NHS commissioners risk losing sight of human cost of their decisions

The revelation that thousands of people could be forced out of their homes into residential care raises serious questions about the judgment of clinical commissioning groups (CCGs).

According to the Health Service Journal story, based on information gathered by campaign group Disability United, at least 37 CCGs have imposed restrictions on access to NHS continuing healthcare funding, which provides ongoing care for adults with a “primary health need”.

Around £2.5bn a year is spent on NHS continuing healthcare, with about 60,000 people receiving support at any one time.

A total of 19 CCGs have said they will not fund care in the person’s own home if it is more than 10% above an alternative – normally going into a care home. The remainder are imposing other restrictions. Up to 13,000 people could be affected among these CCGs; since 87 CCGs did not reply, the national figure could be around 22,000.

Lawyers are wary of a legal challenge, such as under article 8 of the European convention on human rights, which protects the right to family life.

Many of the rationing decisions appear to conflict with the NHS England operating model for NHS continuing healthcare, which says “treating individuals and their families with empathy, respect and dignity is at the core of NHS continuing healthcare delivery”.

Commissioners need some latitude to contain these costs; medical care provided in the home cannot be limitless. But the Department of Health’s guidance stresses that comparative costs have to be balanced against a person’s desire to continue living in their own home.

Overall, Disability United identified 42 CCGs whose responses to Freedom of Information requests on this issue gave cause for concern. In the last performance assessments, NHS England said 20 of them required improvement while nine were rated inadequate – proportionately worse figures than the overall national scores.

That gives little confidence that commissioners pursuing this approach have exhausted all other reasonable options for meeting their budgets.

Of course, this is not straightforward. Many of the choices facing CCGs trying to hit their financial targets are unpalatable, as the growing argument over the threshold for hip and knee replacement surgery demonstrates, while the best solution for some continuing healthcare patients may well be residential care.

But to deprive people of the right to live at home on the basis of a 10% limit on additional cost seems arbitrary and callous. It leaves the uneasy feeling that a vulnerable group of patients – many of the recipients of continuing healthcare have brain injuries, significant disabilities or are dying – are being shunted into a care home because it is an easy saving. In their desperation to find cuts, commissioners are in danger of losing sight of the human cost of their decisions.

Continuing healthcare sits on the fault line between the NHS and social services, and access to it has long been a source of controversy, notably for patients who have had serious strokes. Many families are left baffled by the fine distinctions drawn between medical care on the one hand and social and personal care on the other, understanding only that it is a device for the NHS to shunt costs on to the care system by deciding that the patient’s needs are not primarily medical.

Now it appears that those who are fortunate enough to meet the stringent criteria for continuing healthcare risk being deprived of rights and choices. The underlying problem is that CCGs simply do not have the managerial, analytical or clinical firepower to make care systems lean, efficient and integrated, or to drag funds out of hospitals and into community services, so they are reduced to managing their finances by drawing entirely subjective lines on a spreadsheet that cut patients off from care.

CCG decisions about who can have services such as continuing healthcare, various types of surgery and IVF are dressed up in the language of local choices, but in reality it is largely a matter of luck which cuts commissioners happen to choose. Forcing people to leave their home looks a bad choice.

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NHS commissioners risk losing sight of human cost of their decisions