A Clinical Commissioning Group has been using a potentially unlawful tool to make savings on its budget for NHS Continuing Healthcare, the free care fund available to people at home or in care homes

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NHS West Norfolk Clinical Commissioning Group has been using a locally-designed screening tool in alternative to the NHS Continuing Healthcare Checklist. The Checklist is the only nationally approved tool that screens people for receiving a full assessment for care funding under the NHS Continuing Healthcare scheme, making the tool potentially unlawful.

Effectively, this means that a large proportion of people in West Norfolk have missed on the full assessment for NHS Continuing Healthcare funding that could pay for their care at home or in a care home.

I first learned about this new tool in an article recently appeared in the Health Service Journal. The article reports that the local screening tool, named Q5 Care Test, had been approved by NHS England. In addition, after seeing what savings from their NHS Continuing Healthcare budget NHS West Norfolk accomplished by using this screening tool, four further NHS Clinical Commissioning Groups in Greater Nottingham – Nottingham City, Nottingham North and East, Nottingham West and Rushcliffe – became interested in using the tool themselves. However, the NHS Improvement agency more recently advised them not to implement the tool. The 5Q Care Test even has his own webpage, which comes with a good dose of stock photos of happy white-haired people: https://www.5qcaretest.org/.

NHS West Norfolk has been using this tool since 1st January 2016. I would urge anyone who has been through the Q5 Care Test to start an appeal immediately and demand that a Checklist or a full assessment for NHS Continuing Healthcare is done for them. If you do not know if a Q5 Care Test was done on you, it is possible that you were simply not informed, and one was indeed done. If since 2016 you have been told by anyone from NHS West Norfolk or from Norfolk County Council that you needed care at home, or in a residential or nursing home, and have also been told you had to pay or partly pay for that care, and an NHS Continuing Healthcare Checklist or full assessment, through what is called Decision Support Tool, was not done for you, you should request one immediately.

I found the document detailing the evaluation of the Q5 Care Test, titled “The evaluation of an innovative Continuing Health Care [sic] pathway in West Norfolk – November 2016)“. The partnership organisations participating includes NHS West Norfolk Clinical Commissioning Group, The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust, Norfolk County Council, and Healthwatch Norfolk. The evaluation also appeared in an article of the journal Health and Social Care in the community.

The West Norfolk evaluation states that the Q5 Care Test comes “under the national ‘Integration Pioneer’ programme, established by NHS England to generate and test grass-roots innovative schemes that enhance integrated care. West Norfolk is one of the Integration Pioneer sites and the project has been actively supported by the national Integration Pioneer team”. That is, NHS England actively supported the implementation of the Q5 Care Test local screening tool.

According to NHS England, the aim of the integrated health and social care programme, a child of the Conservative and Liberal Democrat coalition government 2010-15, was to “make health and social care services work together to provide better support at home and earlier treatment in the community to prevent people needing emergency care in hospital or care homes”. It seems that West Norfolk aim was, instead, to cut people’s care funding outside of hospital and thereby reducing the costs of NHS Continuing Healthcare budget, which is itself aimed at keeping people in their own home or in care homes, and avoid being in hospital.

The 5Q Care Test is also praised by the organisation that helped evaluating it, the NHS Arden and Greater East Midlands Commissioning Support Unit. I found the 5Q Care Test also mentioned in an action plan for NHS Continuing Healthcare review jointly written by Herefordshire Clinical Commissioning Group and Herefordshire Social Services.

Even if it is beyond the scope of this article to present a thorough analysis of the 5Q Care Test, I think that at least I should draw your attention to the model of the test. The diagram below, taken from NHS West Norfolk evaluation report, shows the process of assessment under the national guidelines for NHS Continuing Healthcare, which NHS West Norfolk used before the implementation of the 5Q Care Test (red highlight is mine).


In the diagram I have highlighted in red the step at which the Checklist or the full assessment for NHS Continuing Healthcare funding are carried out. At this step there is potential for delayed discharge of patients from hospital, as they must wait for assessments that are time consuming. Here comes the 5Q Care Test to the rescue. The new process is shown in the diagram below, as reported in the evaluation (red highlight is mine).


See that now the Checklist appears in the process much later, and out of hospital. However, the crucial aspect is that the model uses vague terms in relation to the Checklist assessment, such as “if patient appears to have”, or “if indicated”. In the text of the evaluation report it is said that a Checklist should be done within 28 days of discharge, even for patients that did not pass the 5Q Care Test (that is, those that flow on the left of the diagram), but the diagram does not reflect this. Also, if someone does not pass the 5Q Care Test, they will be means tested, and they will have to pay, partly or fully, for the ongoing care. The report says that the NHS will make back payments if then the person is deemed eligible for funding. However, this can only happen if a Checklist or full assessment are done timely after discharge.

I doubt that most people who did not pass the 5Q Care Test got a follow up visit of an NHS Continuing Healthcare nurse assessor and a social worker to complete a Checklist. To clear this doubt, I have sent to NHS West Norfolk Clinical Commissioning Group a Freedom of Information request asking how many people received a checklist after having been through the 5Q Care Test. Also, I have asked them to tell me how many patients received NHS Continuing Healthcare Funding before 1st January 2016, date of incept of the 5Q Care Test, and how many patients did so after that date. I am expecting a major decline, that is, a major saving on the budget for a satisfied NHS England. Stay tuned.

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