Luke Clements

The Problem with Fast Track in Wales

As previous posting on these pages have sought to highlight,[1] there are in our opinion profound problems with the Welsh Government’s Guidance concerning the process by which eligibility for Continuing NHS Healthcare funding (for adults and young people alike) is determined. 

As this paper, by guest contributor Adam Greenow,[2] demonstrates, the problem also extends to the process by which Fast Track decisions are also made in Wales.

 

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This paper argues that a lack of clarity in the Welsh Framework (‘Continuing NHS Healthcare, The National Framework for Implementation in Wales’)^[3] in relation to Fast Track CHC is leaving latitude for practice that can lead to poor outcomes for individuals.  While not wishing to portray the English Framework^[4] as the Gold Standard, objectively it leaves far less room for ambiguity. It is in consequence instructive to compare the two frameworks in relation to how they cover Fast Track.

The first major difference of note is that the English Framework provides a Fast Track Tool (underpinned by Regulations^[5]) along with guidance on how it should be used. The Welsh Framework does not provide a tool, nor underpinning regulations nor indeed specific guidance – leaving it open to each Health Board to provide its own Fast Track Tool (confirmed by a 2021 freedom of information request^[6]).

The 2022 English Framework advises (para 242):

The intention of the Fast Track Pathway is that it should identify individuals who need to access NHS Continuing Healthcare quickly, with minimum delay, and with no requirement to complete a Decision Support Tool (DST). Therefore, the completed Fast Track Pathway Tool, with clear reasons why the individual fulfils the criteria and which clearly evidences that an individual has a rapidly deteriorating condition and the condition may be entering terminal phase, is in itself sufficient to establish eligibility.

 

The above extract is explicit that there is no requirement to complete a Decision Support Tool (DST). The Fast Track form^[7] itself makes no reference to a checklist. This is important – and the clue is in the title – because the fast track process should be fast. DST meetings can, in the current climate, take months before completion due to workforce issues. This is compounded by a bureaucratic CHC process that often seeks evidence to the level that might not be out of place in a court of law. The point of a fast track process must be to avoid this often lengthy ‘normal’ process that focusses on a checklist, primary health care need approach and the organisation of a DST meeting.

The English Framework makes it clear that only in the most obviously inappropriate cases should a completed Fast Track form not be ratified (for example if it ‘makes no reference to them having a rapidly deteriorating condition which may be entering a terminal phase’ (para 261). It is also explicit that (para 253.):

…an individual may currently be demonstrating few symptoms yet the nature of the condition is such that it is clear that rapid deterioration is to be expected in the near future.

 

The English Framework references ‘anticipated deterioration’ and that it’s ‘helpful if an indication of how the individual presents in the current setting is included.’ (para 255.):

However, ICBs should not require this information to be provided as a prerequisite for establishing entitlement to NHS Continuing Healthcare using the Fast Track Pathway Tool.

And, indeed, the Fast Track Tool reflects this, making clear that all that is required is that (page 2):

The individual fulfils the following criterion:
They have a rapidly deteriorating condition and the condition may be entering a terminal phase. For the purposes of Fast Track eligibility this constitutes a primary health need. No other test is required.

 

The English Framework and accompanying Fast Track Tool therefore make two things clear and explicit:

1.        All that is required is an appropriate clinician to state someone has entered a terminal phase and has a rapidly deteriorating condition.

2.        The individual may currently be demonstrating few symptoms.

 

The Welsh Framework, unfortunately, lacks this level of detail and hence clarity.  For example, it fails to explain that the key issue is a diagnosis / prognosis (of a rapidly deteriorating condition that may be entering a terminal phase) and not the existence of ‘symptoms’. It also fails to make clear that a checklist is not required.

Arguably, this lack of explication leaves the door open to Health Boards developing administrative procedures that might run counter to the ‘end of life’ principles that must be at the heart of a Fast Track process of this kind: in essence writing a distinct familial scrabble rulebook.^[8]

An example of this approach is a locally produced Fast Track Tool^[9] that includes the need for a Primary Health Need checklist and a requirement to specify how long the individual is expected to live when the Framework clearly states that length of time remaining should not be imposed. Compared to the English Tool this is at best confusing as it asks the Doctor to provide evidence of a primary health care need. In preparing this paper clarification was sought from the Senior Policy Manager in Welsh Government – who confirmed that a primary health care need was not required and that all that was needed was the clinician’s recommendation.

This example calls into question how many Health Boards in Wales have Fast Track Tools that are consistent with the Framework and the policy manager’s advice?  Tools of this kind do not appear to be published / readily available (necessitating a freedom of information request to each Health Board). 

The process by which Fast Track approvals are reviewed in Wales raises further concerns. The English Framework quite sensibly offers the following guidance (para 266. To 267.):

266. Where an individual who is receiving services from use of the Fast Track Pathway Tool is expected to die in the very near future, the ICB should continue to take responsibility for the care package until the end of their life.

267. ICBs should monitor care packages to consider when and whether a reassessment of eligibility is appropriate. 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.

 

In contrast the Welsh Framework only states the following (para 3.38):

3.38 No individual who has been identified through the fast track process should have their care package removed without their eligibility being reviewed in accordance with the review process set out in Section 4. The review should include completion of the DST by the MDT, including a recommendation on future eligibility.

 

There is a significant and troubling difference between these two approaches. An individual in Wales could be deemed eligible for Fast Track CHC on the basis of a Clinician’s recommendation even if the individual was at the time not meeting the threshold required for a Primary Health Care Need. However, at any given time a review could be completed and CHC funding removed based on not meeting the criteria for a Primary Health Care Need via a DST. An individual with an end-of-life prognosis will remain at risk of losing their funding based on eligibility criteria that was not required when they were provided with that care and funding in the first place. An individual whose illness has not progressed as quickly as may have been anticipated would be at continuous risk of losing their funded care. In contrast to the English Framework, there is nothing in the Welsh Framework to caution against this.

In the preparation of this paper the Senior Policy Manager in Welsh Government has been asked to comment on this apparent anomaly, but at the time of writing, no response to this request has been received.

Objectively it is troubling that in relation to such an important issue as ‘end of life care’, the Welsh Government has chosen not to adopt the English Tool (or provide a similar level of detail to this document).  It Is to be hoped, however, that a consideration of the failings identified in this paper will prompt the Government to take action to remedy these failings.

Outcomes themselves are difficult to measure in this area as we know that many decisions are made without recourse to formal referral or assessment. Decisions as to whether to place someone on a fast track pathway can be based on the understanding of the professionals involved and may include junior clinicians not clear in relation to eligibility criteria or more seasoned professionals who follow embedded, local cultural practices in the latitude left by the sparse guidance available in Wales.

If the English Framework was adopted in Wales along with better training for clinicians, we might see some of the current myths in relation to Fast Track dispelled and significant improvements in this area of practice. Fast Track CHC should be the one area where it is easy to get it right most of the time. Unfortunately, the current guidance requires considerable improvement in terms of clarity and direction. Guidance should, after all, be there to help practitioners make lawful decisions – and when it’s unclear or leaves too much latitude this should be amended.