- In 2023,Transformation Nous (TN) was commissioned by the Director of Adult Social Care of a local Council to conduct a detailed bottom-up diagnostic regarding Continuing Health Care (CHC) funding for adults, and Continuing Care funding for children and young people (CYP).
- CHC is a package of care for adults with particularly intense, complex, or unpredictable primary care needs, which is arranged and funded solely by the NHS to cover all of the individual’s associated care costs (health and social care) – see Figure 1 for an overview of the process by the standard and fast track referral pathways. Continuing care is an additional NHS-funded health package for CYP with complex health care needs which cannot be met by existing universal or specialist services.
- The specific deliverables of the programme were to:
- Understand how spend by health and social providers changed over time
- Identify conversion rate and local resolution request / appeal rate of health funding for adults (CHC) & children (Continuing Care) and how rates changed over time
- Benchmark spend and access to CHC funding with other places
- Map the current process for allocating health funding to adults and children, how it varies in practice and understanding of the process by system partners
- Develop recommendations for the local system to change its approach / process to improve accessibility to the right funding, at the right time for residents
- Analysed and triangulated over 15 data sources (e.g., to understand how referrals, and referral eligibility conversion rates for CHC funding varied over time and across places – both in the ICB, and nationally)
- Engaged with over 30 social and health colleagues, both at the Council and ICB-level, to identify challenges and opportunities regarding processes and ways of working, while regularly testing and refining insights
- Held a large multi-agency workshop with 30+ social, health and voluntary sector colleagues to bring people along and generate consensus
- The place is an outlier in its London ICB for CHC funding, with consistently lowest referral conversion rate for both standard and fast track referrals (see Figure 2A)
- For standard referrals, the place also had the smallest total number of adults who receive CHC funding, despite having a larger, more deprived population with higher health needs. Although standard CHC referrals have risen, more people now receive a negative checklist so fewer people progress to the full DST assessment stage (see Figure 2B)
- For fast-track referrals, the conversion rate in the place has risen since Covid which is against the trend of other places in the same ICB; however, within the place, for adults who did not receive fast track CHC funding, ~73% died within1 week of the funding decision (see Figure 2C)
- In 2019/20, the place had the highest number of people who receive funded nursing care (FNC) per capita – driven by a high number of care home beds – and the most appeals, but smallest proportion of adults eligible for CHC funding following appeal compared to other places in the same ICB (see Figure 2D)
- Following extensive, in-depth conversations with system colleagues, we also identified several qualitative challenges relating to two key themes:
- Mindsets
- Transactional, rather than collaborative working relationships between health and social colleagues, leading to pressurised ways of working and feelings of tiredness or frustration with current processes
- Discussions and decisions are led by a ‘who pays what’ mentality regarding funding, rather than a needs-led discussion with a focus on what is best for the individual
- Processes (see Figure 3A)
- Misaligned understanding of roles and responsibilities, evidence requirements and target timelines for CHC referrals, contributing to different funding outcomes for the same individuals (see Figure 3B) and process delays as referrals are often ‘bounced back’ between teams
- Absence of standardised funding protocols and inconsistent application of national framework across different places contributes to different funding outcomes for individuals with similar needs
The local place is now embarking on an ICB-wide transformation project to support a system reset to address challenges that have intensified since onset of Covid and to collectively move toward more consistent, collaborative ways of working (see Figure 4A). Key recommendations developed during the programme (see Figure 4B) included:
- Engage in independently-led system-wide ‘refresher’ training on local processes, with example case studies, to upskill and empower the workforce and clarify system roles and responsibilities
- Agree standardised funding protocols and robust processes, utilising national frameworks and best practice, to increase the consistency of funding outcomes and align ways of working between places
- Develop a shared dataset on jointly funded care packages for health, social and education (for CYP) to provide system oversight of the total costs and splits
- Analyse ward-level variation in CHC referrals, conversion rates, and appeals by different demographic and deprivation levels within the local system to understand areas where support could be expanded to make access to funding more equitable
- Support system leaders to enhance their teams consensus and find middle-ground, within the spirit of current system-wide efforts to increase integration and agree next steps
