Nuffield Trust CHC report – Key Findings and Recommendations

Nuffield Trust’s report looks closely at CHC (NHS Continuing Healthcare) in England, particularly the access and eligibility that exists. Care England has summarised the key findings and recommendations, to read the full report please click here.

CHC is a complex issue of accountability, funding and eligibility processes. Therefore, it provides a good lens to assess the interface of health and social care systems, often exposing flaws. The Casey Commission is a key opportunity to create a resilient and fair care system to work alongside the NHS as an equal partner. People have needs that span across the health and social care sectors and they are at the heart of this.

This report also looks at the existence of CHC – should we and how should we fund and provide are for those with complex needs outside of hospital? Does CHC exacerbate an inbuilt unfairness where some needs are supported and others aren’t? The struggling social care sector adds to the complexity of this issue, as it is difficult for individuals to get support when CHC applications are rejected.

Key Findings

CHC does not reach all those that need it.

This is an increasing problem with total demand increasing by 17%, but total number of people found eligible falling 9% 2017-2024.

Furthermore, 2017-2024, with exception of 2020/21, there was a fall in the average number of people eligible for CHC in the last two quarters, compared to the first. Financial pressures on ICBs are widely acknowledged as playing a part. Access to CHC should be based on eligibility, not financial constraints.

The current ‘all or nothing’ approach to deciding who gets this free care does not reflect the nature of need.

There is almost a 5 fold difference between ICBs with the highest and lowest rates of CHC eligibility

• Some variation is explainable by differences in population demographic, for example age and deprivation, but this only explains a 24% variation

There are systemic inequalities – spending per eligible recipient in north of England is lower, even after adjusting for geographical differences.

• 2022/3 (latest) data showed eligible individual in north England had £22,432 less spent on care per annum compared to England average, £65,012.
• Median amount spent in most deprived fifth was £47,300 vs least deprived fifth £95,085

This results in a postcode lottery, with varying and inconsistent CHC practices. The following factors are thought to influence this variation, and wider trends of accessibility and eligibility:

• Local structures and processes
• Commissioning and the provider market
• Awareness and understanding of CHC amongst public and professionals
• Relationships and integration
• Recourse (namely funding) and system capacity

Recommendations

Addressing CHC is an important step in the governments goal to shift care from hospitals into the community.

1. To build a strong care system that works alongside NHS as a equal partner.

The Casey Commission is an opportunity to do this, as well as learning from other countries where health and social care systems are effectively bridged through:

• Clarity of entitlement to care
• Consistency of the care offer
• The existence of a long term care system that is supported through stable funding.

2. To improve the consistency and fairness in how CHC operates

Consistency can be developed through:

• spreading good practice
• sharing learning
• training
• ensuring that assessments are conducted in line with the requirements of the National Framework3 for NHS Continuing Healthcare and NHS-funded Nursing Care
• understanding who is and who is not accessing CHC by proactively capturing and analysing information about where referrals are coming from, CHC assessments and eligibility by demographics, and using the information provided in the NHS CHC Patient Level Data Set4 to monitor and address potential inequalities in access

Commissioning practices and thus fairness, can be improved through:

• collaborative working that enables appropriate and personalised care for people with complex needs
• proactive working between integrated care system partners to shape the local provider market
• establishing clear and transparent processes and policies for how care is commissioned for people eligible for CHC

3. To support integration, ensuring clear governance and accountability 

• clarity through NHS England changes where the accountability lies for overseeing CHC
• all ICBs should have an easily accessible dispute resolution policy
• NHS England should review the effectiveness of this dispute resolution policy
• DHSE should explore the different funding options and do an evaluation of how the processes are working
• the CQC considering CHC as part of its assessment
• given the financial context, the National Audit Office investigating how CHC is funded and delivered and whether improvements can be made.