NHS Continuing Healthcare: delivering excellence

Key points

Introduction

NHS Continuing Healthcare (CHC) is a package of ongoing health and social care that is arranged and funded solely by the NHS, where the individual meets specific criteria laid down by the DHSC. For adults, this funding is offered to meet health and associated social care needs that have arisen as a result of disability, accident or illness.

The assessment and funding award process often comes at a very difficult time for the patient and their families, as they come to terms with ongoing care requirements. It is also a challenging experience because if eligibility is not found, then patients may sometimes have to pay large sums of funding for their ongoing, means-tested care.  

While individual NHS CCGs have been responsible for CHC funding, working closely with their LAs to implement nationally set process is imperative. As of 1 July 2022, this responsibility will transfer over to the integrated care board (ICB), following the passage of the Health and Care Act (2022). Such packages of care are often complex and social care professionals will usually be involved in managing and planning the care for these patients. Collaborative working between NHS and LA professionals means that the individual’s needs can be planned for in parallel to the funding source being agreed, so that the patient or service user has continuity in their care.  This research for this report was initially intended to locate examples of CHC best practice and to disseminate the findings and a set of principles among our members and stakeholders to take forward into ICSs. However, as CHC assessments were not required between 19 March and 31 August 2020 as a result of COVID-19, we refocused the research to look at the implications the pandemic had on improved working and what ICSs should reflect on for future CHC models.

This report identifies some key themes that determine good joint working practice and the lessons learned about good discharge planning and ongoing support, particularly during the COVID-19 pandemic response with its different funding and process implications. To support our research, we conducted interviews with a range of CCG and LA CHC leads from across England, who offered their experiences and suggestions on the opportunities and challenges presented, and how CHC might evolve in the era of statutory ICSs. These first-hand testimonies are featured throughout the report. Based on the perspectives of these local leaders, we set out a vision for CHC going forward across four key areas:  

1. Partnership: Building on existing relationships and empowering staff. 
2. People: Improving workforce retention by supporting wellbeing and optimising the workforce through training and development.
3. Innovation: Embedding new and virtual ways of working. 
4. Funding: Shared responsibility and using discharge-to-assess funding.

The report describes how CCGs and LAs have worked hard to overcome barriers and achieved a more collaborative approach, and the positive impact this has had on people needing ongoing care. Following the accelerated integration that took place during the COVID-19 pandemic, it provides a shared vision of good practice through some agreed principles and calls for several changes to ensure a clear legacy of best practice is handed on from CCGs to ICBs.

Key recommendations

• NHS organisations, LAs and partner services should continue collaborating to ensure a smoother and more robust CHC process for patients and staff – ICSs and LAs should facilitate data sharing, clearly communicate responsibilities and expectations, and agreeing on financial responsibilities. CCGs and LAs should align the Care Act and CHC assessments to support recovery of the health and care system.  
• Support a high-trust working environment – ICSs’ senior clinical leaders should continue to trust their teams to use their training and expertise to make decisions quickly and follow through. For larger systems, consider maintaining place-based CHC teams to continue the good working relationships  and therefore more collaborative working, across NHS and LA boundaries.
• Recruitment, retention and development – ICSs should work with LAs and NHS England to ensure the recruitment offer is future-proofed, so that current and new members of the CHC workforce feel valued. Training opportunities should be readily available to support the professional development of staff.
• Supporting and promoting staff wellbeing – ICSs should provide flexible working arrangements, engage in more informal catch-ups with staff to monitor wellbeing, and signpost where support is available for those who are struggling in what are extremely strenuous working conditions.  
• Continue to support remote/virtual working where appropriate – Taking the person-centred approach for CHC is essential to ensure the individual’s and/or representative’s views are observed. ICBs should continue to enable virtual working, where appropriate, which can accelerate assessments and reduce caseloads.  This also allows staff outside of the local area to be recruited.  
• Encourage innovation – ICSs should allow teams flexibility to work innovatively, within the scope of government guidelines, in new ways that benefit the local area patient care, flow and transition in and out of care.  
• Develop a streamlined process to manage future funding – HM Treasury and DHSC should move away from reactive one-off funding streams to an approach that provides appropriate levels of funding, longer-term clarity and flexibility to ICS partners. This will support a population planned approach and enable all partners to successfully implement discharge policies most appropriate for the local environment.
• Managing expectations – DHSC should revise the current checklist for considering patients who will be progressed to CHC assessments, so it is closer to actual CHC eligibility criteria. Currently, the gap between the criteria for consideration, set by the checklist, and the criteria for approval at full assessment is too large, which results in false hope for families and patients that they will receive a package of care when they actually fall short of the eligibility criteria. This is a highly sensitive issue, and we ask that the checklist be amended so that expectations and outcomes are realistic.  When discussing the checklist with patients and families, proactive conversations should be held about how both the checklist and CHC work to manage expectations from the beginning of the assessment process.

Partnership: building on existing relationships and empowering staff

A major lesson learned from the ongoing pandemic has been understanding the value and effectiveness of the health and care sectors working in partnership. There was unanimous agreement among our interviewees that COVID-19 was key to encouraging joint working across NHS and LA boundaries.

Despite navigating four discharge-to-assess (D2A) pathways during COVID-19 under the government’s Hospital Discharge and Community Support: Policy and Operating Model 1 , CCGs were able to work closely with LA partners on developing a more streamlined work process to manage the D2A scheme. This close working created a high level of shared trust, increasing the number of patients who were discharged home for an optimal period before being assessed to establish the longer-term package of care required and its funding sources within the allocated funding schemes as they were implemented. CHC leads agreed that this shared sense of responsibility helped build on existing relationships and develop new relationships between health and care staff at every stage through the patient journey; system flow and pace of work was improved to the benefit of patients involved. Stakeholders also appreciated the improvements, telling us that CCGs, LAs, care sector providers, and the voluntary sector were ‘working hand-in-glove’ to improve the process for all.

CHC teams should use ICSs’ integrated architecture to further develop collaborative working with LAs and wider partner services to ensure a smoother and better CHC experience overall for patients and staff. They should facilitate data sharing, clearly communicate responsibilities and expectations, and agree on financial responsibilities. CCGs and LAs should align the Care Act and CHC assessments to support recovery of the health and care system.

Both CHC and LA colleagues consistently reported that improvements in relationships were driven by a greater appreciation of the importance of mutual trust: simply trusting the people they were working with was significant enough to change the dynamic of the working relationship. Colleagues found that once trust had built between CCGs, LAs and/or providers, there was a willingness to support one another long term. To successfully work together, there must be a partnership of equals, where there is shared interest and mutual understanding for the good of the patient.

Strong working relationships do not form overnight, so the status of pre-existing relationships pre-pandemic is important. In some areas, interviewees reported that there was little functional relationship between CCGs and LAs to build on, making it considerably more difficult and time-consuming to handle caseloads and to make assessments. To understand the significance of partnership working, we must identify areas where partnership working is not evident and compare the processes and outcomes of CHC cases.

Previously, in many areas, the CHC process had been steeped in layers of decision-making, often including a panel that clearly only met at specific times. This can build in several layers to the decision-making process and potentially add delays until the next panel meeting, all of which adds to patient and family frustrations. A CCG CHC operational lead described this process as ‘jarring.’ Although the national framework allows for a panel, it does not recommend or encourage it and it is clear this is an area of assessment where it is imperative to be as consistently applied as possible.

However, during COVID-19 the need to discharge patients from hospital to free beds required quick precision calls and highlighted how ‘old-fashioned ideas needed to be challenged’ to reduce unnecessary bureaucracy. Several of our interviewees stated that staff and teams were given the opportunity to input in the decision-making process, which empowered them to use their expertise and experience to make the best call for the patient in a short amount of time.

The impact of giving power back to staff at local level was immense. Not only did it instill confidence within teams in their decision-making abilities, but we found that it also ‘improved relationships with the local authority because they do not feel like they’re constantly being challenged.’

Once CHC activity resumed in September 2020, there is evidence of an appetite to streamline the CHC process, so whilst decisions regarding assessments and pathways were still taken according to national framework guidelines, they were made by clinicians who were close to the patient and in full transparency with local authority colleagues.

People: Supporting development of the workforce

The impact of COVID-19 on the workforce has been immense. Staff across health and social care, especially those involved with CHC, are exhausted from the persistent workload pressures associated with the multiple surges and peaks of COVID-19; managing patient flow alongside the maintenance and oversight of existing CHC caseloads and now dealing with the aftermath of new and backlog of assessments. Some respondents have described how CCGs have supported staff physical and mental health and wellbeing, tackling abuse against staff, managing the impact of national recruitment challenges, and facilitating training and development across NHS and LA boundaries. Experiences during the pandemic have highlighted some effective ways of supporting the workforce. To support staff wellbeing, ICSs should provide flexible working arrangements, engage in more informal catch ups with staff to monitor wellbeing, and signpost where support is available for those who are struggling in what are extremely strenuous working conditions.  

Overall, CHC staff are passionate and loyal to the service and, with the right support, have proven that they can continue working in challenging conditions. A key factor in achieving this is ensuring staff satisfaction by prioritising and promoting health and wellbeing. Our interviewees suggested various successful methods, including virtual morning check-ins and breakfasts; coffee breaks; yoga sessions; wellbeing homework and self-study; walking team meetings in local areas; and after-work groups. These sit alongside regular one-to-one, personal development reviews (PDRs), formal team meetings and CCG full-staff meetings. The lesson from the pandemic is to be open to using varied methods of communication. This does not necessarily require innovation, it could simply be talking to colleagues on a personal level. We found that personal interaction was preferred over staff surveys. One CCG chose to send out a weekly COVID-19 bulletin update to all staff, which included ‘funny anecdotes, withdrawal jokes, but also full of recent guidance,’ to lighten the mood and humanise the situation.

When asked about workforce concerns, interviewees cited the lack of staff in the care sector, including domiciliary care and nursing/care homes, which led to home closures and increased strain on remaining services. COVID-19 has shone a spotlight on the tremendous amount of work pressure and strain staff have had to continue working under, paired with issues around care and nursing home staff.

It has been widely documented ²  that recruitment into the nursing workforce has been a challenge for some time. Interviewees were clear that recruiting and retaining nursing staff within CHC teams was no exception. The workforce is dwindling as a result of staff approaching retirement and, in some cases, simply a high turnover of staff, which risks consistency of assessments and process if temporary staff are used.

The nursing skills required for CHC care include the ability to understand and operationalise the assessment criteria as consistently as possible, often while dealing with highly emotional families whose loved ones have a complex condition. Any churn in this workforce should be kept to a minimum in order to retain expertise and experience; not only nursing staff, but staff within business and administration teams. Many of our interviewees also noted the importance of the: ‘increased temporary funding from the Treasury during COVID-19 enabling both LA and CCG colleagues to recruit some temporary admin, agency clinical staff and some agency admin, which helped with the spike in clinical activity and assessment backlog from September 2020 to March 2021, which had a knock-on effect on admin functions.’  ICSs and NHS England should take the necessary precautions to ensure these roles are future-proofed and staff feel valued.

Abuse of staff

Historically, pressures on staff within CHC have been exacerbated by an unfortunate amount of abuse from patient families while conducting assessments. Interviewees were reluctant to describe this in detail, but many had experienced levels of abuse that were very challenging and were clear that this was a long-standing, pre-COVID-19 problem. Some agreed that there was an increase in complaints and experienced varied levels of abuse from patients and/or families predominantly into the second lockdown. Arguably, this was a direct impact of COVID-19 where emotions ran high and tolerance low.

Colleagues across the NHS and LAs have agreed that we must campaign for a zero-tolerance policy on abuse of staff. Undermining nursing staff and the profession negatively impacts recruitment into this much-needed area of the nursing workforce.

Some respondents described how part of the CHC process, particularly the checklist for considering patients who will be progressed to CHC assessments, often raised expectations of families that the patient would be eligible for NHS-funded care. Currently there is a large gap between the criteria for consideration in the checklist and the criteria for approval at assessment. As a result, it gives false hope to families and patients that they will receive a package of care when they actually fall short of the eligibility criteria. At this stage, it is vital for staff involved to carry out constructive and clear conversations with patients and families to manage expectations regarding eligibility. Official data show that of, 14,415 completed referrals for Standard CHC in Q4 2021/22, only 2,447 were assessed as eligible ³ .  As only 17 per cent of cases that make it through the checklist are then actually eligible at the assessment for CHC, a substantial majority that pass the checklist are then assessed as not eligible.  This is a highly sensitive issue; the current process raises false hope for both patients and families who assume that a positive checklist guarantees that they will be eligible to receive care. These false hopes can contribute to pressure on staff from patients and families. It is also an inefficient use of staff time, which could be reinvested in supporting care. The checklist should be updated so that it is closer to the standard set for assessments, ensuring expectations and outcomes are more realistic.  

Training and development: optimising the workforce

Our research has found significant variation in the availability of training and development of staff. Allocation of funds plays a major role in how appropriate training is delivered. Ensuring training opportunities are available not only improves skill sets for current staff, but also encourages retention. If staff feel they are able to develop and progress in their careers, this provides an incentive to stay.

Across all interviews, we found that through redeployment and working under COVID-19 pressures, staff developed skills more rapidly as the pandemic exposed them to high-intensity situations. COVID-19 forced systems to work differently and in doing so, decision-making skills and nurses’ confidence in their own abilities increased. Respondents felt that the ‘top-down’ approach was reduced, and team members were encouraged to put forward ideas of how best to deal with situations ^{4 4} .

Innovation: embedding new and virtual ways of working

The pandemic has provided opportunities to work innovatively, particularly virtually. Virtual working has become somewhat of the norm and has allowed people to readjust their work-life balance. Many day-to-day tasks can now be done virtually, such as writing reports, updating databases and conducting assessments. This also allowed staff who were shielding to continue working safely.

All our interviewees reported virtual working has worked well and most staff wish to continue working in this way where appropriate. Most organisations have adopted a hybrid model, which allows for some CHC assessments to be made virtually. However, some patients still require and prefer face-to-face assessments. This hybrid model contributed significantly to a leaner and more timely assessment process, including easier access for family members who may live some distance from their loved ones and previously have had to take leave from work to attend. In appropriate circumstances, use of virtual assessments can accelerate access to care. Organising dates and times to conduct in-person assessments can cause avoidable delay; what could be done in a brief video call usually takes a few weeks to schedule in to ensure the right people are in the room at the same time, including families. Conducting virtual assessments allows CHC teams to get through more assessments in a shorter period. Furthermore, it has enabled a more flexible use of staff from across the country, allowing them to work in different areas as the limit of location and physical presence has been removed.

The level of experience that assessors have plays a key role in deciding whether a virtual assessment is appropriate. Unless explicit requests have been made by the patient or families, nurses and social care workers performing assessments sometimes need to see patients in person to gauge the level of care needed. Sometimes, looking at a patient, the environment or meeting carers and relatives provides sufficient intelligence into what is needed to support the patient going forward. Some patients and families may feel hesitant to accept virtual assessments because they lose human contact, and this can be difficult. Therefore, ensuring the process is patient centred will provide the best outcome.

Although this method is timesaving and facilitates better use of staff across wider geographies, we must strike a balance between quality and quantity of assessments. Staff must have the capacity to perform high-quality assessments, as back-to-back virtual meetings can often mean they are unable to take a break. As mentioned, clarity is required if this is to become embedded future practice. Use of virtual working should not distract from the fact that the workforce is under pressure and simply exhausted. To ensure staff satisfaction and retention, there must be a high level of support put in place. If virtual working is to become embedded practice post-COVID-19, national guidance would be welcome to support local decision-making about whether to conduct assessments virtually or in person. This will help also help facilitate consistency in the assessment process across different areas.

Funding: shared responsibility and using discharge to assess (D2A)

Shared responsibility

CHC assessments were suspended between 19 March and 31 August 2020 to release NHS capacity to deal with COVID-19. In March 2020, additional funding was offered by the Treasury to facilitate timely discharge from hospitals to free up beds for COVID-19 patients using a D2A approach ⁵ . Discharge guidance has been revised several times in the last 20 months and discharge processes have been supported by the D2A funding stream. The reintroduction of CHC referrals from September 2020 meant CCGs have had to focus on two streams of work: successfully restarting the routine CHC referrals process, and tackling the backlog of assessments that had been deferred between March and August 2020.

Stakeholders agreed that funding received during COVID-19 removed tensions within systems that existed between organisations in the initial period post-discharge.  This allowed them to focus on the work at hand and be more efficient in assessing patients at their optimum to determine the correct level of eligibility, the correct care environment and appropriate funding stream. The challenge for systems going forward is maintaining those relationships when earmarked funding ceases.

The improved close working with local authorities should be preserved to support the best practice ongoing care planning for patients. However, the nature of the funding streams do not facilitate this; CHC funds are not yet accurately allocated according to the predicted local population need and other discharge support through COVID-19 were one-off funding streams. Moving towards a population planned approach, with transparency around funding allocations for CHC and discharge, will further enhance the trust within system partners.

Both NHS and LA interviewees cited good and consistent communication as the first step to successful cross-organisational working. Having regular meetings between CCGs and LAs has proved to be highly productive, as individuals got to know each other and their preferred ways of working. Also, having government D2A funding in place meant that discussions were based on patient experience and care delivery rather than organisational financial responsibility. However, stakeholder feedback suggests there is significant variation in how relationships are managed. Our research suggests that larger systems tend to have more challenges in maintaining relationships, whereas smaller systems tend to manage them better and reported more positive closer working. Having greater consistency in stakeholders who work together facilitates better collaborative working, which is easier to do in smaller footprints. Therefore, ICSs could consider adopting the principle of subsidiarity in managing CHC, ensuring more local input to help foster joint working. 

Using discharge-to-assess funding (D2A)

Early on during the pandemic, capacity in hospitals and the ready availability of beds was a huge concern. In March 2020, DHSC issued new guidance on hospital discharge and additional funding was made available to support hospital discharge flow. The DHSC updated the discharge guidance to confirm that CHC assessments would resume in community settings from 1 September 2020, following a short pause. The funding provided allowed for six weeks of additional care following discharge, accelerating discharges by allowing CHC assessments to take place safely in a community setting. Interviewees largely agreed that increased funding was extremely helpful in getting through the backlog. However, it was highlighted several times in our interviews that having that funding potentially increased patient expectations and may create a ‘cliff edge’ once the funding is removed. To address this, some systems have used the national discharge leaflets released with the guidance to inform patients and families that, at the end of funding process, an assessment will be undertaken to establish eligibility and responsibility with LA and health colleagues and may result in them having to contribute to their ongoing care fees.

Conclusion

To consider an individual’s eligibility for CHC, there is often a complex assessment process to ascertain the patient’s needs. Whilst CHC is wholly funded by the NHS, good collaborative working between CCGs and LAs can be really helpful in ensuring timely and appropriate ongoing care.

The most significant component to delivering effective and quality care is having a resilient workforce that can offer consistency in system relationships and in the assessment process itself. COVID-19 highlighted the magnitude of pressure put on staff and the expectation to deliver a quality service in challenging circumstances. Updating the checklist process which leads to CHC assessments could both reduce the pressure on staff and avoid setting false hopes and creating difficult experiences for patients and their families.

Senior leadership teams are responsible for ensuring the physical and mental health and wellbeing of their staff is a priority and regularly monitored. Ensuring training and development opportunities are readily available is key to empowering staff: there must be an incentive to continue working in this sector. Additionally, organisations should enforce a zero-tolerance policy to abuse of staff. The environment in which nursing staff, social workers, healthcare assistants and others work must be safe. Although risk assessments are completed and encouraged, this is not enough to guarantee safety. 

The challenge around recruitment to and retention of the workforce remains and is proving difficult to resolve. This is not a direct impact of the pandemic but a longstanding concern and has been addressed in the NHS People Plan.

The pandemic provided opportunities to work differently but effectively, particularly with virtual working, the success of which can be seen across the health and care sector. Through homeworking, the teams found that they were able to operate ‘business as usual,’ remaining connected to each other, partners, key stakeholder, care sector colleagues and with patients and their families. They were able to adapt in order to achieve a work-life balance without this impacting their ability to get through caseloads. From our research, we have found that the preferred model is hybrid working going forwards. Where appropriate, assessments and CHC core business functions can be completed remotely from home. However, interviewees felt that clinically there is a need to perform some face-to-face assessments to fully gauge circumstances that impact the level of care required for certain individuals. National guidance on when to conduct assessments virtually or in-person would help to inform consistent local decision-making.

Clear communication to patients and families about discharge and CHC processes is hugely important. This is not just about the initial assessment, but also the longer- term care reviews that will ensure the patient continues to receive care that is most appropriate for their needs. Interviewees described real difficulties in managing patient expectations when the process had not been described properly.

CHC remains a critical component of NHS care that can make a huge difference to the wellbeing of patients. We hope that the learning set out in this report, including learnings during the pandemic, and the recommendations set out, will be considered by national policymakers and ICSs so the NHS and our partners can support our staff and continue to improve the service provided to patients and their families.