Guidance

Fast-track pathway tool for NHS continuing healthcare guidance

Updated 23 August 2022

What the fast-track pathway tool is

1. This revised tool accompanies the:

• National framework for NHS continuing healthcare and NHS-funded nursing care 2022 (‘the national framework’)
• NHS continuing healthcare checklist (‘the checklist’)
• NHS continuing healthcare decision support tool (DST)

This is the version that integrated care boards (ICBs) and NHS England^{[footnote 1]} should use from 1 July 2022.

Please use the tool in conjunction with the national framework, with particular reference to paragraphs 240 to 269. All staff who use the fast-track tool should be familiar with the principles of the national framework and have received appropriate training.

2. Individuals with a rapidly deteriorating condition who may be entering a terminal phase may require ‘fast -tracking’ for immediate provision of NHS continuing healthcare.

3. The intention of the fast-track pathway is that it should identify individuals who need to access NHS continuing healthcare quickly with:

• minimum delay
• no requirement to complete the checklist or the DST

Therefore, the completed fast-track pathway tool – which clearly evidences that the person has a primary health need arising from a rapidly deteriorating condition and the condition may be entering a terminal phase – is in itself sufficient to establish eligibility.

Who can complete the fast-track pathway tool

4. In fast-track cases, the National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) Regulations 2012 (‘the standing rules’) state that it is an “appropriate clinician” who determines that the individual has a primary health need. The ICB must therefore determine that the individual is eligible for NHS continuing healthcare, and should respond promptly and positively to ensure that the appropriate funding and care arrangements are in place without delay.

5. An ‘appropriate clinician’ is defined as a person who is:

a) responsible for the diagnosis, treatment or care of the individual under the 2006 Act the National Health Service (Consequential Provisions) Act 2006] in respect of whom a fast-track pathway tool is being completed; and

b) a registered nurse or a registered medical practitioner.

6. The ‘appropriate clinician’ should be knowledgeable about the individual’s health needs, diagnosis, treatment or care and be able to provide an assessment of why the individual meets the fast-track pathway tool criteria.

7. An ‘appropriate clinician’ can include clinicians employed in voluntary and independent sector organisations that have a specialist role in end of life needs (for example, hospices), provided they are offering services pursuant to the National Health Service (Consequential Provisions) Act 2006.

8. Others – who are not approved clinicians, as defined above, but are involved in supporting those with end of life needs (including those in wider voluntary and independent sector organisations) – may identify the fact that the individual has needs for which use of the fast-track pathway tool might be appropriate.

They should contact the appropriate clinician who is responsible for the diagnosis, care or treatment of the individual and ask for consideration to be given to completion of the fast-track pathway tool.

When the fast-track pathway tool should be used

9. The fast-track pathway tool must only be used when the individual has a rapidly deteriorating condition and may be entering a terminal phase.

10. The fast-track pathway tool replaces the need for the checklist and the DST to be completed. However, a fast-track pathway tool can also be completed after the checklist if it becomes apparent at that point that the fast-track criteria are met.

11. The fast-track pathway tool can be used in any setting. This includes where such support is required for individuals who are already in their own home or are in a care home and wish to remain there. It could also be used in other settings, such as hospices.

12. If an individual meets the criteria for the use of the fast-track pathway tool then the tool should be completed, even if an individual is already receiving a care package (other than one already fully funded by the NHS) that could still meet their needs.

This is important because the individual may at present be funding their own care or the local authority may be funding (and/or charging) when the NHS should now be funding the care in full.

13. The completed fast-track pathway tool should be supported by a prognosis, where available. However, strict time limits that base eligibility on a specified expected length of life remaining should not be imposed:

• a) ‘rapidly deteriorating’ should not be interpreted narrowly as only meaning an anticipated specific or short time frame of life remaining
• b) ‘may be entering a terminal phase’ is not intended to be restrictive to only those situations where death is imminent

14. It is the responsibility of the appropriate clinician to make a decision based on whether the individual’s needs meet the fast-track criteria.

15. An individual may at the time of consideration 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.

In these cases it may be appropriate to use the fast-track pathway tool in anticipation of those needs arising, and agreeing the responsibilities and actions to be taken once they arise, or to plan an early review date to reconsider the situation.

It is the responsibility of the appropriate clinician to base their decision on the facts of the individual’s case and healthcare needs at the time.

How the fast-track pathway tool should be used

16. Appropriate clinicians should complete the accompanying fast-track documentation (see the Fast-track pathway tool for NHS continuing healthcare referral form), and set out how their knowledge and evidence about the patient’s needs leads them to conclude that the patient has a rapidly deteriorating condition and that the condition may be entering a terminal phase.

17. It is helpful if an indication of how the individual presents in the current setting is included with the fast-track pathway tool, along with the likely progression of the individual’s condition, including anticipated deterioration and how and when this may occur.

However, ICBs should not require this information to be provided as a prerequisite for establishing entitlement to NHS continuing healthcare.

18. While the completed fast-track pathway tool itself is sufficient to demonstrate eligibility, a care plan will be required that describes the immediate needs to be met and the patient’s preferences.

This care plan should be provided with the fast-track documentation, or as soon as practicable thereafter, in order for an ICB to commission appropriate care.

19. The setting where an individual wishes to be supported as they approach the end of their life may be different to their current arrangements (for example, even though they are currently in a care home setting they may wish to be supported in their family environment).

The important issue is that, wherever possible, the individual concerned receives the support they need in their preferred place as soon as reasonably practicable, without having to go through the full process for consideration of NHS continuing healthcare eligibility.

How the individual or representative should be involved

20. The overall fast-track process should be carefully and sensitively explained to the individual and (where appropriate) their representative to support their informed and active participation, and their views should be considered.

21. It is also important for the ICB to know what the individual or their representative have been advised about their condition and prognosis, and how they have been involved in agreeing the end of life care pathway.

22. Clinicians completing the fast-track pathway tool should make the individual aware that it will be important to review the individual’s care needs and the effectiveness of the care arrangements. In doing this, there may be certain situations where a change in needs indicates that it is appropriate to review eligibility for NHS continuing healthcare. This could potentially affect the funding stream depending on the outcome of the review.

Any such decisions should be made with sensitivity. Please refer to paragraphs 264 to 269 in the national framework for further details.

23. There are a number of principles that underpin the NHS continuing healthcare process: most importantly that assessments and reviews should always focus on the individual’s needs and follow a person-centred approach. The individual should be fully informed and empowered to participate actively in the assessment process and any subsequent reviews, and their views should be considered.

In addition, there are a number of legal requirements when it comes to an individual’s consent for parts of the NHS continuing healthcare process.

24. In the spirit of the person-centred approach, practitioners should make all reasonable efforts to seek the participation of the individual (or their representative) for the assessment and review process for NHS continuing healthcare, during each stage of the process.

For a comprehensive assessment, the best evidence available at the relevant time should be considered. This should involve consideration of the individual’s (or their representative’s) view, and they should be empowered and assisted to participate. Throughout the process, this person-centred approach should be embedded in all decisions that relate to the individual’s needs assessment and their care planning.

25. Consent is a legal requirement for any physical intervention on, or examination of, a person with capacity to give consent. To the extent that the completion of a fast-track pathway tool involves such an intervention or examination, informed consent must be sought from an individual with capacity to give consent. Please refer to paragraph 85 of the national framework, which gives detailed guidance on what is required for consent to be valid.

26. It is necessary to obtain an individual’s explicit consent before sharing any personal data with a third party such as a family member, friend, advocate and/or other representative.

27. However, it is not necessary to seek consent from an individual in order to share their personal data as part of their NHS continuing healthcare assessment (and subsequent reviews) between health and social care professionals.

28. If there is a concern that the individual may not have capacity to give consent to a physical intervention or examination that is part of the assessment process, or to the sharing of personal data with third parties such as a family member, friend, advocate and/or other representative, this should be determined in accordance with the Mental Capacity Act 2005 and the associated code of practice.

It may be necessary for a ‘best interests’ decision to be made, bearing in mind the expectation that everyone who is potentially eligible for NHS continuing healthcare should have the opportunity to be considered for eligibility. Guidance on the application of the Mental Capacity Act 2005 in such situations is provided in paragraphs 89 to 96 of the national framework. 

Careful decision-making is essential in order to avoid the undue distress that might result from changes in NHS continuing healthcare eligibility within a very short period of time.

Appropriate clinicians should complete the accompanying Fast-track pathway tool for NHS continuing healthcare referral form, original and accessible versions of which are available in PDF, Word and ODT format alongside this guidance.

1. For the purposes of this guidance, references to ICBs after this point also include NHS England where it is responsible for commissioning services for an individual for whom a fast-track pathway tool has been completed. ↩