Can The NHS's Trusted Assessor Model Be Trusted?
As the health and social care system buckles under the strain, many NHS Integrated Care Boards (ICBs) are now using the “Trusted Assessor” model to facilitate CHC assessments without the presence of a multi-disciplinary team.
The NHS Continuing Healthcare (CHC) assessment process comprises two stages – the screening Checklist and Decision Support Tool. While the Checklist can be completed by a variety of health and social care professionals – GPs, District Nurses, Nursing Home staff, Social Workers – the Decision Support Tool (DST) must be undertaken by a multi-disciplinary team (MDT).
The National Framework (government guidance for Continuing Healthcare assessments) explains:
“In accordance with regulations an MDT in this context means a team consisting of at least:
- two professionals who are from different healthcare professions, or
- one professional who is from a healthcare profession and one person who is responsible for assessing persons who may have needs for care and support under part 1 of the Care Act 2014”.
Once a positive Checklist is submitted to the ICB, it has 28-days within which to complete the DST. This seems to be the only deadline the NHS manages to meet with any reliability, so we can safely assume strict penalties apply for failure!
A major reason for CHC assessments being delayed, is the lack of Social Workers to make up the MDT. To combat this, the NHS has introduced what it calls the “Trusted Assessor” model, or “TAM”, which effectively means the DST being completed by a sole Nurse Assessor, then signed off by a Social Worker after the fact.
We were recently contacted by a member of the public, whose relative had been assessed using this new approach. They very helpfully shared the ICB’s policy with us, to enable us to raise awareness about the issue. The policy provided by the ICB explains:
This process is where the CHC assessor populates the DST template with information that is shared with her regarding the current health needs of the individual that requires the assessment. Information includes written evidence from health and social care professionals that are currently supporting the individual. It also includes the verbal information usually provided by family members and the current care provider. During the process, there is also an opportunity for all parties present to offer views in relation to the level of need within each of the 12 care domains.
When using the TAM process, there is the requirement to have input from an appointed social work representative to ensure that the assessment is compliant with National Framework guidance. The case is then presented to a TAM panel which consists of a full multidisciplinary team made up of a lead nurse from CHC, and a senior practitioner from the county council. They review the DST documents and the supporting evidence that was gathered. Once a recommendation is made then this is sent to the IBC for verification, as they hold the statutory responsibility for the decision making-process.
Quite what the above means, in practice, is unclear and will undoubtedly cause yet more confusion for families trying to navigate the already complex and confusing world of CHC.
Our thoughts…
- Certainly, it would appear to suggest that no Social Worker will attend the completion of the DST, meaning they are unable to question the views of the Nurse Assessor as to the correct levels of need in the family’s presence.
- There appears to be no requirement for the Social Worker to have assessed the patient themselves, in which case, they are reliant on the evidence gathering undertaken by the Nurse Assessor, which we know is often lacking!
- The family will not have the benefit of describing their relative’s needs with the Social Worker present and must rely on the Nurse Assessor accurately documenting their verbal testimony, and that of the care staff. How the Social Worker can properly ensure the assessment is compliant with the National Framework in these circumstances is, again, unclear.
- That a “senior social work practitioner” is included on the Panel does not resolve the potential issue of incorrect or inadequate information being documented on the DST at the evidence gathering stage, skewing the outcome of the assessment.
The Trusted Assessor approach is used by the NHS in a variety of different scenarios, from triage to hospital discharge. When applied correctly, it can be an effective way of reducing waiting times and ensuring patient safety. However, the foundation of the CHC assessment process is the lawful division between health and social care. The DST is designed to help health and social care professionals decide which side of this very fine line the individual being assessed falls – is their primary need for health or social care? The outcome can make a huge difference as to who pays for care, and indeed, whether the individual has to self-fund their own care from private means (and sell their home). The Nurse Assessor, as the NHS representative, must uphold the provisions of the Health Act, while the Social Worker is responsible for ensuring the needs fall within the confines of the Care Act. The eligibility criteria are highly subjective, meaning it is far from uncommon for two people to interpret the same facts differently. An open discussion between professionals, with each voicing their own opinion, is often the best way to resolve such differences and ensure all relevant information is considered.
Although the NHS has ultimate decision-making responsibility, the National Framework makes clear that a good multi-disciplinary CHC assessment relies on a robust application of the criteria, by people from different backgrounds and experience. Reducing the role of the Social Worker to a box ticking, paper exercise surely affects the quality of their input, and the overall assessment.
As the Trusted Assessor model has been sanctioned by NHS England for CHC assessments, there is likely little families can do to prevent the ICB from adopting this approach. However, there are certainly questions families can ask, to get as much information as possible, for example:
- Please could I see a copy of the TAM policy adopted by the ICB?
- Has the Social Worker visited my relative before participating in this process?
- Has the Social Worker completed their own Care Needs Assessment?
- If so, please can I have a copy before the DST is completed?
- What is the name of the Social Worker?
- Am I able to contact them to discuss any concerns about the assessment process, levels of need, or evidence recorded in the DST?
- At what point will the Social Worker be asked to contribute to the assessment?
- Will I have the opportunity to review and comment on their contribution before the DST is considered by a Panel?
We anticipate the likely outcome of this novel approach may well open the floodgates for a barrage of appeals across the county, as families are dealt unjust outcomes by Nurse Assessors who may not up be up to scratch, and Social Workers following in their wake, left to adopt an outcome that may not be accurately reflective of the individual’s needs. We shall have to wait and see how this new intervention works…
For more reading around the subject here are a selection of helpful blogs from our caretobedifferent website:
Read about Zara’s experience of her mother’s Multi-Disciplinary Team Assessment…
How to access free NHS funded care upon discharge from hospital?
What? You’re enquiring about care funding AND you’ve never heard of CHC!
Contact us if your relative is due to be assessed by using the Trusted Assessor approach and you want impartial advice visit https://caretobedifferent.co.uk/ or call us on 0161 979 0430.
If you have had an assessment using the Trusted Assessor, share your experiences and comments below, to help others about to go through this process…
I have not been, as the holder of a POA for my relative, a victim of this new process except in the sense that the lead assessor signed off the DST 7 days before the social worker signed, even though the social worker was present throughout my own involvement in the DST. I was excluded under protest from any discussion of the 4 characteristics ostensibly because the MDT wished to discuss these privately and come to a recommendation. So one interpretation might be that the nurse assessor signed and completed the recommendation herself and sent it to the social worker to sign off later. If so, it seems that they are playing fast and loose with the rules as they appear to be with the trusted assessor system.
The MDT do not breach the law by ignoring the Framework according to the case of Gossip although if they do, there needs to be a good reason for doing so according to the judgement in that case.
This is important because there is a clear understanding in the Framework that the MDT “team” will be present at the DST stage and then themselves, having gathered evidence, go on to make a recommendation based of course, as in a court, of their assessment of the veracity of the applicant and their evidence. In this new system, the MDT will never meet the applicant but simply receive on paper the views of the trusted assessor before themselves making a recommendation in the absence of the TA.
There is nothing wrong, according to the Framework, with the MDT making their actual recommendation in private but that is clearly on the basis of the MDT being the people who have met the applicant and discussed the matter with them. The new system appears to be a planned and deliberate subversion of the rules as opposed to a one off case as in R v Gossip in which the ICB was allowed to ignore the Framework.
It was my experience, that although a multidisciplinary team attended, it was only the nurse assessor who spoke.
The nurse Assessor kept trying to minimise health care needs and became quite frustrated that I had prepared evidence to back up my views.
Perhaps, this was why noone else volunteered to speak, but in my view the others present couldn’t effectively challenge anything I put forward.
In my view it doesn’t really matter if one or four people carry out the assessment. As long as you can evidence the need (not just putting forward in words), then you should find the process easier.
I have had fully funded NHS Continuing Healthcare for 20 years now and I don’t see anything threatening that funding yet.
My understanding of trusted assessors in our area is that they are neither health or social care professionals (registered nurses or social workers), they may be a senior care worker or a care home manager, but they do not seem to be qualified to deliver mental or physical nursing care assesssments, which is fundementally what CHC/FNC is about – but do admit that I am really confused as to how a person is supposed to get a health professional level of health care whether or not they meet the arbitory levels for CHC or FNC to have funded ‘social care’ or nursing care