How time flies! The first National Framework was published in 2007 and here we are almost two years later.  

On 22 July 2009 the Department of Health (the DH) published a revised version of the National Framework for NHS Continuing Healthcare and NHS funded Nursing Care (the revised framework). The DH had committed itself to revising the original document which was published in September 2007. The revised framework will be implemented on 1 October 2009.  

The revised framework reflects issues raised during the review process, together with experience that has been gained through using the original framework. The revised framework is a much more substantial document than the original, being 22 pages longer than the original 38 pages! Although the revised framework does not change the basis of eligibility decisions it aims to provide greater clarity, and changes have been made to the various assessment tools to aid evaluation of the levels and types of presenting need.  

One of the significant changes in process is the use of the “Fast Track Pathway Tool”. If an “appropriate clinician” considers a person to have a primary health need arising from a rapidly deteriorating condition that is entering a terminal phase, a completed Fast Track Pathway Tool will require the PCT to determine that the individual is eligible for continuing healthcare (CHC) until a full assessment using the Decision Support Tool (DST) is completed, (see paragraphs 85 – 94).  

The following advice about the eligibility threshold for CHC is given:  

  • Within the “Primary Health Need” section (paragraphs 25 – 32) “nature”, “intensity”, “complexity” and “unpredictability” have been further defined as part of an expanded explanation of the primary healthcare need test.
  • Emphasis on assessment being need, rather than condition, focused; eg, a “severe” learning disability does not necessarily mean a “severe” score should be awarded for cognition (paragraph 23 of DST user notes).  

The following is provided to assist in undertaking assessments:  

  • More detailed guidance is provided on the assessment process and use of the DST, including a target (paragraph 84) for completing DSTs within 28 days of the “checklist” being completed, or referral being received.  
  • Guidance is given on mental capacity issues relevant to CHC assessments (paragraphs 39- 42).
  • Creation of a 12th care domain (paragraph 76) within the DST: “other significant care needs”, to give multi disciplinary teams (MDTs) scope to include needs not covered in the 11 named domains.  
  • Descriptions of need within the DST’s care domains have been expanded to help MDTs decide which score to attribute according to an individual’s presentation.  
  • Wherever possible the individual, or a representative, should be present when the DST is completed (paragraph 10 of DST user notes).  
  • Where the multi disciplinary assessors disagree about which score to recommend the higher should be recommended and the disagreement should be noted on the DST (paragraph 22 of DST user notes).  
  • Where an effect of the individual’s condition can be reflected in more than one domain a score should be awarded in both but the multiple scoring of what is one need should be clearly recorded on the DST. Where multiple scores are given for what is one need care should be taken when considering eligibility; two “severe” scores in such a case may not indicate eligibility (paragraph 26 of DST user notes).  
  • Well managed needs should still be considered but guidance is given on scoring needs which are well managed, eg, if challenging behaviour is now well managed by medication it may be best to score the need under “drug therapies and medication” instead of “behaviour” to avoid inappropriate duplicate scoring (paragraphs 29 & 30 of DST user notes).  

The revised framework will be supported by additional documents due to be published later in the year. These include:  

  • Revised Directions, to replace the NHS Continuing Healthcare (Responsibilities) Directions 2007.
  • Guidance on responsibility for provision of care pending a decision on CHC eligibility.  

Other new, or expanded, sections of the revised framework include guidance on:  

  • Access to other NHS funded services, including guidance on access to NHS services where CHC funding is in place and where there are joint NHS/local authority care packages (paragraphs 102 – 111).  
  • Relationship between CHC and care under section 117 Mental Health Act 1983 (paragraphs 112 – 116).  
  • Planning for transition from child to adult services (paragraphs 18 – 132).  
  • Personalisation of care planning, and ways to promote this for CHC patients (paragraphs 133 – 137).  
  • Independent Review Panels reviewing PCTs’ CHC assessments, including a statement that parties should not usually be legally represented before Independent Review Panels (paragraph 157).

Continuing healthcare eligibility remains a high profile issue and assessments are frequently challenged by patients and their families. The additional guidance contained in the revised framework, and the revised assessment tools, should provide some welcome assistance to PCTs.