continuing health care lynne phair consultant nurse for older people crawley pct...
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The battle for NHS Continuing Care
Changing emphasis of care in the early 1990s
Introduction of eligibility criteria 1996 Coughlan Judgement July 1999 It was unlawful to transfer responsibility of
patients general nursing care to local authority unless it was merely incidentally or ancillary to the provision of accommodation and of a nature which could bee expected social services to provide
The battle for NHS Continuing Care
October 2001 introduction of funded nursing care. 3 levels of RN care for which the government make a RNCC contribution
February 2003 Ombudsman’s Report for long term care
This found some Health Authorities had not been lawful in their continuing care criteria and had not adjusted them in accordance with the Coughlan Judgement
The battle for NHS Continuing Care
Recommendations- The DoH should review the national guidance for eligibility for continuing NHS care
This guidance must be much clearer in showing when the NHS must provide funding and those where it is let to the NHS bodies locally.
The guidance may need to include detailed definitions of terms and case examples
The DoH were also required to make efforts to remedy consequent financial injustice
The definition
The nature or complexity or intensity or unpredictability of the individuals health care needs (and any combination of these needs) requires the regular supervision by a member of the NHS multidisciplinary team, such as the consultant, palliative care, therapy or other NHS member of the team
The definition of NHS continuing Care
The individuals needs require the routine use of specialist health care equipment under the supervision of NHS staff
The NHS has a rapidly deteriorating or unstable condition
Individual is in the final stages of a terminal illness and is likely to die in the near future
The location of care does not determine the eligibility
Working definitions of the key words
DoH did not directly provide definitions in the circular of the key aspects of care
Stability, predictability and complexity were all take from the funded nursing care definitions
These terms have also been defined in RCN Assessment tool and previous DoH eligibility criteria
How the DoH managed the recommendations
Each SHA had to review their criteria some also developed assessment tools
and scoring methods.Thus all SHAs have an individual
interpretation and scoring systemPotential still exists for variation in
interpretation and application
The Grogan Judgement January 2006
The high court ruled that eligibility for NHS CHC used by the Trust was unlawful since the criteria contained no guidance as to the test or approach to be applied when assessing a person
There as no express reference to the “Primary Health Need Approach” or the incidental or ancillary test
There was no decision as to whether Mrs Grogan did or did not meet the criteria
The Grogan Judgement
The DoH issued an action statement ( 03 March 2006) identifying that a persons health needs is not just the need for registered nursing, but is overall need and the need for the accommodation is part of that overall need.
All SHA and PCTS had to once again review how they have applied the criteria
CHC is not jut the next step up from FNC
Intensity of Care
Working definition described by Bexley Care Trust Retrospective Review Team November 2003
Health or disease process/ disorder, including emotional physical behavioural and psychosocial needs, requiring extensive levels of care time and or frequent periods of direct care, treatment or observation to achieve/ maintain self- actualisation
( including the maintenance of life, e.g breathing, swallowing, eating drinking) from one or more professionally qualified health professionals.
Intensity of Care
Intense includes high levels of care needing extensive direct handling and or use of invasive techniques and intensive refers to a very thorough/ rigorous type of care to achieve maximum capacity of the patient
A practical example
Agnes aged 87 years. Lived in a Nursing Home for 3 years.
Unable to communicate or understand any instruction or language. Legs had become contracted, no sitting balance and no voluntary movement of arms or hands
No recognition of people objects, risks or aids to living
Doubly incontinent
Agnes
Thin papery skin, cachectic weight loss.Inability to recognise food or fluids in her
mouth Becomes agitated when care is deliveredAll responses are primativeLives in a twilight state sometimes opens
he eyes to sound stimulation no facial responses
He husband visits daily
The Care needs of Agnes
Staff needed to anticipate all her needs.Skilled abilities to read non verbal communication
and marry up requirements with history from family ,for all aspects of care including pain
Anticipatory skills re pain, hunger, thirst, Ability to manage and monitor dietary intake
without invasive techniques. support of dieticianRemedial Physio re contractionsManage risks
Risks
Intrinsic risks from total incapacityPressure risk, falls, DVT, Oral Thrush
constipation, dehydration, contractions, chest infections UTIs.
Total environmental risks due it advanced cognitive impairment
Health risks associated with old age
Why is this not just basic personal care?
Complexity of the interrelationship between all fundamental functions of life
Intensity of needs as Agnes would die with a few days without total compensatory action
Overwhelming risk of complicationsNeeds for specialist involvement to
balance physical and emotional needs
Is this health care?
Nursing is… The use of clinical judgement in the provision
of care to enable people to improve, maintain, or recover health, to cope with health problems, and to achieve the best possible quality of life, whatever their disease or disability, until death
( RCN 2003)Nursing can be carried out by people other
than registered nurses ( RCN 2003 & Ombudsman 2003)
Is this health care?
She deserves the regular review and support of a specialist Registered Nurse who has advanced skills in the physical and mental health of old age who has the skills to offer palliative care which of course can empower other care staff to deliver her health care needs
Who has the skills to be able to assess and prescribe care in a non clinical setting and who can support the family and Agnes
She requires the involvement of SALT Dietician and OT
She needs specialist equipment to assist her healthcare needs
Is this health care?
Agnes’s needs are complex, every simple action or inaction can have a number of consequences
Her life depends on the intervention of others she has no capacity even to recognise water or understand her need for it.
She requires daily review and reassessment but of a subtle nature but if not carried out will have catastrophic consequences
Her problem is that she is receiving pure nursing, she requires no tubes, the tools of the staff are within themselves, hidden from view
The skills required to assess
Competent but not Expert assessors may view the needs of Agnes in a positivist way - over simplistic interpretation of seeing the situation on face value
Expert assessors would use use critical theory techniques to reveal hidden factors and different perspectives on a complex situation Thomas (2006)
The skills required to assess
Using the term “basic care” can be likened to the term “common sense” both of which are not common or basic but a dance between different beliefs priorities and needs and an ability of the assessor to use positivist and critical theory to feed the judgement. Thomas (2006)
The danger is that many nurses cannot articulate what the depth of care is and so leaps to use the term basic thus diminishing the complexity of care required to maintain the status quo
A practical dilemma
All people leaving hospital are entitled to a CHC assessment before referral to SSD
Development of a trigger tool in West Sussex Pilot as only partly successful as discharge nurses
said it was very difficult to assess against the criteriaOrdinary Ward nurses did not have time to learn it and
they would only assess those who they thought might be eligible
The Section 2 referral was made as soon as the person came is and so the process of CHC assessment could not be done when the person was considered stable.
The SHA and SSD are encouraging hospitals to find ways of implementing it
The worry is the lack of understanding of the legal right of older people to have the assessment
A practical Dilemma
The SHA and SSD are encouraging hospitals to find ways of implementing it
The worry is The lack of understanding of the legal right
of older people to have the assessmentThe lack of acceptance that assessing for
CHC is a highly skills activityThe lack of understanding that RNs must
document a rationale for their decision making
Useful literature
Defining Nursing RCN 2003 Anderson W Bungay H ( 2004) Assessing patients’ eligibility for fully
funded nursing care. Nursing times 100;2,38-41 Steed A ( 2004) Compensation still in the pipeline money
telegraph .co.uk 24.4.04 The Health Service Ombudsman NHS funding for long term care 2nd
report 2003 Continuing Care NHS and local councils’ responsibilities HSC 2001//015: LAC(201)18 Essence of Care (2001)- patient focused benchmarking for health
care practitioners DoH NHS Funded Nursing Care Practice guide & workbook (2001) DoH Thomas P ( 2006) Integrating primary health care Routledge London DoH(2006)NHS continuing Care action following the Grogan
Judgement www.dh.gov.uk