Agenda Item 5

HAMPSHIRE COUNTY COUNCIL

Report

1. Summary and Purpose

1.1. This report provides Members with information about the issues brought to the attention of the Committee and the response to these referrals. It sets out the inquiries received, the source of this inquiry and any action taken. Where appropriate comments have been included and copies of briefings or other information attached.

1.2. The approach adopted provides the route through which Local Involvement Networks (LINks) and other partner organisations (Hampshire district councils, NHS organisations, voluntary and independent sector providers and organisations that are representative of social care service users and carers) can raise issues with the Committee.

1.3. Where inquiries raised with the Committee are already subject to monitoring or other performance management activities the action taken will be focused on the local resolution of inquiries through appropriate sign-posting to the agency best placed to respond.

1.4. Where an issue cannot be satisfactorily resolved between the parties concerned then the Committee can consider options for further action.

1.5. New issues raised with the Committee, and those that are subject to on-going reporting are set out in Table One of this report.

1.6. The recommendations included in this report support the Corporate Strategy aim of maximising wellbeing through the overview and scrutiny of health services in the Hampshire County Council area.

Table One: Inquiries Received and Action Taken

Section 100 D - Local Government Act 1972 - background papers

The following documents disclose facts or matters on which this report, or an important part of it, is based and has been relied upon to a material extent in the preparation of this report.

NB the list excludes:

1. Published works

2. Documents that disclose exempt or confidential information as defined in the Act.

Appendix One: Continuing Health Care - Cost Improvement Plan (CIP) Update

1. Introduction

For a number of years the costs for those people meeting the eligibility for fully funded healthcare have been steadily increasing. The implementation of the National Framework for Continuing NHS Healthcare in October 2007 has resulted in a lower threshold for eligibility and this, alongside an ageing population, has contributed to the increasing volume of people being assessed as eligible.

NHS Hampshire inherited highly fragmented spot purchasing arrangements from its predecessor Primary Care Trusts with limited formal contract management for over 200 individual NHS providers. The management of this is time consuming and inefficient resulting in significant variations in cost for similar packages of care. NHS Hampshire identified that there is potential to manage the market more effectively, utilising more robust procurement processes in order to contain the general increase in costs.

This paper outlines the progress made in delivering the cost improvement programme, establishing a preferred provider network, the impact of changes to the Continuing Health Care and NHS Funded Care revised guidance and progress in delivering the cost improvement savings for Continuing Health Care

2. Preferred Provider Network

The continuing care cost improvement plan (CIP) commenced in 2008. The objective was to review the top 60 most used nursing homes for older persons and people with physical health needs. The aim of the CIP was to develop a preferred provider net work; thereby leading to improved procurement efficiencies and savings. In addition the establishment of a network would enable NHS Hampshire to have a closer relationship with a smaller number of providers resulting in more frequent monitoring and review of services with increased likelihood of quality improvements.

Preferred providers would be expected to sign up to a new contract and service specification detailing improved clinical and quality standards plus an improved and transparent pricing strategy. In return, preferred providers could expect a higher rate of referrals and therefore a more stable income base from NHS Hampshire.

3. Progress in Developing the Preferred Provider Network

NHS Hampshire is implementing a Preferred Provider Network for both residential and domiciliary care, initially concentrating on residential providers. Of the 122 care homes a network of 65 preferred Nursing Home providers and 5 domiciliary care providers has been developed which provides reasonable cost, quality and geographical coverage. This network has been established to ensure value for money in the use of NHS resources and to assist NHS Hampshire in delivering on its statutory duty to live within its available funding.

In the past NHS Hampshire has had no explicit policy regarding choice of provider particularly in relation to Nursing Home provision and alongside hospital discharge planners and care managers had offered open choice to the patient or their family as appropriate.

With the establishment of the preferred provider network it is proposed that all new placements for people meeting the eligibility criteria for fully funded NHS continuing care will made to into the network assuming the following conditions can be met such as the service user has a level of need that can be met by a network Nursing Home. A policy for the Management of the Continuing NHS Healthcare Preferred Provider Network has been developed and is attached at Appendix 1. It sets out procedures in order to maximise use of the network and to manage any appeals.

4. Impact of the revised NHS Continuing Health Care and NHS- Funded Care

The National Framework for NHS Continuing Health Care and NHS- Funded Care which was revised in July 2009 expects PCT's to implement the guidance by 1st October 2009. The main changes may result in a significant rise in referrals and associate rise in the cost of the care packages, in summary the changes include;

1. All fast track applications for people at end of life should be accepted, funded by the PCT and only questioned after the fact or until a full application can be completed. Whilst the underlying guidance continues to suggest that the "primary health care test" should apply to fast track applications, the revised guidance states that we should take into account "where deterioration is likely to occur in the near future". This means that patients who are currently asymptomatic may become PCT funded. It is anticipated that current high numbers of fast track referrals could increase by an additional 30% approximately £1.5m. In addition to the additional cost, there are capacity issues for the teams in order to undertake timely reviews.

2. Checklist. The guidance retains a low threshold for indication of full assessment. It strengthens the requirement for formal written consent and assessment of capacity at checklist stage. Also, written outcome is required with notification of formal appeal process. A full assessment must then be undertaken if required. Finally, the revised framework formalises the expectation that the checklist should only be completed when the individual's needs on discharge are clear. This increases the administrative burden within hospitals regarding the checklist and has potential to push a significant proportion of full assessments into the community. As a consequence the PCT will be obliged to fund increasing numbers of `interim' placements regardless that some individuals may not become eligible for NHS funding. In addition, the burden of undertaking and coordinating continuing care assessments for this cohort will transfer to the PCT continuing care team resulting in the requirement for additional resource.

3. The framework directs that the individual/representative should be enabled to play a central role in the assessment process. Currently, involvement is variable and improvement could add in a significant time delay and administrative burden.

4. Current assessments involve only those members of the multi disciplinary teams (MDT) who are involved in the patients care. The revised guidance recommends that the MDT should refer for other specialist assessment where necessary. This adds to public expectations and makes decisions more liable for dispute if all possible avenues of expertise have not been exhausted.

5. The Decision Support Tool (DST) now has a twelfth domain to take account of any other needs. Overall additional clarity and guidance within the DST is likely to again result in a lowering of the threshold for eligibility. It is possible that this element alone may result in a 5 -10% increase in cases being deemed eligible which could equate to be between £3 to 6million.

6. Currently a significant percentage of DST recommendations are overturned at PCT panel. The guidance states that DST's can be sent back if not complete or if there is lack of consistency but should not go back or the recommendation should not be rejected just because the MDT make a different decision. This is a key concern for Hampshire due to the number of health and social care clinicians completing applications with varying levels of understanding. It is likely that an increase in number of poor recommendations will be approved and in order to counter this a significant increase in the capacity to train staff in the application of the DST and eligibility criteria must be found.

7. The revised guidance provides greater clarity around the expectation that

decisions regarding eligibility should only be made following consideration of

whether there is further potential for rehabilitation or recovery in order for

independence to be regained and how the outcome of any treatment or

medication may affect ongoing needs. In the meantime the PCT remains

responsible and indicates the need for a significant increase in NHS funded

therapy, rehab, intermediate care, interim packages of care etc outside of the

acute hospital setting. Whilst these services are lacking there is potential for

increased delayed discharge or increased pressure on CHC budgets when

patients are funded without confirmed eligibility and who then become dependant upon the services provided. The framework recommends that PCT's generate clearer protocols and commissioning arrangements with provider organisations.

8. The guidance reinforces the expectation for joint packages of care but provides little clarity about how responsibilities between PCT and LA are decided. The likelihood is that the PCT will come under greater pressure to make financial contributions to packages where individuals are not eligible for fully funded health care.

9. The framework adds welcome detail in order to increase the robustness of

process regarding implementation of the mental capacity act with clarity

regarding use of Best Interest Assessments and advocacy when appropriate.

The administrative burden this entails within CHC will need to be further

considered.

10. The appeal process is extended to include an initial hearing at local level where currently appeals go straight to the SHA for consideration for Independent Review Panel (IRP). It is not thought likely that a local resolution process will significantly reduce appeals for IRP and will result in additional administrative burden.

11. The process for disputes between PCT and LA regarding decisions is given greater detail and clarity. Key to this is the expectation that arrangements for reimbursements between PCT and LA need to be agreed. It is likely that this will result in a further cost pressure to the PCT.

Overall, it is estimated that implementation of the revised national framework will result in an increase in referrals of 40 - 50% with numbers becoming eligible increasing an estimated 20 - 30%, the majority of these being fast track applications. The revisions will also result in a significant additional administrative burden to the PCT and require service reform to facilitate improved discharge arrangements. The PCT is working through the impact of the changes but the establishment of a preferred provider network will help to manage the increasing demands on the service.

5. Financial Position for Continuing Health Care

The total continuing care/specialist placements budget is £71.989 million. This covers all care groups including learning disability, mental health, children and payment for retrospective cases. The spend that relates to continuing Health Care totals £41.721 million. The savings target for 2009/10 from this budget was £3.7million

At the end of month 4 the actual spend against the continuing care/specialist placement saving plan was £24.023 million, which is an overspend of £1.419 million. The year end outturn position is a £5.3 million overspend. The scheme is currently rag rated red.

For the Continuing Health Care element,

· A total of 1601 new elements of care have been agreed in the three months of this year and 1036 packages of care were ended.

· At the end of month 4 the actual savings against CIP are £73,000 against a overall target of £652,000

The breakdown of the spend so far by care group can be found in appendix 2

The savings forecast in 2009/10 is £361k with a full year effect of £1.2million.

A detailed action plan has been developed for Continuing Health Care which looks to bring the project back in line such as renegotiating with high cost providers who are outside of the network, packages of care for existing clients. In addition action plans for the other areas within the budget are also being refreshed with the development of a preferred provider network for specialist providers of health care. Fortnightly exceptional reporting to the management board has also been put into place.

A formal action plan with update on progress will be presented to the next Board meeting.

Appendix Two; Continuing care Cost Improvement Plan - letter to NHS Hampshire 28 September 2009

I am writing by way of follow-up to the above paper, which was discussed at your Board meeting on 24 September 2004. Unfortunately other commitments meant that I had to leave this meeting before this item was considered by the Board however there were some specific points of clarification that I felt would be helpful as continuing care supports so many of our most vulnerable people in Hampshire.

We are aware that the implementation of recent Department of Health Guidance will place additional demands on continuing care services. Given this point it would be helpful to understand why the current budget is so significantly overspent, what additional resource NHS Hampshire intends making available to address this shortfall and what further funding will be provided to ensure that people with continuing care needs are able to access the services they require. Although the cost improvement paper made reference to these pressures no information was included about the resources required to address this issue.

Turning to the specific content of the Continuing Care Cost Improvement paper that the Board considered we would appreciate your comments on the following:

· Paras 2.1.1. & 3.1.1

- It would be helpful to have a map setting out the geographic distribution of the `preferred' nursing home and domiciliary care providers.

- There is reference to `reasonable' cost and quality but no indication of what this actually means in terms of your expectations of providers and who is assessing the services to establish assess these criteria. We would be concerned if cost was the only determination of inclusion in the network.

- Are other providers able to apply for `preferred' status and at what point would NHS Hampshire consider removing a home or service from the network.

- The three conditions that are set out are a useful point for discussing placements/services with service users and carers however we would be concerned if they were to be interpreted too rigidly without scope to take account of individual circumstances. Who for example would decide what a `reasonable' distance was?

- What happens if there is no vacancy/ capacity in the preferred provider

· Paras 2.1.2 & 3.1.2. Individual circumstances would need to be taken into account

· Paras 2.2.3 & 3.1.3 Is this the best way to resolve a dispute, how will these concerns be dealt with, by whom and in what timeframe.

· Paras 2.1.4 & 3.1.4. This implies that a vulnerable person could be placed in one setting/service only to have that subsequently changed. This could result in unnecessary moves for people that are already vulnerable and in need of a high level of support and care- who would decide if such a move was necessary and in the interests of the patient?

· Paras 2.1.5 & 3.1.5. Would appellants be able to bring an advocate? The Panel is heavily PCT orientated. What timeframes would they be working to?

· Para 2.2.1 & 3.2.1. Reiterating our point above we are concerned that this implies a vulnerable person could be moved/ receive alternative services when their condition deteriorates. Can you confirm who would conduct the assessments required to support any decision of this nature?

In addition to the above it would also be helpful if you could confirm how service users and stakeholders have been able to contribute to the development of this policy, including Hampshire County Council Adult and Children's services.

Please do contact me should you have any questions about the queries raised in this letter. Your response would be appreciated by 28 October 2009.

Appendix Three: Continuing Care Cost Improvement Plan- NHS Hampshire response

Thank you for your letter dated 28 September 2009, regarding the Continuing Care Cost Improvement plan presented to the Hampshire Primary Care Trust (PCT) Board meeting on 24 September 2009.

I have addressed your specific comments in the order presented in your letter.

Paras 2.1.1 and 3.1.1

There has been careful consideration of the geographic distribution of providers, not only by residential and domiciliary care but also by specific care group, e.g. adults with physical disabilities or service provision e.g. end of life care. This distribution has been mapped out to maximise equity of provision but is not yet available electronically.

Regarding quality, there is a clear expectation that a 2 star CQC rating is the minimum criteria for inclusion. In addition a new contract is being used which builds upon CQC standards in order to specify the expectations of the PCT regarding increased quality. There are some providers within the network that have a number of care homes. Those homes which do not reach 2 star status will not be preferred, whilst the organisation as a whole will continue to be part of the network as a result of the better quality homes.

Preferred providers have been selected primarily on the basis of the existing positive relationship with the PCT. The network aims only to formalise and strengthen existing relationships. Inclusion in the network is voluntary from a provider perspective but is dependent upon meeting standards as laid out in the contract. For a variety of reasons the PCT will continue to contract with non network providers and is open to discussions regarding preferred provider status if there is mutual benefit in doing so.

We recognise that in managing any area of health care policy there are issues of interpretation regarding its application, which is why an appeals process is being implemented in this case. The appeals process acknowledges that individual circumstances differ and may warrant individual consideration. Clearly what would be considered a reasonable distance for one individual would not be considered reasonable for another.

As noted previously, the PCT will continue to contract with non network providers on a spot purchase basis. This activity is being monitored in order to further develop the preferred provider network.

Paras 2.1.2 and 3.1.2

It is acknowledged that an appeals process would be necessary in order to ensure that individuals could present any exceptional circumstances. This is being developed.

Paras 2.2.3 and 3.1.3

The dispute process is outlined in paras 3.1.5. and 3.1.6. It is acknowledged that the process would benefit from the inclusion of timescales, particularly for the initial hearing to take place.

Paras 2.1.4 and 3.1.4

This element of the policy is broadly in line with the more general policy of step down care or local authority interim placements, whereby it is felt that prolonging an acute hospital stay is least likely to be in the best interests of the individual. The option to move vulnerable people would not be undertaken lightly and clinical considerations would take precedent.

Paras 2.1.5 and 3.1.5

This refers to those people who may benefit from an advocacy service rather than a legal advocate. As noted the addition of timescales would be beneficial.

Paras 2.2.1 and 3.2.1

As noted above, clinical considerations would be of primary importance in deciding whether a move is appropriate. The assessments themselves are undertaken by the multidisciplinary team, which would minimally consist of a PCT Nurse Assessor and Local Authority Care Manager.

The development of this policy has been shared with colleagues within Hampshire County Council Adult Services and there is a clear commitment to further align our procurement intentions over the coming months. This policy represents the first stage in developing a network of providers within Hampshire in order to provide improved value for money and increased quality of care for those individuals with more complex need. The aim of NHS Hampshire and the Hampshire County Council Adult Services Department is to develop a shared network of approved providers with one set of policies and processes. As a result the policy itself is likely to develop over time enabling opportunity for broader consultation with service users and other stakeholders.