Joint Packages of Health and Social Care

The National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care recommends that the ICB should consider joint package of care arrangements whenever:

1. A person is not eligible for NHS Continuing Healthcare; but
2. They have health needs that would benefit from a joint approach to service delivery that cannot be met through NHS-funded Nursing Care (either because the person is not eligible or because the cost of the support they require to meet health needs exceeds the level of NHS-funded Nursing Care funding).

A person is eligible for a joint package of care when:

1. They are over 18; and
2. Their eligibility for NHS Continuing Healthcare has been considered; and
3. They are not eligible for NHS Continuing Healthcare; and
4. They are not eligible for NHS-funded Nursing Care (or the cost of the support they require to meet health needs exceeds the level of NHS-funded Nursing Care); and
5. The local ICB has recommended a joint package of care; and
6. The Local Authority agrees to the joint package of care proposed; and
7. There are local joint package of care arrangements in place (see below).

Where the person is a patient in an acute hospital the Framework expects the ICB to determine eligibility for NHS Continuing Healthcare post discharge in most cases. In this situation the ICB remains legally responsible for providing all care and treatment to the person in the interim period. Examples of how this could be arranged include intermediate care, the provision of domiciliary care or a short term placement.

One exception

If the person was in receipt of a solely Local Authority funded service prior to admission the Framework allows for the ICB to request the Local Authority reinstate and continue funding that service whilst the eligibility assessment takes place.

The Local Authority does not have a duty to do this and before responding to such a request you must be clear about local arrangements that have been agreed between the Local Authority and the ICB. Where applicable, this should also include reimbursement of any financial contributions made by the person.

Furthermore the ICB can only make such a request if;

1. The same service is still open and available;
2. The service does not need to be altered to meet the person's post-discharge needs.

Where the Local Authority agrees to reinstate services and the ICB subsequently decides that the person is eligible for NHS Continuing Healthcare or any other health funding provision (NHS-funded Nursing Care or a joint package of health and social care) the Local Authority must be reimbursed for relevant costs from the date of discharge. Where applicable, any financial contribution made by the person should also be reimbursed.

If the Local Authority is already providing services to the person,  it remains the legal responsibility of the Local Authority to meet the person's eligible needs until;

1. A decision about eligibility for NHS Continuing Healthcare is made; and
2. Where not eligible, a decision is made about eligibility for other health funding provision.

With the exception of referrals made in acute hospital settings, the arrangements in place at the point of referral to the ICB should remain in place until a determination is made.

In most cases, the ICB is expected to make a final decision about eligibility for NHS Continuing Healthcare within 28 days of receiving the referral (or sooner if it is more urgent). In situations where there are valid and unavoidable reasons for doing so, decisions can take longer.

The Local Authority and the ICB should agree arrangements for appropriate reimbursement if a decision is subsequently made that the person is eligible/ineligible for NHS Continuing Healthcare or any other health funding provision. Where applicable, this should also include reimbursement of any financial contributions made by the person to the Local Authority.

If a person is already receiving a joint package of health and social care no changes should be made to services or funding arrangements until the reassessment process is complete and a decision made.

The practitioner that coordinated the NHS Continuing Healthcare process should notify you of the decision made by the ICB as soon as possible after it has been made. You should:

1. Record the decision on the person's electronic file; and
2. Answer any questions that the person may ask of you regarding the outcome or implications.

If the decision is to arrange a joint package of care they should also inform you of the health practitioner who will be involved in agreeing and arranging the joint services.

The practitioner that coordinated the NHS Continuing Healthcare process is responsible for formally notifying the person of the outcome of the process (including any determination about eligibility for a joint package of care or NHS-funded Nursing Care). When notifying in person they should also follow up in writing, confirming;

1. The implications of the outcome; and
2. If a joint package of care is to be arranged, the next steps; and
3. If a joint package of care has not been agreed, how they can make a complaint about the decision.

Joint package of care funding levels should be set as per the local arrangements agreed between the Local Authority and the ICB.

If a joint package of care is not agreed the Local Authority remains legally responsible for meeting eligible needs under the Care Act, which can include support provided by a health professional when:

1. It is merely incidental or ancillary (secondary) to doing something else to meet Care and Support needs; or
2. It is of a nature that the Local Authority could be expected to provide.

Challenges to the decision

If you disagree with any outcome that refuses a joint package of care you should discuss any action that may (or may not) be needed to challenge the decision with your line manager. Challenges should be made in line with the local dispute resolution process.

Complaints about the decision

If the person (or their representative) is unhappy with the decision of the ICB they should complain about it directly to the ICB.

In all cases, if the ICB subsequently reverses its decision, it should make arrangements to reimburse the Local Authority for the cost of services that it has provided during that time. Where applicable, any financial contribution made by the person for those services should also be reimbursed.

In the absence of any confirmed funding level agreement the indicative Personal Budget of the Local Authority should be used to support initial planning of joint services, so long as it has been determined based on the person's current needs.

You should work with the lead health professional to apply the principles of effective Care and Support planning when deciding the best way to meet the person's eligible needs. These include, but are not limited to:

1. Involving the person and any carer;
2. Having an outcomes focused approach;
3. Having a strengths-based approach; and
4. Having a positive approach to risk.

If the person is self-funding

The concept of self-funding does not exist when a person is receiving a joint package of care. This is because even if the person is likely to contribute the full amount of the Local Authority funded elements of their services, they cannot be classified as 'self-funding', because the NHS is meeting the cost of their remaining services

If the person lacks capacity

If there are concerns that a person may lack capacity to make decisions about, or consent to care and treatment, a proportionate mental capacity assessment needs to be carried out.

You can carry this out, or it can be carried out by the lead health professional. However, it is important that you both agree the outcome of the assessment before proceeding to consider the need for any decisions to be made in the person's Best Interests.

If a Best Interests decision is required, you will need to agree with the lead health professional who will act as the Decision Maker. Depending on the circumstances this could be you, the health professional or a shared role can be assumed.

Note: Remember, before assuming the role of Decision Maker you must establish whether:

1. There is a Deputy with the power to make the decision; or
2. There is a Lasting Power of Attorney able to do so; and
3. If so, they must act as Decision Maker.

If a Best Interests decision is to be made regarding residency you must specifically consider whether an IMCA (Independent Mental Capacity Advocate) needs to be appointed.

If there is disagreement about what care arrangements are in the person's Best Interests an application to the Court of Protection should be considered.

If proposed care arrangements will deprive a person of their liberty you (or the lead health professional) must take the necessary steps to seek authorisation, either;

1. Applying to the Court of Protection; or
2. Asking the care home manager to request a standard authorisation under the Deprivation of Liberty Safeguards (DoLS).

Further information about assessing mental capacity, Best Interests decision making and applying to Court should be accessed as required. It is available in the Mental Capacity Act 2005 Resource and Practice Toolkit.

Services out of the area

Out of area services can be arranged when:

1. There are no appropriate services locally; or
2. The person has made a request that has been agreed under the Wellbeing principle; or
3. The person lacks capacity and an out of area placement has been agreed as in their best interests.

If the above circumstances apply and the person is placed into regulated provision as defined in the Care Act there is:

1. No impact on their ordinary residence status; and
2. No impact on their eligibility for health funding with the placing ICB.

Regulated provision in the Care Act is:

1. Permanent residential or nursing care;
2. A supported living scheme; or
3. A shared lives placement.

The Local Authority has a statutory duty to complete a Care and Support Plan whenever it provides any services under the Care Act, even if:

1. The plan also includes services being met by others, such as the ICB; and
2. Another organisation is also completing a similar plan (for example a health plan).

The Care and Support Plan should record all of the services proposed, for example;

1. Adult care and support services; and
2. Any dedicated health services; and
3. Informal support and services (for example carers and community support).

The total cost of the plan should be recorded, with a clear breakdown of the following:

1. How much of the cost is payable by the Local Authority; and
2. How much of the cost is payable by the ICB; and
3. Any financial contribution the person will be making towards the Local Authority costs.

The Care and Support Plan should be submitted for sign-off as per local processes and arrangements.

When agreeing a jointly funded Care and Support Plan authorisers must have regard for:

1. The local joint package of care arrangements;
2. The professional views of both lead professionals;
3. How the reasonable preferences of the person have been considered;
4. The plan's appropriateness and proportionality; and
5. The plan's use of available resources (health and social care).

Both lead professionals should be notified of the outcome as soon as possible after a decision has been made.

If the plan is agreed you should:

1. Liaise with the lead health professional about who is best placed to notify the person (and then notify the person);
2. Finalise the plan;
3. Provide a copy of the plan to the person;
4. Provide a copy of the plan to the lead health professional (unless recording systems are shared); and
5. Proceed to arrange the services in the plan.

If the plan is not agreed you should:

1. Understand the reasons why the plan has not been agreed;
2. Agree with the lead health professional next steps required;
3. Liaise with the lead health professional about who is best placed to notify the person (and then notify the person, explaining next steps and revised timeframes);
4. Carry out any further steps required; and
5. Resubmit the plan.

Dedicated health services

The lead health professional is responsible for arranging any dedicated health services in the plan (for example Psychology services, District nursing or Speech and Language Therapy services).

All other services

All other services should be arranged as set out in the local joint package of care arrangements. Rather than there being two contracts with a service provider, the Framework permits the Local Authority to commission all chargeable services and agree reimbursement processes with the ICB for their agreed contribution to the cost.

As long as the person meets the normal criteria for a Direct Payment under the Care Act 2014 the Local Authority can provide their element of funding as a Direct Payment.

See: Direct Payments, part of The Care Act 2014 for more information about eligibility for a Direct Payment.

As long as the person is eligible for a Direct Payment under the National Health Service Act 2006 the ICB can provide their element of funding as a Direct Payment.

If a person is eligible for both a Direct Payment under the Care Act and a Direct Payment under the National Health Service Act 2006 it is lawful for payments to be combined into a single payment, so long as there are appropriate arrangements in place locally to manage this.

Appropriate and proportionate monitoring arrangements should be agreed with the person, any carer and the lead health professional whenever:

1. The person's needs are likely to change;
2. The person's situation is likely to become unstable;
3. The person's circumstances are anticipated to change;
4. The level of risk to the person is not well managed.

Arrangements should include:

1. Who will monitor what;
2. How information will be recorded and shared; and
3. How monitoring arrangements will be reviewed.

The timing of a review

The Local Authority is required to review the person's Care and Support Plan in line with the Care Act 2014 (6-8 weeks after the plan begins then no less than annually after this).

The ICB normally hold an initial review of the plan within 3 months and then every 12 months after that.

Wherever possible a health plan review and a Care and Support Plan review should be scheduled for the same time to avoid duplication for the person, and make the most effective use of available organisational resources in the ICB and the Local Authority.

The process of review

Regardless of whether review dates correspond, the process of reviewing a joint package of health and social care should, wherever possible be a joint one.

This means that if a Care and Support Plan review is to be arranged you should contact the lead health professional to advise them of this, and to seek their co-operation and involvement in the review.

The nature of their involvement should reflect:

1. The current needs and circumstances of the person; and
2. The likely outcome of the review.

The lead health professional is required to co-operate with any request to be involved in a review, unless doing so would prevent them from carrying out their own duties under the Care Act or any other legislation.

If you are contacted by the lead health professional regarding any health plan review they are carrying out, you are required to co-operate with this request in the same way.

During any review it is your responsibility to ensure that the process meets all of the statutory requirements of a Care and Support Plan review, even if the review is being led by the lead health professional.

See the Legal Requirements of a Care and Support Plan Review Procedure.

If any review indicates a need for a reassessment of need this should be carried out as a joint process, with as little duplication as possible for the person.

If the reassessment process indicates that the person's health needs have changed the lead health professional should notify the ICB and the level of health funding should also be reviewed.

The level of joint funding should be reviewed if a review or reassessment provides evidence that:

1. The person's health needs have decreased; or
2. The person's health needs have increased; or
3. The person may be eligible for NHS Continuing Healthcare.

During this time the ICB must continue to provide joint funding at its current level until a decision is made.