NHS England (see box below). The CCG has said it does not replace the CHC process.
An internal review of the project, published in December 2016, said the test was introduced to determine which patients should be screened under the CHC checklist. DHSC guidance does not dictate how a local system should decide who should be assessed, but says “where there may be a need for NHS CHC, a checklist should normally be completed”.
Mr Harbour said: “The great innovation purported to have been achieved by the 5Q test is to identify whether somebody primarily has health needs or social needs. By law, the only way of determining that question is through the CHC assessment process.”
Meanwhile, HSJ has learned several other CCGs that were considering using the 5Q test have now dropped their plans.
The four CCGs in Greater Nottingham – Nottingham City, Nottingham North and East, Nottingham West and Rushcliffe – said they were “advised by the [NHS Improvement] emergency care improvement programme not to proceed and have reverted to following the national guidance”.
Sheffield, and Ipswich and East Suffolk CCGs have also dropped the test, but would not explain why.
NHSI declined to comment and the DHSC referred questions to NHS England.
NHS England would not comment on the 5Q test, but said “decisions must comply with the guidance and legislation that underpins hospital discharge”.
CCGs are under significant pressure to reduce CHC costs, with NHS England saying £855m needs to be saved cumulatively within the CHC budget by 2020-21.
A West Norfolk CCG spokesman said: “[The 5Q test is used] as a process to support the hospital staff in deciding whether to discharge a patient to their home or a residential/nursing home setting for a period of re-ablement within the health funded discharge to assess process.
“At the point social care and/or health staff identify a patient may meet the threshold for [CHC] funding the checklist is used which, if positive, will result in a full [funding assessment].”
The 5Q test
According to papers published by West Norfolk CCG in 2016, continuing healthcare spending in Norfolk was “disproportionately high” due in part to the higher proportion of elderly residents.
The papers said around 953 people were eligible for CHC funding at any one time across the county, which cost around £55m per year.
The 5Q test was devised in response to these pressures, as well as “frustrations” over the difficulties in determining a patient’s primary need under the CHC process.
They said there was “overzealous” use of the CHC screening checklist when patients had not necessarily had time to recover from their hospital admission, which resulted in a high proportion of patients passing through the initial screening stage and qualifying for a full assessment.
The papers said 90 per cent of patients in West Norfolk that passed the initial screening (and therefore received NHS funded care until a full assessment) were then rejected in the full assessment, which could result in “considerable disruption” and “disappointment” as they would potentially have to move to a different care setting.
The papers suggested the 5Q test had enabled recurrent savings of around £562,000.
They added: “It is important to state that this test does not in any way replace the CHC checklist or CHC assessment and does not alter patients’ rights to request a CHC assessment due to a change in their needs.”