Herefordshire and Worcestershire Integrated Care Board

3. Mr F complains Herefordshire and Worcestershire Integrated Care Board (the ICB) wrongly removed his father-in law, Mr H’s fast track funding on 13 June 2023 before he died in August. Mr F says the ICB did not follow the correct process when carrying out this review.

4. Mr F says this impacted Mr H financially as he had to pay towards his care. And because fast track funding was withdrawn, the family had to insist he remained in the care home he was in as there was pressure to move him into a cheaper home. They say the situation was very stressful and upsetting for them, particularly at a difficult time as Mr H was reaching end of life.

5. Mr F says he and the family would like the ICB to apologise for the distress caused to them by its wrongful decision to remove fast track funding. He would also like the ICB to reimburse the money to the estate that Mr H paid towards his care when the funding stopped.

6. Continuing healthcare (CHC) is a package of care for people who are assessed as having a ‘primary health need’. It is arranged and funded by the NHS. The fast track pathway is intended to identify individuals who need to access CHC quickly, with minimum delay, where an individual has a rapidly deteriorating condition and may be entering a terminal phase. It avoids the standard assessment process, which involves completing a checklist (a screening tool) and then a full assessment using the decision support tool (DST), which can take several weeks. If a person has a CHC funded package of care, either fast track or standard, the local ICB should review them regularly.

7. The ICB granted fast track funding for Mr H from 2 February 2023 and he moved into a nursing home. The ICB’s nurse assessor did a review on 6 March. They felt he no longer met the fast track criteria.

8. In March and April, the ICB did a standard CHC assessment. It decided Mr H did not have a primary health need and it confirmed it would not meet his healthcare costs after 14 June 2023. The ICB found Mr H met the criteria for NHS funded nursing care (FNC). This is a flat rate weekly payment to the care home to cover the aspects of his care that needed to be provided by a registered nurse.

9. Mr H’s fast track funding stopped on 13 June. The local authority (LA) took over responsibility for his care. LA care is means tested and Mr H then contributed towards his care. He sadly died on 18 August.

13. Before we decide if we should do a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indication that something has gone wrong.

14. The National Framework says this about the fast track funding pathway:

‘Individuals with a rapidly deteriorating condition and the condition may be entering a terminal phase, may require ‘fast tracking’ for immediate provision of NHS Continuing Healthcare.’

15. So for a person to meet the fast track criteria, they must be deteriorating rapidly. The person doing the assessment must also believe they are likely to be coming to the end of their life.

16. The National Framework says once fast track funding is in place, it is important to review an individual’s care needs and the effectiveness of the care arrangements. It says there may be situations where their needs indicate it is appropriate to review eligibility for CHC, and that ICBs should monitor care packages to consider when and whether reassessment of eligibility is appropriate.

17. Mr F feels the ICB carried out the review too soon after putting Mr H’s fast track funding in place. There is no specific timescale for when ICBs should review fast track. The ICB says the reason for reviewing Mr H after a month is because the only available nursing home said he would have 1:1 funding over a 24 hour period. It says this level of care is considered highly restrictive in terms of safeguarding. Its internal process is therefore to ensure this type of care is reviewed on a frequent basis, every 48 hours to every two weeks. This is to ensure that the restriction remains appropriate and is the least restrictive care.

18. The National Framework says where it is apparent that the individual is rapidly deteriorating and may be entering a terminal phase, and the original eligibility decision was appropriate, it is unlikely that a review of eligibility will be necessary.

19. We asked our CHC nurse adviser to consider Mr H’s records to help us understand whether the ICB was right to conclude Mr H no longer met the criteria for fast track funding at the point of the 6 March review.

20. We understand that when the fast track pathway tool was initially completed, Mr H had multiple falls, severe frailty, vascular dementia, stage three chronic kidney disease, hypertension (high blood pressure) and atrial fibrillation (irregular heart rhythm). During his hospital admission Mr H was treated for pneumonia and was Covid-19 positive, requiring oxygen and steroid treatment. The ICB says this exacerbated his existing conditions which is why it put fast track funding in place.

21. At this time the fast track pathway tool stated Mr H had entered the ‘last months of his life’ and his condition ‘could rapidly deteriorate very quickly’. It said anticipatory medications (medicines for symptoms likely to occur in the last days of life such as pain, breathlessness and agitation) had been prescribed, but had not yet been needed. We are not giving a view on the decision the ICB made at the time fast track funding was put in place, but this is evidence we need to consider as part of whether Mr H met the criteria. Our adviser says this suggested he could deteriorate, not that he was rapidly deteriorating at that time. However, we know the ICB put fast track funding in place at that time.

22. At the time of the review on 6 March, the records do not indicate Mr H had yet required anticipatory medicines and our adviser says they do not indicate he had a rapidly deteriorating condition or was in a terminal phase. The ICB says he was not sleeping, appeared agitated and unsettled, particularly at night, and was restless and not safe to mobilise independently. It says these needs are not typical of someone with a rapidly deteriorating condition entering a terminal phase. The ICB also says Mr H’s breathing needs had reduced as he had not experienced any further acute breathing episodes when he recovered from pneumonia. The records do not indicate any breathing difficulties.

23. Records from around the time of this review show Mr H had still experienced falls, but that he was eating and drinking well, not losing weight, mobile with a frame and his carers and he had settled in well at the home. The records show Mr H would frequently sit in his armchair or in the lounge area, awake and watching TV. He would go in the lounge for activities and the dining room for lunch. He was able to engage with others. The records show he could become agitated at times and shout.

24. The records do not indicate Mr H was rapidly deteriorating or entering a terminal phase on 6 March and he was stable. It was important for the ICB to consider his needs in full, as his condition had changed and he had recovered from pneumonia.

25. The National Framework says:

‘No individual identified through the Fast Track Pathway Tool who is eligible for NHS Continuing Healthcare should have this funding removed without their eligibility being re-considered through the completion of a DST by a multidisciplinary team (MDT), including this MDT making a recommendation on eligibility for NHS Continuing Healthcare’

26. The ICB completed a DST and did a full standard CHC assessment, before removing Mr H’s fast track funding. This was the right thing to do in line with the National Framework. This made sure the right organisation took responsibility for his care going forward.

27. We understand the family were unhappy the ICB did not offer them to give any input on Mr H’s fast track review. There is no requirement for family members to give input for fast track consideration. The National Framework makes it clear, this is a clinical decision and can only be made by a doctor or a nurse.

28. We are sorry this is not the outcome Mr F was hoping for. We hope Mr F and his family do not feel in any way our decision diminishes the impact of the worry, upset and distress this caused them at a difficult time. We are sorry to hear it was stressful for them when they had to insist on Mr F staying in the care home he was settled in.

1. We have carefully considered Mr F’s complaint about Herefordshire and Worcestershire Integrated Care Board. We can only imagine how stressful it was for Mr F and the family to hear the ICB was removing Mr H’s fast track funding, and that as a result he may have had to move care homes. We have considered the evidence and got clinical advice, and we have seen no indication that anything went wrong.

2. We have not seen any indication the ICB reached the wrong decision when removing Mr H’s fast track funding. It followed the correct process by appropriately assessing him for other NHS funding before removing this, in line with the National Framework.