NHS Continuing Healthcare Equity and Choice Policy

1. Version Control

Version	Date	Author and Role	Detail of Change
V.0.03	21 July 2014	Service Lead Continuing Healthcare	Newly developed policy sent for review and formatting
V.0.04	23 July 2014	Information Governance and Risk Manager	Format into ICB style
V.0.05	12 August 2014	Service Lead Continuing Healthcare	Updated following comments and reissued for policy approval
V.1.00	13 August 2014	Information Governance and Risk Manager	For approval by Clinical Scrutiny and Clinical Executive.
V.2.00	17 December 2014	Head of Quality and Patient Experience and Governance Advisor	Additional information regarding appeals process and consent. Renamed Equity and Choice – previously Choice Policy
V.2.01	12 January 2015	Service Lead Continuing Healthcare	Updated following comments and reissued for policy approval
V2.02	6 May 2015	Service Lead Continuing Healthcare	Extended review period for 12 months
V.3.00	23 Oct 2016	Clinical Assurance & Professional Lead	Updated policy
V.3.01	09 Oct 2019	Clinical Assurance & Professional Lead	Updated policy
V 3. 02	21 Sept 2021	Head of NHS Continuing Healthcare	Updated policy
V 4.00	25 Jan. 24	Head of NHS Continuing Healthcare	Updated policy

2. Approval History

Version	Date	Approver
V 4	09/05/2024	ICB Quality Committee

3. Next Review Date

The date this policy is due for review is January 2027

4. Contents

1. Version control
2. Approval history
3. Next review date
4. Contents
5. Statement of overarching principles
6. Introduction
7. Purpose
8. Equality statement
9. Scope
10. Cross reference to other policies
11. Policy details
12. Appendix A: Abbreviations And definitions

5. Statement of Overarching Principles

All Policies, Procedures, Guidelines and Protocols of the Suffolk and North East Essex Integrated Care Board (ICB) are formulated to comply with the overarching requirements of legislation, policies or other standards relating to equality and diversity.

6. Introduction

Suffolk and North East Essex Integrated Care Board (SNEE ICB) is responsible for NHS Continuing Healthcare. The NHS Continuing Healthcare Team is the name given by the ICB for the team managing these funding streams.

This policy describes the way in which Suffolk and North East Essex ICB will commission and make provision for equitable, safe and effective care for individuals who have been assessed as eligible for NHS Continuing Healthcare.

7. Purpose

The purpose of this policy is to provide clarity regarding the commissioning processes undertaken in relation to NHS Continuing Healthcare, ensuring that the process is person led; that equity, equality and risk is managed and that the ICB are able to demonstrate the most effective use of NHS resources. The NHS Continuing Healthcare eligibility process is not within the scope of this policy.

The policy defines the way in which resources will be commissioned. Commissioning will be undertaken in a way that reflects the choice and preferences of individuals, balanced with the need for the ICB to strategically commission and manage the demand for healthcare for all the people of Suffolk and North East Essex in a safe and effective manner. At all times the ICB will ensure the best use of NHS resources both locally and nationally commissioned, and provide a level of service that is sustainable, equitable (fair) to the health and wellbeing of the people of Suffolk and North East Essex.

This policy does not change the ICB’s statutory responsibilities to comply to national standards and legislative duties, however it promotes consistency of decision making and transparency in how the ICB will comply with their obligations as commissioners of NHS funded services as stated in the Department of Health, Choice Framework (2014) and the associated national policy in the delivery of healthcare.

Within Suffolk and North East Essex the ICB wants to provide an open and transparent decision making process that balances individual choice with the healthcare requirements of the people of Suffolk and North East Essex. The ICB accept this policy by design, limits individual choice in order to promote standardised choice to meet the requirement of equitable and sustainable healthcare for all.

In balancing the use of limited NHS resources, the ICB fully respect equality and diversity, and fully embrace the established NHS values and principles on equality and fairness, as set out in The NHS Constitution for England, Department of Health (2013) and the laws under the Equality Act 2010 together with the European Convention on Human Rights.

Within this document the ‘individual’ will be used in all instances for the patient, person or resident as well as their relative and representative.

8. Equality Statement

This Policy will operate alongside the ICBs Equal Opportunities, Diversity at Work Policy, and Equality Delivery System. The ICB’s vision is to have in place a sustainable people driven service system of care which is best of class, and values based on hope inspiring environments and embracing diversity. The ICB will ensure that all staff, volunteers, service users and visitors are treated with dignity and respect, and no individual is treated differently on the grounds of their marital status, maternity, race, gender, gender reassignment, disability, age, religious belief or their sexual orientation.

The ICB assures staff, volunteers and people entitled to our services are treated fairly, equally and with respect and dignity. The ICB will challenge discriminatory attitudes and provide rules and standards of behaviour.

The ICB will monitor the use of this Policy, and will ensure that the policy is implemented fairly, and will take action if it appears that it is has a disproportionate effect.

9. Scope

This policy applies to all employees of the ICB, including fixed term employees when working within the ICB and whilst on ICB business

10. Cross Reference to Other Policies

SNEE ICB commissioning of one-to-one within care home settings policy and procedure
National framework for NHS continuing healthcare and NHS-funded nursing care
Hospital discharge service guidance – GOV.UK (www.gov.uk)

11. Policy Details

11.1. Provision of services for people who are eligible for NHS Continuing Healthcare

The ICB has a delegated duty to promote a comprehensive health service, and each year must ensure that we provide this service within our allocated budget. While there is an expectation that individual choice is considered, it must not compromise overall service provision.

The ICB are obliged to meet the health and care needs of individuals who are eligible for NHS Continuing Healthcare, however, guidance does not prescribe the type of healthcare required to meet the need. ICBs have discretion as to the manner of provision of NHS Continuing Healthcare services and must exercise reasonable judgement to provide the most appropriate care within the resources available, considering overall expenditure.

Given these constraints, the ICB NHS Continuing Healthcare Equity & Choice Policy has been developed as a guide to support the overall provision of NHS Continuing Healthcare, whether in residential settings or own homes, and will ensure that all decisions on funding will:

Be person-led.
Be robust, fair, consistent, and transparent.
Be based on the objective assessment of healthcare need, safety, and best interest.
Involve the individual and/or their representatives wherever this is possible and appropriate
Ensure the safety, effectiveness and appropriateness of care is considered in line with the National Framework for NHS Continuing Healthcare.
Take into account the need for the ICB to allocate its financial resources in the most cost-effective way.
Support individual choice and personalisation to the greatest extent possible in the light of the above factors.

The ICB has a duty to provide care to an individual with healthcare needs to meet those assessed needs. An individual cannot make a financial contribution to the cost of the provision of NHS healthcare. An individual however, has the right to decline NHS services and funding and make their own private arrangements should they wish.

However, where service providers offer additional services which are unrelated to the individual’s healthcare needs the individual may choose to use their own funds (self-funding) to take advantage of these additional facilities, services, and treatments.

Examples of such services falling outside NHS provision could include hairdressing, a bigger room where there is not an assessed healthcare need for a bigger room, a room with a nicer view or elements of daily living which represent as ‘wants’ not ‘needs.’ Any additional services which are unrelated to the assessed healthcare needs will not be funded by the ICB as these are services over and above those which the NHS can reasonably be expected to fund.

Provision of any additional services unrelated to an individual’s health and care needs should be arranged and contracted separately from any NHS arrangement or contract. Assurance must be provided that the care provider can continue to provide the appropriate care for the individual within the care facility should the individual decide to end the agreement for provision of additional services. An example of this would be where a care

home has a luxury wing with a higher specification room at a higher price than the NHS agreed price. Under this arrangement the NHS will pay the standard rate and the individual will take out an additional payment agreement for the luxury standard on the understanding that if they become unable to pay for these additional services then they would be moved to the standard NHS level of room within the same home, and their health and care needs would still be met.

Where Individuals and providers decide to offer or take up additional services of the nature described above, they must acknowledge that the ICB can accept no liability for any failure by individuals to pay for the additional services provided.

Any assessment of a care option will include the psychological and social care needs and the impact on the home and family life as well as the individual’s care needs. The outcome of this assessment will be considered by the ICB when arriving at a decision.

The setting in which care / treatment is provided is based on clinical risk and is a matter to be decided by the ICB with due consideration of the individual’s wishes.

11.2. Care Home Placements

Where an individual has been assessed as needing care in a care home environment, the role of the ICB is to identify and commission a suitable placement. The ICB will endeavour to identify a choice of care home placements within the individual’s preferred geographical area, however this is dependent on the availability of care home vacancies, the ability of specific care homes to meet the individual’s needs, and the care home’s acceptance of the ICB’s weekly fee. Where an individual has been awarded Fast Track funding, where the objective is to secure services for the individual as quickly as possible, less choice may be available.

A weekly fee which the ICB reasonably considers sufficient to fund a care home placement for the individual will be agreed. The ICB are unable to commission placements within care homes that do not accept the agreed weekly rate.

The ICB will not normally fund a placement where the requested care home can only safely or resiliently meet the individual’s identified care needs with additional staffing at significant extra cost to the ICB. Where enhanced observations in the form of 1:1 care is required, this will be arranged and reviewed in line with the ICB policy on commissioning of one-to-one within a care home.

The ICB understands that the location of a care home is an important factor in decision making for many individuals. Where possible, the ICB will endeavour to provide a choice of care home within a reasonable distance of the individuals preferred location, considering the rurality of Suffolk and north east Essex and availability of appropriate care home vacancies in the preferred area.

In some circumstances, an individual may wish to live in a care home that has not been identified by the ICB. In these circumstances, as long as the fee for the placement is comparable to the fee agreed by the ICB, the care home is able to meet the individual’s needs and the care home satisfies appropriate criteria set by the Care Quality Commission and local authority social services, the ICB will consider this option.

Where a care home has had its registration or right to accept admissions suspended or cancelled by the Care Quality Commission, or the local authority social services have

embargoed admissions, the ICB are unable to consider commissioning any new placements within the care home until any suspensions, cancellations and embargoes have been lifted.

11.3. Funded packages of care at home

The expectation is that individuals who are eligible for NHS Continuing Healthcare and require care at home will be offered a notional Personal Health Budget (PHB) by default. A PHB is an amount of money to support the identified healthcare and wellbeing needs of an individual, which is planned and agreed between the individual, or their representative, and the responsible ICB. It is not new money, but a different way of spending health funding to meet the needs of an individual.

A notional Personal Health Budget means that an individual is advised of the amount of money the ICB would normally spend on commissioning their care, the ICB holds this money on behalf of the individual and procures the services that are required to meet the individual’s health and care needs. There is no requirement for an individual to maintain any financial records where the ICB is managing a notional personal health budget.

The ICB will take into account patient choice, the availability of equipment including assistive technology, the appropriateness of the physical environment and the availability of appropriately trained care and/or other staff to deliver the care at the intensity and frequency required when considering funding a home care package for an individual.

People who are eligible for NHS Continuing Healthcare funding have a complexity, intensity, frequency and/or unpredictability in their care needs, which means it may be less likely that care can safely be delivered at home. Although individual circumstances will be considered, it must be understood that it is usually not possible to replicate support services that would be available within in-patient NHS settings and nursing care facilities, and if this level of care is required, it would not usually be possible to care for the individual at home.

The ICB will consider funding packages of care at home providing care can be delivered safely, taking into account the risks to the individual, the staff or other members of the household (including children), and the level of risk that is acceptable to the individual.

The ICB will take account of the following factors before agreeing to fund a care package at home:

The individual’s current and likely future needs;
The individual’s GP agreement to provide primary medical support;
The suitability and availability of alternative care options;
The absolute cost of the care and support required to meet the assessed needs and health and well-being outcomes, compared to the relative costs of providing the package of choice, both considered against the relative benefit of each package to the individual;
The psychological, social and physical impact on the individual;
The willingness and ability of family, friends or informal carers to provide elements of care where this is part of the care plan and the agreement of those persons to the care plan;
The provision of contingency if the care provider fails or is unable to get to the individual.

Many individuals wish to be cared for in their own homes rather than in a residential or nursing care home, especially people who are in the terminal stages of illness. An individual’s choice of care setting should be considered but the decision about where a package of care is provided is made by the ICB. The ICB’s decision will be balanced against the factors set out above. The option of a package of care at home should be considered,

even if discounted, and the reasons for its unsuitability should be clearly documented and communicated to the individual.

The ICB consider that in some circumstances an individual’s needs are most appropriately met within a care home setting. The general assumptions are set out below; however, the ICB will take into consideration all relevant circumstances to establish whether these assumptions can be displaced:

Individual’s whose health and care needs mean that they cannot be left without care and/or supervision for more than a short period of time during their waking hours. An example of short period of time would be a care worker using the bathroom or making a hot drink.
Individuals who need waking night care would generally be more appropriately cared for in a care home. The need for waking night care indicates a high level of supervision is required at night.
Placements are generally deemed more appropriate for individuals who have highly complex health needs.
Where there is a need for the presence of a Registered Nurse over a 24-hour continuous period, the ICB would only be expected to provide this within a care home with nursing environment.

Each assessment will consider the appropriateness of a home-based package of care, considering the range of factors and principles within this policy.

Respite is an interim, short-term arrangement for carers, which provides relief from their caring duties. The ICB will consider commissioning respite care in the form of an interim care home placement, or a short-term increase in formal home care to provide a break for unpaid carers who are providing care to meet needs which would otherwise require formal, paid care to meet them.

When working in an individual’s home, care workers do not have access to the full range of support services that are available within a hospital or nursing home environment, and in most cases, care workers will be working in isolation. If an individual care package at home is agreed, this must be acknowledged, and any implications identified and fully understood, with contingency plans put in place where required.

Alternative arrangements in case a home care package breaks down should be discussed with the individual by the health professionals involved in their care before the package of care commences. These arrangements could require an alternative package of care to be arranged. On some occasions, there may be a delay in re-arranging a home care package due to availability, or the ICB may be unable to re-arrange a home care package. In these circumstances, rapid admission to a care home may be required to ensure care and safety is maintained.

There may also be occasions where home care providers or care workers are unable to get to an individual, for example, due to adverse weather or high level of staff sickness. The ICB are not usually able to obtain rapid access to additional homecare in these cases. When an individual decides to receive care in their home, these risks should be clearly explained to them, and considered as part of the decision-making process.

If an individual does not allow an alternative care arrangement to be put in place in the event of existing care arrangements breaking down, the ICB will follow safeguarding policy and the Mental Capacity Act (2005) to ensure the best interests of the individual are maintained.

Where care at home has broken down, providing the conditions of this policy can still be met, the ICB will fund a replacement care package from a second provider. At this point, the ICB will give written notice to the individual that should the second care package breakdown, the ICB will not be able to consider continuing to fund a home care package and would only consider funding an appropriate care home or other appropriate place of safety that both meets their needs and satisfies the ICB criteria as set down in this policy. If the placement offered is not acceptable to the individual receiving care, they may wish to consider a Personal Health Budget (PHB) in the form of a Third Party Budget or Direct Payment or may arrange to fund their own personal care package or alternative care home placement.

The above does not apply to situations where care providers have withdrawn from a package of care because they no longer provide a service in that geographical area, have ceased trading, have had restrictions placed on them by the Care Quality Commission, or where the ICB has decided to stop commissioning that care provider due to safeguarding or care quality concerns

Where it has been identified by the ICB that the safety of its staff or those providing care is at risk the ICB shall take the action it considers appropriate to remove or minimise the identified risk. Where this relates to the conduct of an individual or the home environment the ICB will request that the individual and/or their representative take the necessary action to remove or minimise the risk. Harassment, bullying or abuse of care workers by an individual or their representatives will not be accepted, and the ICB will take any action necessary to protect its staff or its agents/contractors in line with the NHS stand on Zero Tolerance. Where there is a continuing risk to the safety of ICB staff or its agents/contractors the ICB retain the right to take any action considered necessary to remove or minimise the risk including withdrawal of the offer of care and support at home.

If an individual refuses care packages offered by the ICB he or she will not be prejudiced should they wish to take up an offer of NHS services at a later date and this policy will be applied to such individuals in the same way as to all those newly eligible for NHS Continuing Healthcare.

11.4. Changes in circumstance

If a review of an individual establishes that their condition has improved or stabilised to such an extent that they no longer meet the eligibility criteria for NHS Continuing Healthcare and an NHS Continuing Healthcare assessment confirms they are no longer eligible, the ICBs will no longer be required to fund the service. The ICBs provide 28 days written notice of cessation of funding to the individual and the local authority and should notify any current care provider of this. Any on-going package of care that is needed may qualify for funding by social services, subject to assessment, or the cost of some or all of the package of care may need to be met by the individual themselves. The transition of care should be seamless, and the individual will be notified of any proposed changes to funding involved when appropriate.

Where an individual who is currently receiving care at home has been assessed and their needs have changed, the ICBs will consider whether the current care provision remains appropriate. Where the ICBs deem the current care and support is not appropriate and does not approve a proposed change to the care and support arrangements, the individual will need to agree to alternative care provision approved by the ICBs. Where the individual does not agree to the alternative care provision, then the Refusal of Funding process will apply.

If an individual becomes eligible for NHS Continuing Healthcare, who was previously funded by social services, the ICBs will apply the same principles as for other individuals. Namely,

that the ICBs have a duty to consider the best use of resources for their population, whilst meeting the healthcare needs of an individual. The ICBs will seek to provide this care with the least disruption to the individual.

Equally, where a provider of care significantly increases their pricing and an alternative provider can deliver the same level of care for better value, the ICBs will consider a change in provider. During this process, the ICBs will ensure the individual is fully informed and case management is provided throughout this process.

11.5. Exceptional Circumstances

The ICB recognises its duty to consider effective and efficient use of resources, in order to deliver NHS Continuing Healthcare to the population of Suffolk and North East Essex. The ICB may not agree to a care package or placement that is preferred by an individual and may require the individual to choose a less expensive alternative that will meet all their identified needs.

When determining cost effectiveness, the ICB will consider the genuine cost of each possible care package, taking into consideration the individual circumstances, including care at home packages, possible assistive technology, and input from family and other carers.

The ICB will aim to agree to fund the most cost-effective package of care that has been identified as appropriate for an individual and will meet their health and care needs. In some circumstances, the ICB may agree to fund a package of care that will cost more than the most cost-effective option identified, considering the following considerations:

the individual’s wishes
likely impact on the individual of any potential move, including psychological and emotional impact.
suitability of alternative arrangements
risks involved to the individual and others
the individual’s rights and those of his or her family and other carers
whether there are any creative alternatives available to enable the best use of resources available and to enable the individual’s choice to be realised
the ICB obligation in relation to equality and the Public Sector Equality Duty
the NHS Constitution commitment to providing the most cost effective, fair, and sustainable use of finite resources.

If the weekly cost of care increases, excluding single periods of cost increase to cover an acute episode, or for end-of-life care where the individual is in the terminal stage and hospital admission can be prevented, the care package will be reviewed and other options (for example, a placement in a care home) will be explored.

The ICB recognises that individuals who are eligible for NHS Continuing Healthcare may have highly complex health needs and that this can mean that commissioning the appropriate care and support can be a complex process. In general, the professionals involved in an individual’s care should be able to work with that individual to commission a package of care that meets their health, care and well-being needs. There may be some occasions where an independent expert may be required to support this process and the ICB may agree to fund an independent expert in exceptional circumstances. This will be on a case-by-case basis with agreement of the Executive Chief Nurse or those with delegated responsibility. The ICB is only required to provide services that meet reasonable requirements. Exceptionality is determined on a case-by-case basis and will require a clear clinical rationale and agreement by the Executive Chief Nurse or those with delegated responsibility.

11.6. Refusal of NHS Continuing Healthcare Funding

The ICB will consider that it is a refusal of NHS services where the ICB have offered the individual what they consider to be an appropriate care package to meet the individual’s assessed needs and this is not accepted by the individual (including where the individual has requested a particular package of care and the ICB have taken a decision that the package will not be commissioned, but offered an alternative package of care).

Where there appears to be a refusal, the ICB will write to the individual with a final offer setting out the care packages that the ICB is willing to consider, and the consequences of refusing a package of care or placement. In this letter the ICB will provide a period of no less than 14 days for confirmation of acceptance of a package.

If the individual does not respond within the stated time period, the ICB will provide a written notice confirming that NHS funding will cease on a specified date, which will be no earlier than 28 days from the date of the notice.

If the individual is considered to be vulnerable, appropriate Suffolk or Essex Safeguarding Adult policies will be applied.

11.7. People with existing care in place who become eligible for NHS Continuing Healthcare

As part of the NHS Continuing Healthcare process for any individual who is in a care home placement or has a home care package which does not meet the requirements of this policy, the individual needs to be informed about how this policy may affect decision making about the existing and future care commissioning. This will enable them to make an informed decision about whether they would like to accept a funded package of care or placement from the ICB should they be deemed eligible for NHS Continuing Healthcare.

It should be made clear that individuals cannot refuse to consent to an NHS Continuing Healthcare assessment, nor refuse NHS Continuing Healthcare eligibility if the ICB has decided they are eligible. Individuals in receipt of funding for care and support from their relevant Local Authority should be made aware that if they are eligible for NHS Continuing Healthcare, their relevant Local Authority will no longer contribute towards the cost of meeting their care and support needs.

If an individual who is currently in receipt of care at home or in a care home becomes eligible for NHS Continuing Healthcare, and the care home or care provider fee is in excess of what the ICB would expect to fund, the ICB would only continue to fund at the higher rate based on evidence of exceptional clinical reasons why the individual’s needs could only be met in that specific placement or by that specific care provider (for example, if there is potential for significant detriment to the individual’s health if moved.) If the individual is deemed to lack capacity to decide about provision of care, the principles of the Mental Capacity Act (2005) will be applied with regard to a best interest decision. If an individual is found eligible for NHS Continuing Healthcare and there is no evidence of exceptional clinical need the ICB will:

Renegotiate fees with the current provider, however, if this is unsuccessful;
- Consider an alternative placement or care provider which can meet the individual’s assessed needs.
- If alternative placements or care providers are offered and rejected, the ICB will consider that funding has been refused and the individual wishes to continue with his or her existing private arrangement with the care provider. From the date of rejection, the ICB will give the individual and the existing care provider 28 days’ notice that NHS funding will not be provided for the existing placement or care provider.

11.8. Funding arrangements for individuals receiving services outside of the ICB area

For individuals who are to receive services in a care home setting, the default position should be a home within the Suffolk and North East Essex ICB area and the rate should not exceed that agreed by the ICB.

Where an individual’s preference is to move outside of the ICB area or if an individual’s healthcare needs would be best met in a location outside of Suffolk and North East Essex and/or closer to family/friends the cost should be set at rate that is comparable to the rate the local ICB would pay for equivalent care.

Where there is no appropriate provision available within the ICB area, the provider will be chosen based on the best value care available (the provider who provides the best level of care at a price which is sustainable).

If an individual wishes to re-locate to an area outside of Suffolk and North East Essex ICB, and live in their own home, Suffolk and North East Essex ICB will cease to be the responsible commissioner for that individual, and any NHS Continuing Healthcare package of care would be the responsibility of the receiving ICB. The current and receiving ICB should work together to ensure a smooth handover of commissioning responsibility.

11.9. Personal Health Budgets (PHB)

A PHB is an amount of money to support the identified healthcare and wellbeing needs of an individual, which is planned and agreed between the individual, or their representative, and the responsible ICB. It is not new money, but a different way of spending health funding to meet the needs of an individual.

Any adult eligible for NHS Continuing Healthcare (except via the Fast Track route) has a right to have a Personal Health Budget (PHB.) The funds made available via the PHB are for use to meet the individual’s agreed health and well-being outcomes as identified in their support plan.

The ICB will consider whether an individual (whether the patient or nominee/representative) is able to manage a PHB/Direct Payments by:

Considering whether they would be able to make choices about, and manage the services they wish to purchase;
Whether they have been unable to manage either a heath care or social care direct payment in the past, and whether their circumstances have changed;
Whether they are able to take reasonable steps to prevent fraudulent use of the direct payment or identify a safeguarding risk and if they understand what to do and how to report it if necessary; and
Considering any other factor which the ICB may deem relevant.

The ICB must balance value for money and PHBs must be affordable within the ICB’s overall budgetary allocation for NHS Continuing Healthcare.

A PHB can be received in three ways or in a combination of these options:

Notional Budget (Contracted/Commissioned Services)

No money changes hands. The individual is advised of the amount of money the ICB would normally spend of a traditional model of care and talks to their health professional or care manager about the different ways to spend the money on meeting their needs. The ICB holds the money on the individual’s behalf and procures the services required to meet their health and care needs.

Where the ICB manages an individual’s personal budget on their behalf as a notional budget, there is no requirement for the individual to maintain financial records. This is the default model for delivery of care in the home for those who are eligible for NHS Continuing Healthcare (excluding via the Fast Track route.)

Third Party Budget

A third party is an organisation independent from the person and the NHS. They manage the budget and arrange support by purchasing services on the person’s behalf. The third party will manage all financial aspects of your PHB and will have responsibility for making sure invoices are paid on your behalf.

Direct Payments

A direct payment is money that is paid directly to the individual or their representative. A representative will buy and manage the care and services as agreed in the personal care and support plan. Financial records and receipts will need to be kept showing how the individual has spent the budget. There will be scheduled reviews and monitoring to ensure that the personal health budget is meeting the individual’s health and wellbeing needs and the money is being spent according to the plan.

Individuals accepting a direct payment will be required to enter into a formal agreement and set up a separate bank account. The individual can choose to have a support service provider hold the funds and make payments on their behalf; this is called a ‘Managed’ Direct Payments Account.

Budget holders are not allowed to contribute to or ‘top-up’ the cost of care as set out in the Care and Support plan from their own resources. If the budget holder considers that the payments are insufficient to meet his/her assessed needs, then he or she should request a review of the care package by the ICB. The budget holder can purchase additional services form their own funds which are not identified in the care and support plan, but this should take place separately with clear accountability.

The principles of this policy apply to the provision of Personal Health Budgets.

11.10. Health funding for care and support on hospital discharge.

The National Framework for NHS Continuing Healthcare sets out that assessment of longer term care needs should take place once someone has reached the point of recovery, where it is possible to make an accurate assessment of long term needs. This is set out within the Hospital Discharge guidance. This might include, where appropriate, an NHS Continuing Healthcare assessment. In the vast majority of cases, this will be following discharge from hospital and following a period of recovery at home. Where an individual is ready to be safely discharged from hospital it is very important that this should happen without delay, therefore, the assessment process for NHS Continuing Healthcare should not be allowed to delay hospital discharge.

It may be appropriate in some circumstances for the ICB to fund an interim package of care and support for an individual, as part of their hospital discharge arrangements, because the individual is highly likely to be eligible for NHS Continuing Healthcare. In these circumstances, the principles of this policy apply.

By the nature of home care packages, there will often be a delay to implementation. It is often not appropriate for an individual to remain in hospital during this time, as there is an increased risk of developing dependency, increased exposure to infection and reduced bed availability for individuals requiring hospital treatment and care. When an individual has been declared medically fit for discharge, they may be transferred to another appropriate facility while arrangements for the home care package are made.

The above applies for other in-patient settings, such as hospice in patient units, community hospitals and mental health units.

11.11. Mental Capacity

If an individual does not have the mental capacity to decide about the location of their commissioned care package and suitable placement, the ICB will comply with the requirements of the Mental Capacity Act, 2005. The ICB will commission the most cost effective and safe care available based on an assessment of the individual’s needs in conjunction with the best interest representation.

All decisions will be evidenced and carried out in consultation with any appointed advocate, Attorney under an Enduring Power of Attorney, Lasting Power of Attorney or a Court Appointed Deputy or the Court of Protection directly and family and/or friends will be consulted where appropriate under the terms of the Mental Capacity Act 2005. Where an individual does not have family or friends to support them, an Independent Mental Capacity Advocate may be consulted in line with the Mental Capacity Act, 2005.

11.12. Review

All individuals in receipt of NHS Continuing Healthcare should be reviewed within three months after commencement and no less than annually thereafter. The purpose of this review is to ensure the care and support arrangements continue to meet the needs of the individual.

Should, at any point, the health needs of the individual materially change, the ICB will consider re-assessing for both NHS Continuing Healthcare eligibility and the care provision in line with the National Framework. This review of care provision could result in an increase or decrease in the care package required to meet those needs. The provision of a package of care at home does not constitute a commitment by the ICB to fund the individual’s care for life, or that the individual will always be cared for at home.

For home care packages, if the individual requires an increase in care long term, then the ICB will reassess the individual against the criteria within this policy to determine whether a home care package remains the safest and most economic option and may offer other reasonable alternatives.

The individual and care providers should update the ICB if care needs reduce or increase so further assessment can be made to ensure the individual continues to receive the most clinically effective services and make effective use of NHS resources.

11.13. Human Rights

In drawing up this policy, the ICB has had regard to the Human Rights Act 1998 and, in particular, the implications of placement for individuals in relation to their Article 8 rights.

11.14. Appeal

Whereby an individual is not satisfied with the choices offered to them or the commissioning decision made by the ICB, they may lodge an appeal in writing to the ICB. The case will be reviewed the Head of Nursing for Clinical Services and at least one other senior clinician at Deputy Director level of above within the ICB. If the care package proposed by the NHS Continuing Healthcare team us upheld, the individual will be advised of their right to complain through the ICB complaints process in line with local and national policy. If the complaint cannot be resolved locally, the individual refer their complaint to the Parliamentary and Health Service Ombudsman.

Where the ICB, having applied the criteria set out in this policy, decides to place an individual in a care home as opposed to providing a home care package and the individual makes an appeal against this decision, the ICB will offer an appropriate interim placement taking account of the individual’s safety as the over-riding factor. For these purposes, ‘interim’ refers to the time between the appeal being lodged and then considered by the ICB. Depending on the outcome of the appeal, such ‘interim’ placement may become permanent.

The ICB decision will be effective until the outcome of the appeal. If the appeal is successful arrangements will then be made to revise the care package provided in consultation with the individual.

If, during the interim, the individual refuses the ICB offer of an interim placement pending the outcome of the appeal, they may arrange and fund their own package of care or placement within their chosen care home. If the ICB’s original decision is upheld, it will again offer the individual an appropriate care package in a care home that meets the criteria set out in his policy. If the care home placement is still not acceptable to the individual, they may continue to arrange and fund their own package of care or placement.

Appeals should be sent via email to: chc@snee.nhs.uk for the attention of the Head of Nursing for Clinical Services.

11.15. Application of the Policy

This policy will apply from 20 December 2016 for all individuals deemed eligible from this date.

For people in receipt of NHS Continuing Healthcare packages of care before this date, providing the risks to the individual, their carers, including NHS staff, of continuing to provide the existing package are manageable (where applicable) and the package of care does not need to be changed, the ICB will continue to provide and fund the existing care package until such time as:

In the case of a home care package, the risks cease to be manageable; or

In any case, a future review or re-assessment of needs indicates the need for a long term placement
Increase in the level of healthcare required to meet reasonable needs; Where upon this policy shall apply.

11.16. Policy monitoring and review

This policy will be reviewed every three years, or if there are changes in national guidance on individual choice or NHS Continuing Healthcare.

12. Appendix A: Abbreviations and Definitions

Abbreviation / Item	Definition
CE	Chief Executive
ICB	Integrated Care Board
ICP	Integrated Care Partnership
ICS	Integrated Care System
NHS	National Health Service
SC	Social Care
We	The ICB
NHS CHC	NHS Continuing Healthcare
PHB	Personal Health Budget