Assessment of patients in long-term care should be used to improve quality as well as allocate funds
Inconsistencies and inequities abound in the current usage of locally drafted eligibility criteria to allocate funding for NHS Continuing Care [1]. Since the formation of Strategic Health Authorities (SHAs), the number of sets of local eligibility criteria has been reduced from 95 to 28. Nevertheless, eligibility by post-code still holds national sway. The research letter of Luxton et al. in this month’s Age and Ageing [2] indicates that even within a single SHA, there is variation in the interpretation of eligibility criteria. An Independent Review of Continuing Care, commissioned by the government, found a similar problem across the nine SHAs it reviewed [3]. Several of these SHAs explored whether using a standard assessment tool would improve consistency of decision making about NHS long-term care eligibility. They indicated they would appreciate greater national leadership and guidance on which tool to use. For the moment, various assessment instruments are used around the country. Some are unvalidated and incompatible. There has been a barrage of complaints to the Ombudsman (who serves as the final arbitrator in this country) provoked by the perceived inequities [4, 5].The implementation of the Registered Nurse Contribution to Care (RNCC) added further confusion [6]. This system, devised in response to the Royal Commission’s recommendation that long-term care for the elderly should be centrally funded [7], transfers the funding of the nursing care of patients in care homes to the NHS. Although the patients so assessed are not currently receiving NHS Continuing Care funding, the eligibility criteria for the high band of nursing care are very similar to the criteria for NHS Continuing Care. To limit the confusion henceforth, the government has stipulated that all patients discharged from hospital must be screened for NHS Continuing Care before being placed. Only if they are not eligible will the RNCC assessment be applied [8].
A gathering precedent of legal challenges threatens, and SHAs have been careful in the wording of their eligibility criteria in order to protect themselves. The government has stated these eligibility criteria are ‘Coughlan compliant’. However, the legal advisors to the Health Select Committee argue that Ms Coughlan would not be given NHS-funded continuing care according to many of the criteria now being used. Although her nursing needs are high, they are predictable and stable [1].
The forthright recommendation of the Health Select Committee to remove the artificial divide between health and social care established in 1947 was rejected by the then Minister for Health on financial grounds [8]. However, he acknowledged that this, in a single sweep, could sort out all the discontinuities and perceived arbitrariness of the system. He restated his wish for health and social care to work together more effectively. The Single Assessment Process (SAP) was recommended by the National Service Framework (NSF) as the key to achieving a more streamlined and seamless pattern of working between different agencies [9]. However, the SAP has not been implemented as quickly as was envisaged. The government has not endorsed a single assessment tool, although several have been accredited as suitable. The Health Select Committee strongly recommended that the government introduce national eligibility criteria for long-term care underpinned with national standard assessment methodology [1].
Organisations advocating the needs of demented patients and those with other long-term neurodegenerative disorders also testified to the Health Select Committee. Such patients and their carers believe they are being treated unfairly because the current eligibility criteria focus on physical disability. They feel that staff performing the assessments do not always fully appreciate their needs. For example, disorientated people, those with hallucinations and other psychological symptoms need constant explanation and reassurance. The government’s response to the Health Select Committee agreed that mental health needs should be given the same weight as physical needs [8]. In any decision about a national assessment tool, its scope to address psychological needs as well as physical ones must be considered.
A new National Framework for Continuing Care incorporating a set of national eligibility criteria for NHS Continuing Care was announced as the way forward [8]. The new guidance will be backed up by a rolling programme of training for front line professionals to ensure that the same information on needs is gathered for each person and tested against the criteria in the same way. The minister stated he would consider a national assessment tool but cautioned that while it could aid the decision-making process, it could not provide definitive answers. The recent White Paper and accompanying statement from the present Minister of Health Patricia Hewitt is more explicit. She promises closer inter-agency working ‘by introducing a single assessment of health and care needs and a joint care plan for people with the most complex needs’ [10]. She also proposes common health and social care budgetary and planning systems for joint commissioning of services [11].
Numerous pilots and local implementations of the interRAI MDS assessment system (www.interrai.org) Home Care system confirm its ability to gather comprehensive, accurate and reliable data about diverse patient needs. The digitally encoded data can transparently determine resource utilisation, and provide a care plan and a personal outcome tracker [12, 13]. Outcomes can be monitored over time within a single home and can be compared between homes. There is increasing international acceptance of this instrument’s advantages as an assessment tool which can reduce arbitrariness of financial decision making and at the same time offer a system of quality assurance for long-term care.
While we debate the pros and cons of candidate national assessment systems, the elderly remain subject to at least three forms of rigorous financial assessment. For example, a patient who is assessed as not meeting NHS Continuing Care criteria could then be tested against RNCC criteria and means tested for social and personal care. The application of these tests involves considerable administrative costs. There are also personal costs for the staff at the front line of making and enforcing these decisions, as well as for patients and their relatives. This is at the time of the patient’s life when our main concern should be their dignity and quality of life. Moreover, how does this rigour in individual cost analysis affect the quality of life of the frail elderly resident? Are potential rehabilitation opportunities being missed? How does the deployment of staff to conduct these assessments impact on the need to improve the training and education of care staff and quality of care? Peter Millard, observing care elsewhere in Europe, concluded that in a society where the aged sick are tended in a dignified way, which reflects their past contribution to that society, the underlying value system so demonstrated benefits the whole society [14].
The availability of social security to fund long-term care placement was recognised in the 1980s as a perverse incentive encouraging institutionalisation. There is now a new set of perverse incentives. Patients who have high dependency receive extra funding. What is the incentive for homes to strive for excellent nursing care when they receive extra funding for patients who have developed pressure sores but not for those who have been prevented from doing so? On the other hand, if success in rehabilitation and regaining of independence was rewarded, this could save money in the long run [15]. Health maintenance is a recurrent theme in contemporary health care policy as it is not only of benefit to the individual but also a way of containing demand on acute health services. Adequate attention to the quality of long-term care of older people could have a similar dual benefit. The predicted demographic expansion of this group of the elderly population makes it all the more important to assess routinely their health care needs and monitor care provision. Rigorous assessment of care needs is not just a way of safeguarding financial equitability. It also provides a way of safeguarding the well being of the largest vulnerable group of society.
1Centre for Health Service Studies, George Allen Wing, University of Kent, Canterbury, UK
2BUPA Care Services, Bridge House, Outwood Lane, Horsforth, Leeds, UK
Address correspondence to Y. Morrisey. Email: y.c.m.morrissey{at}kent.ac.uk
References
- House of Commons Health Committee. NHS Continuing Care. Sixth Report of Session 2004–05. London: The Stationery Office.
- Vindlaheruvu M, Luxton T. Continuing NHS health care eligibility: an audit of the application of criteria by primary care trusts in Norfolk, Suffolk and Cambridgeshire Strategic Health Authority. Age and Ageing 2006; 35: 313–6.
[Free Full Text] - Henwood M. Continuing Health Care: Review, Revision and Restitution. A Summary of an Independent Review. London: Department of Health, 2004.
- Ombudsman HS. NHS Funding for Long Term Care. London: The House of Commons, 2003.
- Ombudsman. NHS Funding for Long Term Care: Follow Up Report. London: The House of Commons, 2004.
- McDonald A. Ensuring that Recipients of High Band Nursing Care Have Been Correctly Considered Against Eligibility Criteria for Fully Funded NHS Continuing Care. London: Department of Health, 2005.
- Department of Health. The NHS Plan: The Government’s Response to the Royal Commission on Long Term Care. London: Department of Health, 2000.
- Department of Health. Response to the Health Select Committee Report on Continuing Care. Cm 6650. Norwich: HMSO, 2000.
- Department of Health. Modern Standards and Service Models: Older People: National Service Framework for Older People. London: Department of Health, 2001.
- Rt Hon Patricia Hewitt. Commons statement. January 2006. London: Hansard.
- Department of Health. Our Health, Our Care, Our Say: A New Direction for Community Services. Cm6737. Norwich: TSO2006.
- Carpenter I, Perry M, Challis D, Kevin H. Identification of registered nursing care of residents in English nursing homes using the Minimum Data Set Resident Assessment Instrument (MDS/RAI) and Resource Utilisation Groups version III (RUGIII). Age and Ageing 2002; 32: 279–85.
- Igekami N, Hirdes JP, Carpenter GI. Measuring the quality of long-term care in institutional and community settings. In: Smith P, ed. Measuring Up: Improving Health System Performance in OECD Countries. Paris: OECD, 2002.
- Millard P. The Bolingbroke long-term care project. In: Denham MJ. Care of the Long-stay Elderly Patient, 2nd edn. London: Chapman and Hall; 1991: 283–8.
- Millard P. A case for the development of departments of gerocomy in all district hospitals: a discussion paper. J R Soc Med 1991; 84: 731–3.[Medline]
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