Since March of this year, COVID-19 emergency legislation has allowed CHC assessments to be paused whilst critical resource is freed up to deal with discharges and other critical care needs across the health and care system. With an estimated 5,000 additional discharges per month in receipt of continuing healthcare, we can assume around c.£0.5bn has already been incurred by the health and care system (potentially rising to £1.5bn by March 2021).
The reality is that CCGs will likely cease to be supported centrally beyond March 2021 for either discharges under COVID-19 or any new hospital discharges – and so radical new conversations need to take place in order to be able to grip this challenge locally in just over 6 months. Discussions at CCGs, NHS Providers and Local Authorities will be frequent and the landscape will change often over the coming weeks – yet this picture also needs further clarity given that CHC received just 3 lines in the NHS Phase 3 response letter to tackle a potential £1.5bn funding gap.
The NHS “Who Pays” guidance for CHC is now 7 years old and our experience of working with the whole health and care system over the last decade has demonstrated mixed successes in determining where "health" needs end and means-tested "social care" needs begin.
Local Authorities and CCGs have developed local procedures to enable them to collaborate in multi-professional assessments to ensure that needs are always met for individuals who require it. However, these are far from perfect and the system doesn’t always hit the mark – 1 in 5 Local Resolutions Requests (the official CHC appeals process) have their original eligibility decision overturned.
Let’s not forget that Local Authorities are also working in different ways to respond to the crisis as well – as the bill-payer and guardian for hundreds of thousands of individuals in care homes, on top of the COVID-19 crisis, a crisis of financial viability has hit both Local Authorities (in terms of loss of income) and independent care providers, as many places are left vacant and new customers are potentially put off by the risk of infections, which have badly affected the market. In addition, Local Authorities are financially supporting Providers outside of their own support grants by paying for additional PPE and covering vacant care home places, as well as funding Local Community Hubs to offer help where COVID-19 has affected Communities’ mobility to complete their daily activities.
This, on top of the ever-present risk of another wave of coronavirus cases and local lockdown pressures looming, means the system is facing what is probably its most challenging period yet.
Tackling the challenge at pace
The NHS is right to develop regional working groups to understand their resource requirements against STP footprints, as the challenge will require a high-level strategic response and an ability to work at scale, in order to tackle it effectively. Collaboratively discovering resource requirements, whilst scouring options across the board to develop a strong action plan will certainly help recovery efforts.
There has also been much positive discussion around the improved working between health and other parts of the system, including the phenomenal work of volunteers and community groups supporting the most vulnerable, as well as co-ordinated efforts by local NHS providers and Local Authorities. This all serves to prevent any further pressures to a system which has been struggling with its own workload even before March of this year.
Whilst many will consider the progress made across the integration agenda a huge win, despite the circumstances of the crisis, the discussions held around CHC will require a completely different step-change in agreeing how to deal (as equal partners between CCGs and Local Authorities) with the amount of continuing support needs across all regions. This challenge will also no longer be dampened with the promise of additional central government funding, as the economic consequences of the pandemic has already hit hard, not just in the UK but globally.
And so, finding strong existing partnerships across the local health and care "systems" will be key. The existence and ability to tackle the CHC assessment backlog by merely resourcing the right nurses with the right experience is only half of the picture. Capitalising on what can be done to support reablement, where possible, and ensuring that means-tested social care assessments can be carried out in a timely fashion are just two barriers that must be overcome on top of this.
In addition, independent MDT assessments must be able to contribute jointly and objectively to decision-making partners at senior CCG and Local Authority level, to ensure no individuals falls through the "gap" – an even greater risk now given the sheer volume of individuals requiring review. Lastly, partners must be able to truly take advantage of Trusted Assessor and other Discharge-to-Assess models in order to have a chance of successfully meeting this challenge in a timely fashion.
In our experience, tackling all of this requires strong leadership, experienced programme management and an ability to negotiate a uniquely complex part of the health and social care system so that all stakeholders can benefit. A successful model will see customers receive the right care at the right time without delay, CCGs can carry out timely assessments, Local Authorities being consulted and, as valued partners, are empowered to provide critical social work capacity and resource to ensure any continuity of care is shared appropriately and proportionately under the Care Act.
The ultimate goal must be to ensure that those that are most vulnerable receive the best on-going care, and those that are able to recover can receive reablement at the right time, giving them the best chance of once again living independently.