Hospital Based Complex Clinical Care - EQIA
Title of Policy
Hospital Based Complex Clinical Care - Director Letter (2015) 11
Summary of aims and desired outcomes of Policy
The purpose of the new guidance is to provide clarity to the decision making process introducing a transparent and fair eligibility criteria based on the simple question "can this individual's care needs be properly met in any setting other than a hospital?". This will also lead to consistency and equity around provision of this type of care.
The outcome for anyone that does need to be in hospital for a longer period of time is to get them well enough to return to whatever setting is most suitable for them in the community while ensuring that all health or social care needs are supported.
Directorate: Division: team
Directorate for Health and Social Care Integration
1. This Equality Impact Assessment has considered the potential impacts of Hospital Based Complex Clinical Care - Director Letter (2015) 11 guidance on each of the protected characteristics. There do not seem to be any detrimental or adverse effects on the basis of the protected characteristics. As a result it is not considered that any changes to the guidance should be made as a result of the assessment.
2. The purpose of the Hospital Based Complex Clinical Care guidance is to make the clinical decision more transparent with the primary eligibility question simply being "can this individual's care needs be properly met in any setting other than a hospital?". Hospital Based Complex Clinical Care can only be provided in a hospital setting or in an inpatient facility funded and managed by the NHS in Scotland.
3. The overall objectives of the new guidance are to:
- Promote a consistent basis for the provision of Hospital Based Complex Clinical Care
- Provide simplification and transparency to the current system
- Maintain clinical decision making as part of a multi-disciplinary process
- Ensure entitlement is based on the main eligibility question "can this individual's care needs be properly met in any setting other than a hospital?"
- Ensure a formal record is kept of each step of the decision process
- Ensure that patients, their families and their carers have access to relevant and understandable information (particularly if the individual does not need to be in hospital but rather an alternative setting in the community)
4. This new guidance contributes to the Healthier Outcome - We live longer, healthier lives.
5. Strategic Objective - Helping people to sustain and improve their health, especially in disadvantaged communities, ensuring better, local and faster access to health care.
6. The main change is that it makes very clear that accommodation costs outside hospital will no longer be paid for by the NHS (excepting short term limited interventions such as intermediate care or health related respite).
7. At the latest census (March 2014) there were 1,634 people in receipt of NHS Continuing Healthcare, 781 male and 853 female. 385 received NHS Continuing Healthcare in a care home, with the majority in hospital. The latter would remain unaffected by the proposed changes and we have made clear that those currently receiving it in a care home would not be disadvantaged by the revised policy (i.e. they will continue to be funded by the NHS as long as they remain eligible under the existing criteria). The percentage of people receiving NHS Continuing Healthcare in a care home has remained fairly constant at around 23% of the total.
8. The overall number of people receiving NHS Continuing Healthcare has steadily declined over the years (falling from 2,731 in 2009 to 1,634 in 2014). We consider this a good thing as more people have been cared for at home with intensive needs due to enhanced home care, intermediate care, rapid response services, hospital at home schemes and Technology Enable Care.
9. 1,268 of people eligible are over 65, and will mostly come under psychiatry of old age and geriatric medicine specialties. 366 are under 65, mostly in general psychiatry or learning disability.
10. In July 2013 the then Cabinet Secretary for Health and Wellbeing ordered an independent review of the application of NHS Continuing Healthcare guidance CEL 6 (2008) following media coverage regarding the reduction of, and variation in, the level of patients receiving NHS Continuing Healthcare.
11 The independent review was published on 2 May 2014 (http://www.gov.scot/Publications/2014/03/2480). The panel made nine major recommendations. The main finding of the panel was that the guidance and operation of NHS Continuing Healthcare is no longer fit for purpose and should be completely revised, and the current eligibility criteria be replaced by a simpler transparent single question - "can this individual's care needs be properly met in any setting other than a hospital?". The then Cabinet Secretary accepted all recommendations which were also discussed and accepted by the Cabinet on 18 March 2014. Alex Neil then announced his intentions on 8 May 2014 to Parliament.
12. The review highlighted the changes in the way care is provided with many advances since CEL 6 (2008). These changes include a move to a reablement approach, increased availability of Technology Enabled Care, the development of intermediate care, incorporating rapid response services and hospital at home, and more intensive home care being provided, including weekend and overnight services. Many such services have been developed over the last few years and already provide capacity for sustaining people with high level needs at home or in a homely setting.
13. A working group chaired by Dr Frances Elliot, then Deputy CMO and now Medical Director - NHS Fife, was established in August 2014 to take forward the recommendations and develop new guidance.
14. Two discussions events were held on 4 March 2015 (Glasgow - 30 attendees) and 11 March 2015 (Edinburgh - 50 attendees) with the support of the ALLIANCE. These were attended by NHS, Local Government and third and independent sectors. This was an opportunity for colleagues to have input into what the final guidance would look like. The stakeholders at these events made it clear that they are primarily concerned with the level, quality and safety of provision and less about who pays. On that basis, we should concentrate on the quality and the setting. In that way we can optimise the way we care for people, maximising the input from primary care and specialist NHS services in the community, emphasising that at all times NHS care is free of charge.
15. The guidance was produced and based on the recommendations from the independent review, in conjuction with the working group and input received from the two discussion events.
The Scope of the EQIA
16. The scope of this EQIA is the impact of the Hospital Based Complex Clinical guidance on individuals who may fall into the the various protected characteristics.
17. A variety of information sources were used in compiling this EQIA, which includes:
Scottish Health Survey 2012/13
Scotland's Census 2011
NHS Information Services Divison: Care Home Census 2012
NHS Information Servcies Divison Care Home Census 2013
Scottish Health and Care Experience Survey 2012/13
NHS Continuing Healthcare Census - 2008 - 2014
Transgender Experiences in Scotland Alliance Survey
Stonewall Lesbian, Gay and Bisexual People
Gypsies / Travellers in Scotland: The Twice Yearly Count - No 16: July 2009
Equality and Human Rights Commission Scotland: Gypsy Travellers in Scotland - A resource for media 2010
Hidden Carers Unheard Voices Report
18. A summary of the data collected to inform this EQIA is below:
The estimated population of Scotland on 30 June 2013 was 5,327,700 with 17% of people estimated to be aged under 16, 65% aged 16 to 64 and 18% aged 65 and over .
Current projections suggest that the population of Scotland will rise to 5.78 million by 2037, and that the population will age significantly, with the number of people aged 65 and over increasing by 59%, from 0.93 million to 1.47 million 2.
The older the adult the more likely they are to make an emergency admission to hospital, with the sharpest increases seen for age bands above 65. For example, for every 100,000 people aged 65 to 69 in 2013/14, there were 14,300 emergency admissions. This compares to 27,000 for those aged 75 to 79 and 51,200 for those aged 85 or older .
At 31 March 2014 there were 35,012 long stay adult care home residents in Scotland . The vast majority of these residents (90%) were at least 65 years old.
The largest proportion of care home residents were admitted to care homes from hospital (46%), accounting for 6,000 long stay resident admissions during the census period.
In 2011 1,040,000 people had a long-term activity-limiting health problem or disability .
The 2014 Care home Census from 31 March 2014 shows that there were 35,012 adults in care homes in Scotland, broken down by client group as follows:
- Older people - 31,943
- Adults with physical disabilities - 464
- Adults with Dementia - 19,579.
- Adults with mental health problems (excluding Dementia) - 893
- Adults with learning disabilities - 1,539
Continuing Care Survey 2014 reported that the gender split is 781 male, 853 female which reflects the respondents of the men and women who responded to the Scottish Health Surveys.
19. The Hospital Based Complex Clinical Care guidance advances equality of opportunity. It does this by providing a more equitable system of care for the whole population.
Recommendations and Conclusion
20. The Scottish Government has concluded that no changes to the Hospital Based Complex Clinical Care guidance are necessary as a result of the EQIA. This guidance provides simplified eligibility in Scotland and will provide clarity and transparency, equity and consitency. This guidance is applicable equally to individuals of all ages with any illness or disability.
21. ISD Scotland will undertake an annual census of people meeting criteria for Hospital Based Complex Clinical Care, with a breakdown by age, sex and ethnicity. The guidance itself will be reviewed in a year's time due to the changing environment of integration of health and social care as more specialist health and social are provided in the community. The guidance may need to be updated to take account of this.
22. The EQIA has confirmed that the guidance will not directly or indirectly discriminate on the basis of age, disability, gender, gender re-assignment, sexual orientation or race and belief.
Email: Kelly Martin