When someone is eligible for CHC the NHS funds the full package of health and social care, including any care home fees. For some people a decision that they are ineligible for CHC can have a significant financial impact - depending upon their income, savings and capital assets, they may be charged for any care provided by social services such as personal care and accommodation in a care home.

The Welsh Government issued a revised framework for CHC in 2010, which set out eligibility criteria for adults and the duties of Health Boards and Local Authorities. Today's report found that the Framework has led to a number of improvements in the way eligibility for CHC is determined, butin several areas the Framework could be improved and its impact monitored more closely. Some aspects of the Framework lack clarity and more specific guidance is required in certain areas, such as how people with a learning disability are assessed.

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Implementation of the Framework for Continuing NHS Healthcare (CHC) has delivered some improvements,but more needs to be done to ensure consistency and fairness across Wales, andthe limited progress in dealing with a backlog of challenges over eligibility for CHC continuesto be a cause for concern,says a report published today by the Auditor General for Wales.

When someone is eligible for CHC the NHS funds the full package of health and social care, including any care home fees. For some people a decision that they are ineligible for CHC can have a significant financial impact - depending upon their income, savings and capital assets, they may be charged for any care provided by social services such as personal care and accommodation in a care home.

The Welsh Government issued a revised framework for CHC in 2010, which set out eligibility criteria for adults and the duties of Health Boards and Local Authorities. Today's report found that the Framework has led to a number of improvements in the way eligibility for CHC is determined, butin several areas the Framework could be improved and its impact monitored more closely. Some aspects of the Framework lack clarity and more specific guidance is required in certain areas, such as how people with a learning disability are assessed.

The funding of CHC is a significant pressure on NHS expenditure in Wales - increasing from £66 million in 2004-05 to £295 million in 2010-11, before reducing for the first time to £278 million in 2011-12. The extent to which the Framework or the way it has been implemented has contributed to thereduction in expenditure since 2010-11 is not clear. This is because at least part of the fall is likely to reflect other developments, including the £37.5 million of Welsh Government funding for modernising complex care services.

Local arrangements for implementing the Framework vary within and between Health Boards, and do not always meet the requirements set out in the Framework in a number of important areas. The effectiveness of joint working between health and social services is highly variable,and ranged from 'positive and constructive' to 'difficult'. There are also variations in the extent to which individuals and their families are being involved in the CHC process.

The report also raises concerns that NHS Wales has been struggling to deal with a large number of retrospective claims that challenge whether someone should have received CHC in the past. The claims are being processed by a national project or by individual Health Boards, depending upon the date of submission. The national project has made only limited progress and, despite additional funding, there remains a significant risk that a deadline of clearing all claims by June 2014 will not be met. No deadline has been set for the claims being dealt with by individual Health Boards, but there is no common process across Health Boards for dealing with these claims and, by September 2012, only 13 per cent of the 1,264 retrospective claims and disputes had been resolved.

Failure to deal promptly with retrospective claims is unfair on the individuals concerned. Many of the retrospective claims that are still being dealt with by the national project relate to periods dating back many years and, given the timescales involved, more than four in every five cases are being pursued by family members on behalf of a relative who has died.

The report makes several recommendations to the Welsh Government including:

•  improving its guidance and working with Health Boardsto develop national protocols and documentation;
•  strengthening leadership for CHC at a national level and within Health Boards;
•  introducing peer reviews between Health Boards to help ensure consistent interpretation and application of the Framework; and
•  establishing an executive group, chaired by a Health Board Chief Executive to ensure all retrospective claims are being processed efficiently, in a timely and consistent fashion.

Today's report also introduces a self-assessment and improvement checklist developed by the Wales Audit Office, and recommends that the Welsh Government makes its use mandatory in all Health Boards.

The Auditor General for Wales, Huw Vaughan Thomas, said today:

'With an ageing population, Continuing NHS Healthcare is vital in meeting the needs of an increasing number of vulnerable people.There can be significant financial implications for those who have substantial health and social care needs but are deemed ineligible to receive CHC, and it is therefore essential that people are treated fairly and consistently when eligibility for CHC is considered. Although the revised Framework has helped in this regard,more needs to be done, and greater urgency is required to clear the backlog of retrospective claims and disputes against decisions that has built up.'

Notes to Editors:

•  The Wales Audit Office mission is to promote improvement, so that people in Wales benefit from accountable, well-managed public services that offer the best possible value for money. It is also committed to identify and spreading good practice across the Welsh public sector.
•  CHC is a package of care and support provided to meet the assessed physical, mental health and personal care needs of an individual. CHC is often long term, although it can be episodic in nature with some people moving in and out of eligibility. As at 31 March 2012, 5,447 people across Wales were in receipt of CHC, which accounts for five per cent of Health Boards' operating costs.
•  When someone is eligible for CHC the NHS has a responsibility for funding the full package of health and social care. Where the individual is living at home, the NHS will pay for healthcare and social care, but this does not include the costs of food, accommodation or general household support. Where a person is eligible for CHC and is in a care home, the NHS pays the care home fees including board and accommodation.
•  Where a person is eligible for CHC, local authorities still have continuing responsibilities. These include a role in assessment and review, providing social work services and support for carers, and meeting housing and educational needs.
•  If an individual is not eligible for CHC they can still access a range of health and social care services. This can include the NHS paying for the nursing element of care provided to someone in a care home, known as NHS Funded Nursing Care. Health Boards reported that 5,887 people across Wales were in receipt of NHS Funded Nursing Care as at 31 March 2012. However for any care provided by social services such as personal care and accommodation in a care home a charge may be made depending on the person's income, savings and capital assets.  Therefore, for some people a decision that they are ineligible for CHC can have a significant financial impact, with care costs being paid from their savings or from the proceeds from the sale of their home.