Feature

posted 1 Mar 1997 in Volume 2 Issue 3

Long Term Care - Free at the Point of Delivery

Ingrid Eyers, a Registered General Nurse and Long Term Care specialist, provides three examples of how long term care can be funded, including how it can be free at the point of delivery.

Long term care can be free at the point of delivery from the NHS. In April 1996 as a development from the "National Health & Community Care Act 1990" local health authorities have produced a document to define their contribution towards the cost of long term care, generally know as "the eligibility criteria". If you meet the criteria determined by your Health Authority, your long term health care needs should be funded by the NHS, irrespective of your financial status.

The Department of Health has produced a document titled "NHS Responsibilities For Meeting Continuing Health Care Needs" as should each Health Authority and Fundholding GP. These policy documents should be available on request from each source. In some areas neighbouring Health Authorities have joined forces to produce the document. Eastern and Western Surrey Health Authority is one example.

Defining the NHS responsibility to provide continuing health care is the latest step to be taken under the "National Health & Community Care Act 1990". Since 1993 the support provided by the state has been Social Services led and therefore means tested. Now the NHS must take on the responsibility of providing needs tested health care which should be "free at the point of delivery". Social Services and the NHS must work together to provide a "Care Package" to meet the individual needs of someone requiring long term care.

The groups of people eligible for continuing care one of the consistent factors throughout a variety of eligibility criteria. The documents determine that care services would be provided to:

* Older People

* Elderly Mentally Infirm People

* People requiring Palliative Care

* People with Mental Health Problems

* People with Physical Disability

* People with a Learning Disability

* People with HIV/AIDS

* Children

Continuing NHS inpatient care would be provided when someone:

* has complex medical needs

* requires frequent and not easily predictable interventions to treat and/or maintain the condition

* needs routine use of specialist health care equipment or procedures requiring the supervision of specialist NHS staff

It is up to a "Consultant led multi-disciplinary assessment" to determine the assistance someone in need receives. Considering that both the NHS and Local Authorities funds are limited, only those who have been assessed and been deemed to be highly dependent or at high risk will receive funding. Not surprisingly each Health Commission includes very detailed appeal procedures in its policy document. The DoH `NHS Responsibilities for meeting continuing Health Care Needs' document states "a patient and his or her family and any carer have the right to ask the health authority, in which the patient is normally resident, to review the decision which has been made about eligibility for NHS continuing inpatient care".

Most people are under the impression that all long term care is associated with Social Service. As stated in the introduction of the DoH document "Both the NHS and local authorities have responsibilities for arranging and funding services to meet peoples needs for continuing care. Collaboration is crucial to ensure the effective and integrated delivery of care." Traditionally the NHS and Social Services do not work well hand in hand. Each identifies and evaluates "needs" from a different perspective. It is to be hoped that the multi-disciplinary approach will succeed in breaking down the professional barriers.

The concept of the NHS funding continuing care is relatively new, to the extent that it is not surprising to encounter professionals working at grass root level who do not fully understand "the eligibility criteria". The services provided by both the NHS and Social Services are resource led. Resources are limited and every professional has become budget conscious, invariably this results in stringent interpretation of the criteria. Financial consideration will also have been influential in establishing each authorities' policy. There is a considerable variation in the criteria between the health authorities. Anyone confronted with the problem of needing, providing or organising long term care needs to be aware of all changes in the system resulting from the "NHS & Community Care Act 1990". In many situations it may be up to the family solicitor to take the initiative to drive a situation forward to gain the best for their client.

How do you obtain funding for your highly dependent client? This is best described in the following three cases studies that will highlight a number of key aspects.

Case 1

Bill is 82, his wife Mary is 76. Bill is diagnosed to be suffering from Alzheimer's Disease. Mary at present has no major health problems. He is a retired Civil Servant. Throughout her marriage Mary's life has evolved around her family and household. The couple live in a bungalow they own. The value of their assets is over £32,000.

Mary is caring for Bill with a "mix and match" package. The Local Authority Social Services are providing support every morning to help Bill get up, washed and dressed and a "sleep in" for one night a week. Mary is billed by the Local Authority for this service. The amount is calculated in accordance with his financial status*. Mary is also purchasing extra Community Psychiatric Nurse visits regularly.

*Each Local Authority has developed its own method and system of charging for the services they provide. For the service described Mary was charge £32 per week.

Bill is becoming more and more difficult to manage at home. He does tend to be aggressive and restless. It is obvious that it will not be suitable to care for him at home for much longer. Mary and her daughter have the enduring power of attorney. What options are available?

a) Mary can independently decide to move her husband to a specialist Nursing Home for the Elderly Mentally Infirm. This would then be funded from their own resources and would cost on average £550 per week. The only financial support available from the state would be Attendance Allowance at the highest rate.

b) Mary could "go through the system" and try to obtain NHS continuing care for her husband. How can this be achieved? The first step is to contact the GP and request that Bill's continuing health care needs are assessed. "The assessment should also take into account the views and wishes of the patient, his or her family and any carer". This is taken from the DoH document.

The GP should initiate a "Consultant led multi-disciplinary assessment". The definition of multi-disciplinary assessment in this context is "involving more than one specialty, for example doctors, nurses, social workers and therapists". This is taken from North and Mid Hants document but is representative. The outcome could be that he meets the criteria for a NHS funded inpatient bed in a hospital or in a nursing home to receive a package of care at home of which the NHS will fund the health care element.

If he does not meet the criteria for NHS funded continuing care he will be referred to Social Services for assessment. This would take us back to the beginning and the care received would be determined by the amount of money the couple have available to pay for care his family would like him to have.

Mary could appeal and also request that her needs as a carer are taken into consideration bearing in mind the "Carers (Recognition and services) Act 1995" which came into force in April 1996.

Case 2

Pamela is an 83 year old widow. She lives alone in her bungalow in Hampshire. Her son and his family live in Berkshire. Whilst visiting her son Pamela suffered a stroke. She has been in hospital for 6 weeks. Her speech is severely impaired, she is not able to write, but is very much aware of what is happening. She is not able to independently turn in her bed nor is she able to transfer independently from the bed to a chair. Her discharge from hospital is imminent. Pamela and her son have agreed that she will move to a Care Home near him in Berkshire.

The son has been informed about the "eligibility criteria" and has ensured that he participates in the discharge planning. Because Pamela is normally resident in a different Area Health Authority the two Authorities liaise and discuss the case.

Pamela's continuing care is not funded by the NHS because "she does not require specialist treatment". Her house will have to be sold to fund her care in a private nursing home. Social Services are willing to place a charge on the property and fund the care. Whilst Social Services fund the care Pamela is not entitled to Attendance Allowance.

Case 3

Elsie is an 81 year old single lady. She live alone in a house that she owns. The house is her main asset.

Her only relative, a nephew lives 200 miles away. Elsie is in hospital, diagnosis: Cancer of the bladder. She has refused further treatment. Having always looked after her own affairs she has contacted her solicitor to put her house in order. Two good friends are given the enduring power of attorney. The friends have known her for many years, they are aware of all her wishes and are able to act as her "advocate" in dealing with the NHS and Social Services. Neither of the two ladies can take on the duties of a carer due to their own family and professional commitments. Elsie is to be discharged from hospital. A discharge care plan must be established.

The definition of discharge care plan in this context: Plans drawn up before a patient's discharge from hospital making appropriate arrangements for any necessary continuing treatment or social care. The plan should include a check list of action to be taken by all those concerned with the patient. This is taken from the document issued by Kingston and Richmond Health Authority.

The solicitor and Elsie's friends were aware of the "eligibility criteria" and were instrumental in ensuring a multi-disciplinary assessment. Elsie was discharged to a private Nursing Home and the NHS covered the cost of her terminal care.

All three case studies are based on a mixture of experiences and observations over the last year. It is noticeable that to receive the best possible service you need to ask the right person the right questions. The family of a highly dependent patient seldom has the energy to struggle through the system and persistently ask questions. In the case where NHS funding was obtained it was due to the solicitor with her knowledge of the "National Health & Community Care Act 1990", the Department of Health document "NHS, Responsibilities For Meeting Continuing Health Care Needs" along with the criteria of the local Health Authority and the "Carers (Recognition and Services) Act 1995" that enabled her to take the appropriate steps and knowledgeably argue the case for her client. For her client long term care was free at the point of delivery.

Ingrid Eyers RGN, Long Term Care Specialist, Faldonside, Kingsley, Bordon, Hants, GU35 9ND, Tel: 01420 472273