Paul Taylor, CHC Transformation Consultant, Liaison Care
Following COVID-19, continuing healthcare (CHC) services will have a number of strategic decisions and options open to them. Many of these services will generate opportunities to change and evolve, rather than just to return to what we did before.
CHC leaders are constantly looking to evolve the services they provide and address a number of issues in doing so. The intention of this transformation of CHC is to deliver the three primary objectives of the SIP Team: Better Outcomes, Better Experience, and Better Use of Resources. Meeting these objectives will run alongside the wider ambitions of the NHS, as defined within the NHS Long Term Plan.
The following looks at seven strategic decisions currently facing CHC leaders.
Health and social care partnerships
In the next few weeks, CHC will have been suspended for 6 months. Some people, including those at a senior level, had been considering whether it should be reinstated at all, following the COVID-19 pandemic? However, the government has now announced that CHC assessments are to resume from September 1st, 2020.
There has been a strong argument for CHC to not be reinstated and, instead, a plan to be developed for health and social care to be integrated. However, the chances of this being achieved in the short term is unlikely.
In several paragraphs of the CHC National Framework, Health and Social Care are required to have joint arrangements in place. Are these arrangements in place, and how effective were they to the COVID-19 crisis? It has been recognised that during the COVID-19 pandemic, when money has not been an issue, working relations between Health and Social Care have greatly improved. Until there is financial equality between the two organisations, these relations may not be guaranteed.
The NHS England and NHS Improvement CHC Strategic Improvement Program produced a checklist of what should be contained within a Health and Social Care partnership agreement. However, it can be seen that few Health and Social Care systems have a partnership agreement in place, let alone one compatible with that checklist.
In a published statement between NHS England and ADASS the following is said:
“All parties/agencies involved recognise that CHC is a whole Health and Social Care system issue and the stronger the partnership the better it is for the system, making better use of Health and Social Care system and the member of public that the system service.” (Joint Health and Social Care statement, NHS CHC Delivery Model)
At present, how many Health and Social Care economies can say that they have a real Health and Social Care partnership? If we cannot form strong partnerships, it is difficult to see voluntary integration without some form of legislation.
If, as suggested, we are unlikely to see integration in the near future, the first thing that all Health and Social Care partnerships could aim to achieve is best practice. This would be done by producing a formal partnership agreement, covering all the sections of the NHS England and NHS Improvement/ADASS agreed checklist. Whilst such a partnership agreement alone will not resolve poor working relations, the very process of agreeing the partnership can dramatically improve working cooperation and trust, especially when there is financial inequality.
At scale working
Currently, Clinical Commissioning Groups (CCG) are the legal entity responsible for CHC. Is that really the right scale to deliver CHC?
The NHS Long Term Plan refers to having a more inclusive operational model, increasing the capabilities, resources, activities and leadership to collectively deliver greater value through integrated care systems. Prior to the Long Term Plan, but with a similar emphasis, the CHC SIP had produced the CHC ‘at scale’ operating model. There are many CCG CHC teams that are doing some parts of delivering well, such as Southampton CCG, who are a leading example of good practise in brokerage, and the Wirral CCG with their use of digital provision.
However, I have not found a single CCG delivering a leading or advanced example of practice across all dimensions of the CHC Maturity Matrix. When we look at the reason for this, could it be that CCGs are too small to operate CHC at a leading or advanced standard? The suggestion is that CHC should be delivered at least at an ICS or STP scale. As we move to the new normal, should any health economy be allowed to operate CHC at any scale below ICS or STP, or should processes of transformation be put in place to increase the scale?
With a single operating model operating across an ICS / STP, it could assist in ensuring a consistent approach across a much larger geography, therefore reducing unwarranted variation. This could then provide several additional benefits, such as the opportunity for a number of specialist roles which are often not financially viable for small CCG CHC teams. It could also deliver the opportunity to modernise the back office function with more efficient use of technology, reduced handovers and significantly improved data quality. This could then allow the Leadership Team to operate at a more strategic level rather than being drawn into day-to-day crisis management.
Another area of activity which may benefit from a single operating model is the team of MDT coordinators. There is a strong suggestion that they should be co-located within the locality teams, alongside community nurses, mental health, physiotherapy, speech and language services, and within primary care. This strategy would also link in with the NHS Long Term Plan. By locating CHC Coordinators within these teams, it could create closer relationships between members of any potential MDT required to provide assessments.
Working at scale should also incorporate the introduction of the Trusted Assessor Model; now a requirement of NHS England and Improvement as announced in the letter from Simon Stevens and Amanda Pritchard, dated 31st July 2020. In this, they state: “The Government has further decided that CCGs must resume NHS Continuing Healthcare assessments from the 1st September 2020 and work with local authorities using the trusted assessors model”.
Should the decision be made to move to at scale working with a single operating model, it would be essential to establish a strong understanding of the starting position in the transformation journey.
Having seen the volume of green self-assessment RAG ratings within the CHAT tool version 2, it shows that it is important that the base line assessment is undertaken independently and based on the Maturity Matrix. Without a robust baseline for each CCG’s CHC performance, for an independent transformation review, it would be extremely challenging to deliver at ICS / STP level.
The final three areas of strategic transformation could arguably be delivered at a regional level by NHS England and NHS Improvement:
The level of CHC variation across England is large, despite NHS England and NHS Improvement’s Strategic Improvement program having been in place. There are two steps which could be taken and have a major effect on reducing variation, delivering better patient experience and improving care.
The first step is ensuring that, across England, CHC training is delivered on a regional level. If each ICS/STP were required to pay a regional training levy, this would ensure a consistent regional level of training. Currently, there are some high quality CHC trainers, but these services are not regulated. This means that there could be scope for CHC trainers and consultants to deliver training that is non-compliant with the National Framework.
If training is provided by the regions, it would ensure that the CHC training is compliant with the National Framework, and has consistent standards based on regional practices, helping to drive down unwarranted variation and increase quality. The regional training function should build on the existing Continuing Healthcare e-learning modules created by the CHC Strategic Improvement Program alongside ADASS.
By linking the e-learning models, with the implementation of the CHC Competency Framework and regional training, we could see improved alignment with the National Framework and reduce unwarranted variation.
We have seen the value of the CHC workforce during the COVID-19 pandemic, and it is fair to say that CHC teams have received the level of recognition for their expertise they have always deserved. As we move forward, it is important that CHC staff should continue to receive that recognition in the actions taken by leadership.
Over the last two years, staff have worked exceptionally hard to clear the backlogs of CHC reviews and assessments. In addition, CCGs have invested millions of pounds on agency staff and consultants to clear those backlogs. However, the directive from NHS England, NHS Improvement and the Government is to reduce the volume of agency and locum staff used across the NHS.
The creation of a regional Nurse Bank, with nurses who are managed and accountable for the quality of their work, could assist with reducing these numbers. With the bank staff being employed by the NHS, they will be in receipt of the many benefits of being NHS staff, with access to development opportunities and wider NHS support. This could also prevent recruitment agencies from creating competition between CCGs and potentially driving up costs. Whilst agency staff and recruitment agencies may not particularly like this approach, the use of regional banks would be a more effective and efficient model for the NHS.
Since the introduction of the COVID-19 Hospital Discharge Service Requirements, we have seen the introduction of discharge hubs across the country. Historically, the NHS has attempted to achieve timely hospital discharge in the past with little success; many hospitals experience a large amount of beds blocked, not just during winter pressures but increasingly all year round. The discharge hubs have to date been a success; they achieved what they were set up to do, free up beds to ensure availability for the COVID-19 pandemic. Within a week, they eliminated DTOC. The question is are the discharges hubs here to stay, how and why would we dismantle something that has been so successful?
However, how successful have they really been? Yes, they emptied the beds, but at what costs in terms of the initial £3.2bn funding for local authorities and £1.3bn for the NHS and local authorities as additional resource? What will their success be once this resource is no longer available? Once they have greater financial controls to be considered, how do we ensure the success continues? The other question is how safe have the discharges been? There have been suggestions that there have been quality and safety concerns. There is no certainty that they were safe or not, but I am sure there will be disclosures as we move forwards. In a crisis situation, they may have taken necessary risks, however, moving forward every discharge hub should be subject to a review, to ensure that patient safety is given the appropriate level of emphasis.
I would be very interested in hearing your opinions on the future of CHC, and would be happy to discuss any of the issues raised.
For those unaware, my background is within the NHS England Strategic Improvement Program (SIP), where I was Collaborative Workstream Lead and co-creator of the NHS England/ADASS Web-based CHC Delivery Model. In addition, I was a co-creator of the CHC Change Agent Facebook group which is used for these such discussions and peer support.