NHS continuing health care (CHC) is a package of health and social care provided outside hospital, such as in an individual’s own home or in a care home, which the NHS arranges and funds. If someone is assessed as eligible for CHC, the integrated care board (ICB) in that person’s area must pay for all of their associated health and social care costs. It is for people aged 18 or over who have significant ongoing care needs that arise from a ‘primary health need’.
People who are ineligible for CHC can be faced with a cliff-edge of potentially catastrophic costs for the social care they need. Or, if they fall under the financial threshold during a social care means test, their local authority may be required to pay part or all of the costs of their care.
CHC is a vital source of support for people with some of the most complex health and care needs. Its existence goes to the heart of both the moral and practical debates about how we do (and should) fund and provide care for people with complex needs outside hospital. But it has become a microcosm of the dysfunctions that a cash-strapped, paltry social care system and a struggling NHS have wrought. At the heart of the issue are individuals and their families who are faced with a complex and challenging process at the most difficult time.
Our conversations with people who had been through the CHC process for their families demonstrated that not only is the assessment process itself challenging, but the toll it takes is also long-lasting, part of an ongoing struggle to access good-quality, timely care for their loved ones.
Looking at the CHC funding process provides a window into how our health and care systems work together – or perhaps more accurately, how they do not. CHC sits within a complex ecosystem of different accountability, funding and eligibility processes, and is one part of a bigger picture around providing care for people who need it. It offers a prism through which some of the fundamental issues at the interface of health and social care can be understood.
Key findings
Against the backdrop outlined above, our research found that:
The number of people eligible for CHC has fallen over time and varies significantly across England.Population need explains some of the variation. We found that sub-ICB locations – organisational units below ICBs and formerly clinical commissioning groups – with higher levels of deprivation, and larger populations aged 75 and over, are more likely to have higher rates of CHC. However, our analysis also found that local area characteristics cannot fully explain the variation in eligibility.Spending on CHC has increased over time but is not distributed equally. Spending per eligible recipient is lower in the north of England, even after adjusting for geographical differences.CHC practice and variation are complex and multi-faceted – many factors at individual, organisational and system levels drive them. These include:how different local areas approach CHCthe knowledge and awareness of CHC among the people involved in the processwhere referrals come fromthe quality of local relationships, with CHC acting as a temperature check on broader integration efforts.There are concerns that financial pressures are playing a key role in the operation of CHC, with all parts of the system facing significant pressure to keep costs down.
Many of the challenges we have identified stem from the way that health and social care are separate systems, with different funding streams and accountability structures. As such, this research underscores the need for action on comprehensive long-term care reform. This should be designed around a person’s needs and be less likely to result in unfair financial ‘cliff edges’ whereby individuals suddenly find themselves facing significant care costs. The current situation means the stakes are high – an ‘all or nothing’ approach that is problematic and does not reflect the nature of need. With both the NHS and social care under pressure to keep costs down and allocate resources equitably, people requiring care are caught in the middle.
The Casey Commission – an independent commission into adult social care – offers a vital opportunity to start to build a strong social care system that can work alongside the NHS as an equal partner. In any reforms that follow, it is essential that supporting people with needs spanning health and social care is a central consideration. There is potential to learn from other countries where the demarcation between health and care systems is effectively bridged through clarity of entitlement, consistency of the care offer and – crucially – the existence of a long-term care system that is supported through stable funding.
Notwithstanding the need for wider reform, urgent action is required to improve consistency and fairness in how CHC currently operates. While this would not address the fundamental issues, it would ensure that the current system is operating most effectively for the people who need it now.
Importantly, doing nothing is not an option. If the government is to make its ambition to shift care from hospital into the community a reality, addressing the problems in CHC will be an important step.
Our recommendations
Our recommendations to improve current practice include:
improving consistency in CHC through:spreading good practicesharing learningtrainingensuring that assessments are conducted in line with the requirements of the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Careunderstanding who is and who is not accessing CHC by proactively capturing and analysing information about where referrals are coming from, CHC assessments and eligibility by demographics, and using the information provided in the NHS CHC Patient Level Data Set to monitor and address potential inequalities in accessimproving commissioning practices through:collaborative working that enables appropriate and personalised care
for people with complex needsproactive working between integrated care system partners to shape the
local provider marketestablishing clear and transparent processes and policies for how care
is commissioned for people eligible for CHCsupporting integration through:ensuring clear and effective dispute resolution policiesevaluating alternative processes to managing and funding CHCidentifying best practice at a local levelensuring clear governance and accountability for CHC within the context of the Model ICB Blueprint and changes to the role of NHS Englandthe Care Quality Commission considering CHC as part of its assessmentthe National Audit Office investigating how CHC is funded and delivered and whether improvements can be made.