Darren Millar AM

Chair

Public Accounts Committee

National Assembly for Wales

Cardiff Bay

Cardiff.  CF99 1NA.

                                                                                                                               Our Ref: DS/AH/TLT

 27 September 2013

Dear Darren,

REVISED DRAFT REPORT ON THE IMPLEMENTATION OF THE NATIONAL FRAMEWORK FOR CONTINUING NHS HEALTHCARE

I am writing in response to your invitation to attend the Public Accounts Committee and provide evidence on the above matter.

We worked closely with the Wales Audit Office as they undertook their review. I attach a summary of relevant issues and our proposed actions in response to their various recommendations made in the report. I will, of course, provide further information or any necessary clarification in response to its various recommendations on 8 October.

Yours sincerely

David Sissling

Cc:      Albert Heaney, Welsh Government

            Alistair Davey, Welsh Government

Enc.    Annex 1 – Evidence Paper

Annex 2 – Synopsis of Wales Audit Office Report

Annex 3 – Table of Wales Audit Office Recommendations and the Welsh Government’s response.

Annex 1 - Evidence paper from the Director General, Health and Social Services to the Public Accounts Committee

Response to the Wales Audit Office Report on Implementation of the National Framework for Continuing NHS Healthcare

Introduction

1. The Welsh Government welcomed the Wales Audit Office (WAO) Report “Implementation of the National Framework for Continuing NHS Healthcare” when it was published in May. The Report recognised the actions that we are taking to place arrangements for Continuing NHS Healthcare (CHC) on a more sustainable basis. These include strengthening governance aspects and enabling consistent assessment of care needs. It also stated, however, that further work was needed to clarify aspects of the Framework and that stronger working arrangements must be introduced to ensure effective implementation.

2. This paper provides the Committee with information on the current and future challenges facing CHC as highlighted by the WAO Report. It sets out the Welsh Government’s response to the Report and the actions we are taking to address these challenges.

Overview

3. CHC is a package of care arranged and funded solely by the NHS where an individual is assessed as having a primary health-based need. As part of the guidance set out by Welsh Ministers, the 2010 National Framework (“the Framework”) establishes a process for the NHS, with Local Authority partners, to assess health needs, decide on eligibility for CHC and, if required, to provide the right care.

Wales Audit Office Review

4. The WAO’s Report into the implementation of the Framework and its effectiveness in ensuring individuals are dealt with fairly and consistently took place over eighteen months. The Report did not examine in any detail the delivery of CHC. The WAO’s initial findings are set out in their report and summarised in Annex 2, attached.

5. The Report recommends the Framework could be improved  in a number of areas to ensure a consistent approach. It also calls for more stringent monitoring of relevant arrangements.

Overall Comments

6. The WAO’s Report was both helpful and informative. I have accepted their recommendations, although my interpretation of the level of risk in relation to retrospective reviews from Powys differs from those of the WAO.

7. It is important to note, as the WAO did in their Report, that although the approach to CHC varies across the UK, there is little difference in approach between England and Wales, with the supporting Frameworks in each country being broadly similar. I was pleased to see the Report recognises that our Framework “…has delivered some improvements”. It is also pleasing that the Report, acknowledged that a full re-write of the Framework is not necessary. I recognise, however, more needs to be done to ensure consistency and fairness across Wales. I understand LHBs did not raise substantial objections with the WAO’s over its findings.  However, it should be noted that owing to the period of time (18 months) it took for the WAO to develop and publish the Report, updates on certain issues were needed to ensure its contents were up to date.

8. Many of the issues raised by the WAO are already being taken forward. Work to revise the Framework is already well advanced. We have, in this regard, worked with officials from the WAO and engaged with other stakeholders, including the Public Service Ombudsman. A revised draft Framework will be completed by the end of October and will be subject to a process of formal consultation. A final version of the revised Framework will be published next summer.

Funding

9. The funding of CHC is a significant pressure on NHS expenditure in Wales. According to the WAO’s Report, expenditure increased significantly from £66 million in 2004-05 to £298 million in 2010-11. This increase in CHC expenditure partly reflects a number of key court judgements which have led to changes in policy guidance and eligibility criteria. Although CHC reduced for the first time to £278 million in 2011-12, as shown in Figure 1 taken from the Report (below), CHC expenditure still roughly accounts for five per cent of LHBs net operating costs. Page 10 of the Report acknowledged the role of the Framework in reducing expenditure is unclear, though conceded “…at least part of the fall may be likely to reflect the £37.5 million [we] made available” in 2008-9 to modernise complex care services. It was also interesting to read the WAO’s conclusion, that no similar reduction in spending has been experienced in England.

10. It is important to note, however, the levelling off of expenditure is not symptomatic of a cost-cutting approach to CHC.   £37.5m was made available to Local Health Boards (LHBs), initially in 2009/10 on a non-recurring basis, to fund strategic CHC projects.  The additional £37.5m strategic funding made available was designed to ensure demand was addressed in a strategic manner, rather than the case by case commissioning  approach that had been in place previously. The schemes and services funded differed across Wales, and were developed to reflect local service patterns and local partnership arrangements. They included:

o more step down facilities to reduce the level of need, (e.g. intermediate care services provided in a care home);

o improved access to Physiotherapists and Occupational Therapists;

o increasing care home capacity for CHC;

o the provision of additional equipment;

o increased discharge liaison nurses;

o pump-priming community reablement teams;

o a more managed approach to the choice of a care home (using third sector as advisors);

o rapid response community teams (both health and social care); and,

o extending community nursing core hours.

11. The funding was distributed based upon the Older People’s Distribution Formula. LHBs and Local Authorities were expected to agree and jointly sign off their priority bids to utilise this money.  The resources were channelled through LHBs, who were responsible for monitoring and accounting for the expenditure.  No funding was provided directly to Local Authorities.  The decision to fund on a recurring, and initially a ring fenced basis, has helped to ensure the continued delivery of those services. Ring fencing has now been removed as spending on new schemes and control measures has become embedded within LHB plans. LHBs will be required to provide a final, brief, summary report on how the additional funding has been allocated.

12. CHC is part of the continuum of care provided to an individual. Innovative service delivery options developed by Health Boards, with partners, and designed to retain independence for as long as possible, should bring system-wide benefits in terms of quality and efficiency.

Issues raised by the WAO

The variation noted across Wales

13. The Report noted variation in procedures and systems across Wales, limiting the opportunity to undertake like for like comparisons across organisational and sectoral boundaries. Whilst LHBs are responsible for the implementation of the Framework, Welsh Government will take action to ensure they do so in a consistent manner. The review of the Framework provides the opportunity to provide clear expectations and greater accountability going forward. Improved consistency will be achieved through a combination of:

• a nationally agreed, streamlined process, with accompanying communication tools;
• the introduction, and facilitation, of an annual peer-review exercise.
• template documentation, policies and protocols in an online ‘CHC Toolkit’
• shared learning, through an annual conference, newsletters and an online staff forum for problem-solving; and,
• a national performance framework, to be implemented from the date of the launch of the updated Framework.

14. The draft update and proposals will be subject to formal consultation during November, December and January. Following amendment in response to the consultation exercise, and subject to formal Welsh Government approval procedures, the updated Framework, Toolkit, Contract documents, Implementation Plan and Performance Framework will be launched in early summer 2014.

Assessment/ Eligibility and the Decision Support Tool (DST)

15. Under the Framework, a person’s eligibility for CHC is comprehensively assessed through a Multi Disciplinary Team (MDT) of nurses and doctors. These take place alongside detailed discussions with the person and/or their family. The resultant information is captured in a Decision Support Tool (DST), to accurately reflect a person’s needs and inform the eventual outcome.  The complexities and unique circumstances surrounding each person’s claim for CHC mean that the entire process can take several days (or weeks) to proceed.

16. The Report raised concerns regarding the consistency with which LHBs have implemented arrangements for continuing eligibility assessment of care needs. Some of these cases have also been referred to the Public Service Ombudsman, who also proposed a number of improvements to the Framework. Many of those proposals will be taken forward as part of our work to review the Framework later this year. These include; looking at ways to speed up the assessment of cases, identifying instances where cases could  be “fast-tracked” to  completion, the issuing of refunds guidance, guidance to LHBs on where their financial liabilities start, and,  setting out expectations on LHBs where there has been inaction or delay in progressing a claim.

17. This summer, my officers worked with the Ombudsman to address the concerns he raised and issued interim guidance (MD/ML/0001/11) to LHBs on this matter, to be appended to the existing Framework. The interim guidance ensures a clear, consistent approach across all LHBs in Wales, advising them to actively consider the eligibility of retrospective CHC claims submitted on, or after, 16 August 2010. This is something the existing Framework currently lacks clarity on, though separate Welsh Government guidance (WGC 13/2011) does exist for retrospective reviews submitted prior to this date.  It also identifies situations and scenarios where a person has been financially disadvantaged and where the responsible LHB should consider compensating the individual.

I also note the report recommended further improvements to the DST. This tool is used to record information, under various domains (such as cognition/dementia, mental health etc), about a person’s health needs, drawing on professional assessments. The WAO Report recognised there was an anomaly between some of the domains used in England and Wales.

18. To address these concerns, the DST has subsequently been the subject of careful consideration across several Task & Finish groups. The current consensus amongst stakeholders is that, subject to formal consultation, NHS Wales should adopt the recently updated and user-friendly DST issued by the Department of Health. This would address the anomalies highlighted in the WAO Report and facilitate seamless cross-border delivery of CHC. The impact would be monitored via the Performance Framework.

Management of retrospective CHC claims.

19. Paragraph 3.12 of the Report raises concerns over the management of retrospective CHC claims, both those earlier claims undertaken through the National Project by Powys (teaching) Health Board (“Powys (t) LHB”) and latterly by individual LHBs. I believe, however, we have responded to escalations of risk as soon as they were identified to us by LHBs and acted accordingly.

20. Turning to those claims managed by the Powys Project team, I expect these to be completed by June 2014, in accordance with Ministers wishes. Although I note the WAO’s concerns, I have received explicit reassurances from the Chief Executive of Powys (t) LHB that the risks to the achievement of the June 2014 deadline are being appropriately managed. Last year, Powys implemented revised handling arrangements to manage claims effectively and to time. To assist Powys in those arrangements, we secured an additional £800,000, match funded by the LHBs. The revised arrangements will reduce the cumulative interest owed on payments to successful claimants by an estimated £1.6 million. I am confident their greatly strengthened plans (with some ‘headroom’) will result in delivery by that date. Of the initial 2,450 claims, at present 1,279 have been completed and closed.

21. Retrospective claims managed by individual LHBs currently have no deadline for completion. The Welsh Government was made aware of the backlog of work in autumn 2012. We immediately raised individual performance with the relevant LHBs and discussed this at both the National Monitoring Board, chaired by Powys (t) LHB and also the CHC Implementation Advisory Group.

22. We have since taken further action. In May we issued interim guidance within the Framework, relating to the post 2010 claims.. This set out Ministers expectations that all LHBs give active consideration to managing the claims they handle, through similar principles and the project based approach that has been employed by Powys.

23. Work is underway to scope the current backlog of claims being processed by LHBs and the length of time it will take to clear them. Directors of Primary, Community Care and Mental Health have been tasked with undertaking the action required to reduce that backlog. Some have already recruited teams to do this, and others are negotiating alternative proposals. We are monitoring LHBs performance on this on a regular basis, based on regular update reports are presented to the Directors and to Welsh Government.

24. To ensure effective arrangements are in place, we established a Task & Finish group to look at the retrospective claims process. That Group proposed a rolling cut-off date for those post 2010 retrospective claims managed by individual LHBs. These arrangements are currently under discussion with Welsh Government legal and finance officers to ensure it is practical, fair to potential claimants and complies with LHBs own financial governance arrangements. Under these proposals, claims relating to the period between1 April 2003 and 30 June 2013 will be submitted for consideration by 30 June 2014 and an annual rolling cut-off date will be implemented for claims received after that date, together with a requirement that they be completed within two years.

25. The proposals will be included in the draft Framework update, which will be subject to formal consultation as detailed previously. The combination of service improvement activity to ‘get it right first time’ plus the rolling cut-off date should control the number of retrospective claims going forward. 

26. The Report recommended an executive group be established, chaired by an LHB Chief Executive, to ensure such claims are being processed in an efficient, timely and consistent fashion. We are currently establishing an Executive Task and Finish group, to be chaired by the Chief Executive of Powys (t) LHB, to take this work forward.

Strategic Leadership

27.We note the Report comments regarding a lack of strategic leadership in respect of the Framework.

28. My officials have worked with the WAO to obtain their views on a sensible approach as part of the review of the Framework. A clear reporting structure has already been agreed, with Directors of Primary, Community Care and Mental Health holding executive responsibility for CHC in their LHBs. They receive monthly progress reports from the CHC Policy and Practice leads, and will be the owners of performance data.
29. We will be supporting this work with new arrangements to measure the performance of LHBs and allow them to demonstrate they apply the revised Framework consistently. A Task and Finish Group is developing a performance framework, which will identify and develop a set of dashboard indicators, as well as utilising the recently established national CHC database. The Performance Framework is currently under development as part of the national review of the Framework.

Transition from Children to Adult CHC

30. The Report considers the transition arrangements from children to adult services to be problematic. These findings are based, to a certain extent, on the visits made to three LHBs as part of the WAO study.  Concern appears to centre round cases where an individual has been in receipt of a CHC package in childhood but is assessed as no longer eligible in adulthood; 

31. The Welsh Government published guidance: Children and Young People’s Continuing Care Guidance in November 2012.  This Guidance includes comprehensive arrangements and action that must be undertaken in the lead up to, and throughout, the transition process. As part of the review process for our Framework, work has been undertaken to cross-reference and align the guidance on transition. Officials and practitioners are working together to address the practicalities associated with implementation.

Joint working between health and social services;

32. I recognise there are some individuals assessed who, although not entitled to CHC, have identified needs that cannot be solely met from a Local Authority. The Framework is clear that LHBs must work in partnership with the Local Authority to agree their respective responsibilities in joint care packages.

33. We have  maintained our commitment to protect social services funding for 2013-14. I have made it clear that health and social services must work together to drive our programme of change – to do things differently in order to achieve transformation.   

34. The perceived lack of strategic leadership for the CHC Framework is therefore disappointing. We will work to reinforce the requirement for NHS Directors of Primary, Community Care and Mental Health to provide the necessary ownership, as recommended in the WAO’s report. We will also monitor their performance and take any necessary responsive action.
35. I will ensure the Welsh Government, for its part, builds on the good practice and protocols developed between LHBs and Local Authorities.  We have started preliminary work on this, including the establishment of Task Groups to address joint packages of funding, national policies and protocols, outcomes-based contracting arrangements, and links to social care frameworks. We will be working with the WAO, the Public Service Ombudsman for Wales and other stakeholders to ensure that future guidance is inclusive, robust and fit for purpose. The revised guidance will be supported by a web-based resource of template documents, practical case studies and examples of good practice. It will be accompanied by a clear plan to support implementation through training, peer review and mechanisms to share learning.

Next Steps

36. Welsh Ministers are committed to reviewing the Framework, building on the issues raised by the WAO’s report. Following engagement with relevant WAG policy officials, and stakeholders,  work is now underway to draft revisions to the Framework by the end of October, followed by formal consultation with interested parties. A final version of the revised Framework is expected to be published next summer.

37. As part of this work we have been in discussions with the author of the WAO report, as well as the All Wales CHC Advisory Group, Directors of Primary, Community Care & Mental Health, the Older Peoples Commissioner, the Public Service Ombudsman, Care Forum Wales, third sector representatives, and frontline practitioners.  Engagement has also taken place with other officials across the Welsh Government, including policy leads for mental health, direct payments and learning disabilities, the Care and Social Services Inspectorate Wales and the Chief Nursing Officer. All have agreed a full re-write of the Framework is not necessary.

38. My officials have set out a plan of work to revise the existing Framework and address gaps in it so it establishes clear principles and practical guidance, in a user-friendly manner. Areas of work include:

· Application of the Framework for people with a learning disabilities, dementia and mental health problems;

· Joint funding arrangements and ways to address Direct Payments, Personal Health Budgets and top-up payments;

· Scrutiny Arrangements, Peer Review & Shared Learning;

· Performance Framework for LHBs;

· Streamlining the CHC process (including improved information sharing and communication);

· National Policies & Protocols;

· CHC National Contract Framework;

· Managing Retrospective Claims;

· Ways to improve the workings of CHC Panels (e.g. regional/national pooling); and,

· Interfacing with Children’s CHC framework & transition arrangements.

Conclusion

39. The Wales Audit Office Report sets out the challenges facing Continuing NHS Healthcare, but acknowledges the actions that the Welsh Government and the Welsh NHS are taking to respond to these challenges. Work is already in progress to address many of the recommendations. We will pursue this with appropriate pace, ensuring consistency across Wales. Of particular significance will be the publication of a revised Framework next summer.  

David Sissling

Director General, Health and Social Services

Chief Executive, NHS Wales

Annex 2                      Synopsis of WAO Review and recommendations

1. In June the WAO published its 18-month study into the implementation of the Welsh Government’s 2010 Framework for Continuing NHS Healthcare. Continuing NHS Healthcare (CHC) is implemented by Local Health Boards (LHBs) and local authorities but the Framework and other associated guidance is set by Welsh Ministers. The study assessed whether individuals were dealt with fairly and consistently under the Framework but did not examine the delivery of CHC in any detail, such as service redesign.

2. The Report recognised the Framework has delivered a number of benefits, including governance issues, arrangements for continuing eligibility and the basis for a consistent assessment of care needs. It did criticise, however, the effectiveness of the implementation of the Framework by LHBs. It also cited concerns over fairness and consistency in decision-making on CHC within and between LHBs. In summary the Report noted:

· CHC governance issues within LHBs had been strengthened, but provided limited assurance that people are being dealt with consistently and fairly;

· the effectiveness of joint working between health and social services was highly variable;

· there was fall in the number and expenditure of CHC cases, though the impact of the Framework in this was not clear. The report noted mixed evidence on the extent and consistency that individuals and their families were involved in the assessment process;

· despite additional funding provided to it, there was a significant risk that the national project to deal with retrospective claims for CHC will not process all cases by the agreed deadline of June 2014, and new backlogs of retrospective claims have developed in LHBs; and,

· many of the challenges to CHC eligibility decisions have not been dealt with promptly, and no deadline set for the cases that LHBs are dealing with.

3. The Report recommends the Framework could be improved and clarified in a number of areas to ensure a more consistent approach and for its impact to be monitored more closely:

It proposed the Welsh Government:

· strengthens guidance and strategic oversight given to LHBs by the Framework;

· introduce a screening tool to determine whether someone requires a CHC assessment;

· compares the Decision Support Tool domains which help determine CHC assessment, in Wales and England, to confirm that the Welsh domains are reasonable in areas such as cognition;

· requires that LHBs complete and action the self-assessment and improvement checklist developed by the Wales Audit Office in support of this report;

· sets and publishes a deadline for the completion of all retrospective claims that are being processed by LHBs; and,

· establishes a task and finish group with executive level representation from across all LHBs and chaired by an LHB Board Chief Executive. This will ensure that all retrospective cases, handled either by the Powys Project or individual LHBs, are processed efficiently and to the set deadlines.

It proposed LHBs:

· allocate overall responsibility for CHC at LHB director level, with specific responsibility for ensuring consistency in the Framework’s application across the LHB, the adequacy of staff resources allocated to CHC, and effective joint working with social services;

· establish arrangements for peer review of the processes for reaching CHC eligibility decisions, and of a sample of CHC decisions; and,

· promotes a means of sharing across Wales the learning from peer reviews.

that the Welsh Government and LHBs should work to develop

· national protocols and documentation, including  fast track arrangements, for obtaining consent, and sharing of local policies and documentation between LHBs; and a,

· common approach to dealing with the retrospective cases being processed by LHBs, and ensures the approach is broadly in line with the approach adopted by the Powys Project team.

4. A table illustrating those recommendations for the Welsh Government is at Doc 2. Officials engaged with the WAO in the development of this Report and to take forward next steps. WAO recognised that owing to the length of study, some of the issues raised have changed from their reported position. Officials felt, however, the Report was materially accurate and a fair representation of the information gathered. Officials did, however make clear their different judgement to that of the WAO on retrospective claims. They believed Minsters (and LHBs) additional investment to help Powys Project handling of claims reduced the risk to delivery of the June 2014 deadline. WAO assessed the risk as being “significant”, whereas officials, were reassured by Powys greatly strengthened plans (with some ‘headroom’) to meet this target and increasing confidence in their delivery.  The WAO Report also highlighted the backlog of post 2010 retrospective claims, that are the responsibility of individual LHBs, had accumulated.

Next Steps – Programme of Work

5. Since its publication, discussion has taken place with the author of the WAO Report, as well as the All-Wales CHC Advisory Group, Directors of Primary, Community Care & Mental Health, the Older Peoples Commissioner, the Public Service Ombudsman, Care Forum Wales.  Engagement has also taken place with other officials here, including policy leads for mental health, direct payments and learning disabilities, the Care and Social Services Inspectorate Wales and the Chief Nursing Officer. All have agreed a full re-write of the Framework is not necessary. In order to ensure the Framework provides clear, practical and user-friendly guidance, however, they identified the following areas of work to address gaps in the Framework and ensure it establishes clear principles and practical guidance, in a user-friendly manner:

· application of the Framework for people with  learning disabilities and mental health problems;

· joint funding arrangements and ways to address Direct Payments;

· personal health budgets and top-up payments;

· scrutiny arrangements, peer review & shared learning;

· performance measures for LHBs;

· improving CHC criteria, eligibility and assessment processes, including the MDT, DST and how they can address issues such as dementia;

· improving the tools used and people involved in reaching a decision, consent,  communication, timescales and reviews;

· national policies & protocols;

· CHC National Contract Framework;

· retrospective claims;

· ways to improve the workings of CHC Panels (e.g. through  regional/national pooling); and,

· linkages with the Children’s CHC framework to address issues such as arrangements for the transition between Children’s and Adult CHC.

6. Work is now underway to amend to the new draft of the Framework, together with practical case examples. This is being undertaken over the autumn by a number of themed task and finish groups with tight terms of reference, and membership drawn from various stakeholders, policy leads, acknowledged experts in the field, frontline staff and service user and carer representatives. Further meetings with specific interest groups will determine if additional working groups are needed. Their findings will feed into a draft consultation document, to be submitted for approval by the end of October. Formal consultation, together with a series of stakeholder roadshow events, will take place between November and January 2014.

7. Formal consultation, together with a series of stakeholder roadshow events, will take place between November and January 2014. The timeframe for publication will be between April and July 2014. Publication will be supported by an Implementation Plan, together with a mechanism to support learning and best practice, such as a national forum, as well as the development of a performance framework.

ANNEX 3

List of Wales Audit Office Recommendations and the Welsh Government’s Response

WAO Recommendation	Welsh Government Response	Progress to date
1. We recommend that the Welsh Government, as part of its forthcoming review of the Framework, uses the findings from this report, to improve the guidance to health boards provided by the Framework.	ACCEPT	We liaised with the Author of the Report throughout its development and the findings as the basis for our own review of the Framework.  We are examining: • how the Framework should be applied for people with a learning disability or a mental health problem; • joint funding arrangements; • the monitoring of care home contracts; • the local policies and protocols that need to be in place in health boards; and, • scrutiny arrangements in health boards, to encourage consistency between panels, local authority engagement and communication, and consistency of scrutiny regardless of the care costs involved. The Task and Finish groups addressing these themes are in the process of drafting the required updates to the Framework. The draft will be completed by the end of October 2013 and will be subject to formal consultation during November, December and January. In some cases, in response to stakeholder engagement, the Task and Finish groups have expanded on the recommendations in the Report. For example, in addition to monitoring care home contracts, it has been recognised that a more robust approach is required to the commissioning of CHC and Funded Nursing Care. By April 2014, Phase 1 of a project to develop a national contract will be delivered. Phase 1 will provide a standard, outcomes-focussed service specification, terms and conditions and review documentation for patients in receipt of FNC and CHC. This will be NHS specific, but Phase 2 of the project will use a partnership approach, aligning work being undertaken by the Social Services Improvement Agency. To support operationalisation, the current practice guidance will be also be updated and incorporated into the Framework. An Implementation Plan will be published at the same time as the updated Framework.
2. We recommend that the Welsh Government: a) strengthens its strategic oversight of the CHC Framework, with a focus on ensuring increased consistency in the application of the Framework and  implementation of the recommendations set out in this report; and b) requires health boards to allocate overall responsibility for CHC at board director level, with specific responsibility for ensuring consistency in the Framework’s application across the health board, the adequacy of staff resources allocated to CHC, and effective joint working with social services.	ACCEPT	A Task and Finish group is developing a performance framework, with a set of dashboard indicators, as well as utilising the recently established national CHC database. This will be ready for implementation from the date of launch of the updated Framework. A baseline evaluation will be undertaken and performance will be measured in order to take forward continuous service improvement. Following publication of the draft Report, an accountability and reporting structure was agreed with Directors of Primary, Community Care and Mental Health. This will be reviewed again as internal Health Board reconfigurations mean that accountability for CHC and Funded Nursing Care has moved, in some areas, to the portfolios of Chief Operating Officers and Directors of Nursing.
3. We recommend that the Welsh Government: a) reconsiders the benefits of introducing a screening tool to determine whether someone requires a CHC assessment; and b) reviews the differences between the DST domains in Wales and England, particularly for cognition, to confirm that the Welsh domains are reasonable	ACCEPT	The Task and  Finish groups have considered various screening tools and the current consensus is that Wales should adopt the English NHS Continuing Health Care Checklist. There is also consensus that the Department of Health’s recently updated Decision Support Tool is more user-friendly and should be adopted in Wales (subject to consultation). This would address the concerns regarding inequity e.g. in the assessment of people with a dementia and would alleviate cross-border issues.
4. We recommend that the Welsh Government: a) requires health boards to establish arrangements for peer review of the processes for reaching CHC eligibility decisions, and of a sample of CHC decisions; and b) promotes a means of sharing across Wales the learning from peer reviews.	ACCEPT	A Task & Finish Group is developing practical solutions for peer review. Its outputs will be delivered by November 2013. Mechanisms for shared learning, not only from peer review but also from reports made by the Public Service Ombudsman for Wales and from issues brought to our attention by members of the public are being explored with stakeholders. Proposals to date include an annual conference, newsletters and a ‘staff only’ online forum for problem-solving.
5. We recommend that the Welsh Government: a) requires health boards to complete and action the self-assessment and improvement checklist developed by the Wales Audit Office in support of this report; and b) works with health boards to develop national protocols and documentation, for example for fast-track arrangements and for obtaining consent, and encourages greater sharing of local policies and documentation between health boards	ACCEPT	It is proposed that the health boards undertake the self-assessment as part of the performance baseline evaluation (see section 2) and will be incorporated into an annual report to Welsh Government. The review has worked with stakeholders to streamline the CHC process as a whole and to develop template policies and protocols, which will be published alongside the updated Framework, as part of an online ‘CHC Toolkit’. The Task & Finish group identified four key communication points with users and carers which require follow up in writing as well as verbal conversation. Standard documents are in the process of being developed with the assistance of Age Cymru and officers from the Office of the Older Peoples Commissioner.
6. We recommend that the Welsh Government: a) sets a deadline for the completion of all retrospective claims that are being processed by health boards; b) works with health boards to agree a detailed and common approach to dealing with the retrospective cases being processed by health boards, and ensures the approach is broadly in line with the approach adopted by the Powys project team; and c) establishes a Task and Finish group with executive-level representation from across all health boards and chaired by a health board chief executive, to ensure that all retrospective cases, whether these are being handled by the Powys project or individual health boards, are processed efficiently.	ACCEPT	The Task & Finish group looking at the retrospective claims process has proposed a rolling cut-off date for future retrospective claims. The proposal is currently under discussion with Welsh Government legal and finance officers to ensure that it is practical.  The combination of service improvement to ‘get it right first time’, plus the rolling cut-off date, should control the number of retrospective claims going forward; this will be a performance indicator.  Work has been undertaken to scope the current backlog of post-2010 claims being processed for health boards and the length of time it will take to clear them. Directors of Primary, Community Care and Mental Health have been tasked with undertaking the action required to reduce that backlog. Some have already recruited teams, others are negotiating alternative proposals. Regular update reports are presented to the Directors and to Welsh Government. In May we issued Ministerial guidance (MD/ML/001/00), appended to the existing Framework. This advised Local Health Boards that they should undertake a consistent approach when undertaking retrospective reviews submitted from 16 August 2010 (and therefore managed by individual Local Health Boards). This was so eligibility of applicants are “…..actively considered by the relevant [Local] Health Board and handled in a similar manner to those prior to that date, on an all-Wales basis by Powys [Teaching] Health Board, under WGC13/2011]” As recommended in the Report, The Task and Finish group is being established and meetings are being arranged. It will be chaired by the Chief Executive of Powys (Teaching) Local Health Board.