NHS Continuing Care

Rosie Cooper Excerpts

Monday 27th November 2017 Commons Chamber

[Norman Lamb]

I will come on to that point in a moment. We are seeing more and more cases of couples being forcibly separated, which is really shocking and a denial of their human rights, so I agree with the hon. Gentleman.

At the end of March 2017, 57,000 patients were eligible for continuing healthcare in England, which was down 1.6% on the previous quarter and 2.7% on the previous year. What possible explanation for that can there be? Demand is rising significantly every year across the country, yet the number of people entitled is going down. That must be due to decision makers imposing tougher eligibility criteria.

[Rosie Cooper (West Lancashire) (Lab)]

Is the right hon. Gentleman aware of the trend in my constituency of people who are already in receipt of continuing care being reviewed and deemed no longer eligible? As a result, the cost of their care is pushed on to local government, instead of continuing to be met from within the health service?

[Norman Lamb]

I am aware of that. Often there is no change in such people’s condition, but sometimes their condition deteriorates. Sometimes the cost is pushed on to the local authority, but sometimes it is pushed on to the family, which is another very serious concern.

There are also a great many complaints about the process that is used. There are complaints about evidence being ignored, which can result in a judgment that someone is ineligible for NHS continuing care, and about professionals lacking an understanding of the condition that they are supposed to be considering. A survey conducted by the Continuing Healthcare Alliance found that 66% of people felt that professionals knew little about the condition that was under consideration. More seriously, there were allegations that medical opinions were being ignored. The BBC heard from three health workers who revealed, effectively as whistleblowers, that medical opinions were actively ignored as part of the process.

--- Later in debate ---

[The Parliamentary Under-Secretary of State for Health (Jackie Doyle-Price)]

I thank the right hon. Member for North Norfolk (Norman Lamb) for securing the debate and giving the House a chance to discuss NHS continuing healthcare. He has achieved a pretty good attendance here tonight, given that it is a Monday on a one-line Whip, which is symptomatic of the interest in the subject. I find that heartening, and he spoke with great sincerity and passion about his concerns. We are grateful to him for that; I know that he thinks very deeply about this subject.

This subject provides challenges, as the right hon. Gentleman pointed out, and he made some valid points about the problems facing the continuing healthcare system. In particular, the Government are aware of issues around variation and the complexity in the system. He highlighted some important examples of that. He also highlighted discrepancies, which he was right to raise. We all recognise the frustration that many members of the public sometimes have with the current system. For those with complex needs, and their families, the process can be very difficult to understand, which can lead to stress and confusion at an already difficult time in their lives. He will know that variation in the system has been a concern for some time. First, I will set out what the Government are doing to address those things and to try to achieve consistency, before I turn to some of the other concerns.

Decisions about NHS continuing healthcare are important and have a big impact on people’s lives, which is why it is right that there is a careful and considered decision-making process in place, which must take into account each individual’s care and support needs. My officials are currently working on updating the NHS continuing healthcare national framework, which is the national guidance that underpins the system. That will help health and social care professionals across the country to apply the framework more consistently and effectively, and improve the experience for individuals. We are working with NHS England, local authorities and key stakeholder organisations such as the Continuing Healthcare Alliance and other charities on this update, to ensure that we draw on the full range of experience and knowledge. Members of the public with experience of NHS continuing healthcare have also made a valuable contribution to this process.

I would like to reassure the House that this update to the national framework will not affect eligibility for NHS continuing healthcare, or the extent of the service provided by the NHS. Instead, the update aims to clarify the process and improve outcomes for patients, carers and their families, and those working in the health and care system. The Department will publish this update to the national framework in the new year. However, we understand that these changes alone are not enough to deliver all the necessary improvements, particularly on issues such as the variation in eligibility decisions that the right hon. Gentleman highlighted. That is why we are working closely to support NHS England with its NHS continuing healthcare improvement programme.

The aim of the improvement programme is to consider how NHS continuing healthcare services can be improved by addressing key areas of concern—namely, variation in patient and carer experiences, and ensuring that assessments occur in the right place and at right time. That issue has also been raised in the debate tonight. The programme will set national standards of practice and strengthen links between other NHS England work programmes that promote the personalisation of care.

To some extent, there will always be some variation in NHS continuing healthcare eligibility rates, and that can be due to wide range of reasons, such as the age dispersion within a local population, variation in levels of health need between geographical areas and the availability of community services, including step-down beds, intermediate care, rehabilitation services and end-of-life services. However, NHS England analysis shows that variation in NHS continuing healthcare eligibility is reducing over time. Work to address variation has already seen improvements, with an approximate 7% reduction in the distribution of variation across standard NHS continuing healthcare eligibility decisions since 2013-14, but the National Audit Office report shows that we obviously have some way to go.

The NHS continuing healthcare assessment process has also been mentioned tonight, and NHS England has introduced a quality premium for 2017 to 2019 to incentivise clinical commissioning groups to carry out more than 80% of assessments within 28 days. Clinical commissioning groups with the highest number of delayed cases are required to establish improvement plans setting out key milestones and planned improvement measures.

The right hon. Gentleman mentioned the claim that budgets are effectively being capped, but I want to emphasise that the national framework for NHS continuing healthcare makes it clear that the starting point for agreeing an NHS continuing healthcare package and the setting where NHS continuing healthcare services are to be provided should be based on the individual’s preferences. However, in some situations, a model of support preferred by the individual will be more expensive than other options and clinical commissioning groups can take comparative costs and value for money into account when determining the model of support to be provided. None the less, the principle that healthcare is free at the point of delivery should and does stand.

Right hon. and hon. Members also raised the breach of human rights and the challenges made to some CCGs. We are interested in the thinking behind that and will explore such issues further.

The right hon. Gentleman discussed the wide variation in the conversion rate of assessments. In his constituency, the conversion rate of 24% appears low when compared with the national average of 31%, but that has to be set against the fact that standard NHS continuing healthcare is currently available for 68.13 per 50,000 people compared with a national average of 43.04 per 50,000 people. I make that point because meaningful comparisons are difficult, but he is right to highlight such issues so that we can satisfy ourselves that we are delivering the commitments in the Care Act 2014, which states that no one should be deprived of care if it is based on their need.

The right hon. Gentleman suggested that some clinical opinions were being questioned, so I want to make the Government’s position clear. CCGs must have regard to the guidance, which states:

“Financial issues should not be considered as part of the decision on an individual’s eligibility for NHS continuing healthcare, and it is important that the process of considering and deciding eligibility does not result in any delay to treatment or to appropriate care being put in place.”

All hon. Members should ensure that that is being adhered to and make appropriate challenges where we believe it is not. The Government and NHS England are looking at strengthening our assurance processes to ensure that those standards are met and that CCGs comply with the national framework. Since April this year, that now includes extended quarterly reporting of NHS continuing healthcare data metrics and robust improvement monitoring, including on eligibility and assessment conversion rates.

I know that the right hon. Gentleman wrote to NHS England about the performance of North Norfolk CCG. I am sure that he is waiting for the outcome of the review with some interest, and I will not be surprised if I hear from him again on this. I am grateful for his interest in this subject and for the spirit in which he made his comments.

As we are all living longer, the challenges to the health service and the care system are becoming ever greater, and he is absolutely right to highlight the need for cross-party co-operation as we address these issues and set the long-term future of care and health on a more sustainable footing.

[Rosie Cooper]

I understand how the system should be and how the Minister wishes it to be, but our comments tonight have been about how the system is. We can make information available to the Minister about instances that show the system is not working as she describes. I have a constituent with a severe spinal injury who was getting continuing healthcare. There was a tick-box exercise that she thought was just a review, but, nine or 12 months later, the care has been taken away.

[Jackie Doyle-Price]

I would be happy to look into that case. I have received advice that continuing healthcare packages for lifestyle or physical conditions are often altered depending on progress. The guidance under the framework is quite clear on what is applicable, who is eligible and what conditions are not eligible. Where there is a question on whether obligations are being met under the law—the obligations are enshrined in the Care Act and under the NHS principle that all treatment should be free at the point of delivery—the hon. Lady is right to make that challenge. I am more than happy to investigate that case.

I am running out of time, and I am sure this will not be the last time we address this issue, so I conclude by thanking the right hon. Member for North Norfolk for securing the debate and thanking all hon. Members who have shown an interest. This debate bodes well for our discussions over the coming months on these vital subjects.

It is vital that we continue to work closely with NHS England, local authorities and key stakeholders to improve the system for everyone. There is a lot of work to do and, although the direction of travel in some respects is positive, as with all these things, we are all less patient than we would like to be.

I hope the right hon. Gentleman can appreciate that the Government and NHS England are very much aware of the challenges in this area, both in his constituency and in the constituencies of other hon. Members. I am confident that the steps we are all taking to improve the system are the right ones and will deliver an improved experience for patients, families and carers based on a more consistent application of eligibility and variation.

Question put and agreed to.