NHS Continuing Healthcare Funding is a complicated subject surrounding issues of funding provided by the NHS, which, whilst fairly well publicised, still continues to cause confusion and frustration notwithstanding the introduction of the National Framework for NHS Continuing Healthcare in 2007.
We have put together a series of frequently asked questions to shed some light on the issues in this subject and some advice as to how we can assist.
CHC is a package of healthcare arranged and funded solely by the NHS. The term ‘continuing care’ means care provided over a period of time to a person aged 18 or over to meet physical or mental health needs that are present as a result of accident, disability or illness.
In short, any person over the age of 18 with a Primary Health Need should be provided with a package of CHC.
Unhelpfully, the term ‘Primary Health Need’ is not defined. The closest we have to a definition is the following, taken from paragraph 34/35 of the National Framework which states that an individual will be ineligible for CHC when;
a) Their needs are no more than incidental or ancillary to the provision of accommodation which Local Authority (LA) social services are or would be but for a person’s needs, under a duty to provide; and
b) are not of a nature beyond which a LA whose primary responsibility it is to provide social services could not reasonably be expected to provide
The National Framework goes on to indicate that there are four main provisions that, when combined, may indicate a primary health need.
Nature – The physical characteristics of an individual’s needs and the type of those needs, and can also describe the overall effect of such needs on the individual, including the type of interventions required to manage them.
Intensity – This relates to the extent and severity of the needs and to the support required to meet them, including the need for sustained/ongoing care.
Complexity – This is concerned with how needs present and interact to increase the skill required to monitor the symptoms, treat the conditions or manage the care. This may arise with a single condition, or it could include the presence of multiple conditions or in the interaction between two or more conditions. It may also include situations where an individual’s response to their own condition has an impact on their overall needs, such as where a physical health need results in the individual developing a mental health need.
Unpredictability – This describes the degree to which needs fluctuate and thereby create challenges in managing them. It also relates to the level of risk to the persons health if adequate and timely care is not provided. Someone with an unpredictable healthcare need is likely to have either a fluctuating, unstable or rapidly deteriorating condition.
Defining a Primary Health Need is therefore a complex study of the various needs of the individual with a focus of the interplay between the factors above.
CHC funding can be provided to any person living in their own home or care setting such a residential or nursing home. CHC funding can also be provided to people in a hospice. However, CHC funding is not available for people in hospital.
CHC funding is not means tested, it is based on whether or not a person has a primary health need. If it can be established that a patient has a primary health need, then CHC funding should be granted irrespective of their financial position.
An assessment for CHC should take place when there are needs that are predominantly health related rather than social care related. Typically, an assessment for CHC should take place as part of the hospital discharge procedure.
An assessment can also take place at home, or in a residential or nursing care setting.
Current regulations require the NHS Clinical Commissioning Groups (CCG’s, formerly known as Primary Care Trusts and Strategic Health Authorities) to assess any person that presents as potentially requiring CHC. This assessment should take place before the local authority (via Social Services) are requested to provide a needs assessment. The reason for this is to ensure that the patients’ needs are being assessed in order of priority, before the question of ability to pay is asked. Therefore, the correct order for various assessments are as follows:
It is often the case that no CHC assessment is given before social services are requested to provide a needs assessment and establish the financial means to pay of the person with needs. This is potentially unlawful. A CHC assessment should always be carried out first.
The assessment for CHC is usually a two stage process.
The Checklist Stage
Firstly, a screening tool is used known as a ‘checklist,’ which presents 12 care domains and scores each one on an A to C basis. The relevant domains are as follows:
Ordinarily, a Doctor or a Nurse would complete a checklist as part of the hospital discharge procedure and a Social Worker would complete the assessment when the assessment is being given in your own home or a residential or nursing home setting.
If the appropriate range of scores are given on the checklist, then the matter would be referred to the CCG, who would then arrange for the convening of a Multi Disciplinary Team (MDT) to conduct a full assessment using a Decision Support Tool (DST) Document.
The Decision Support Tool Stage
The MDT should consist of a healthcare professional (i.e. a Nurse Assessor) and a Local Authority Representative (i.e a Social Care Worker). The purposes of the MDT is to establish what needs the patient may have that are health related and which needs may be social care needs.
The DST is a standard document used by the MDT to conduct the assessment, which should also involve, as far as possible, the individual themselves or their appointed representative.
The DST uses the same domains of care as the checklist stage, although as those needs are explored in more detail via evidence (usually gathered from GP records, care home records and other sources of evidence such as close family members), the scoring threshold is harder to satisfy, with the domains being scored in terms of:
Technically, there is no correct range of scores required to prove a primary health need, and it is that which makes it difficult to show what may, or may not, constitute a primary health need. The assessment will look at the all of the needs of the individual and then assess whether, in their opinion (and based on the complex method of determining a primary health need as shown above) the individuals needs demonstrate the presence of a primary health need.
The MDT will then present their findings to a panel at the local CCG, who will then give their recommendation as to whether CHC funding should be granted.
As part of the procedure, families are usually shown the evidence gathered and given a period of approximately one month to make their own comments to the CCG before the evidence is presented to the decision making panel.
Usually a lot longer than expected!
There is no firm answer to this, as it will depend on CCG workloads and how easy it is to gather the evidence required from the GP, care homes or other sources of evidence. It is often the case that this will take months, and in some cases, even longer. Retrospective applications have been known to take up to 3 years to evidence gather.
In certain urgent cases, it is possible to apply for CHC under the fast track procedure.
This would be appropriate where an individual requires immediate access to an urgent package of continuing healthcare due to a rapidly deteriorating condition that may be entering a terminal phase and has an increased level of dependency.
In such cases, the Fast Track Pathway Tool can be used but unlike the DST, it is not completed by an MDT and may only be used by an appropriate clinician, which is likely to be Consultants, Hospital Registrars, GP’s and perhaps senior nurses.
Guidelines to the NHS state that the NHS must immediately accept and action the recommendation for fast track CHC where the Fast Track Tool has been completed correctly by the appropriate clinician.
In short, everything. The NHS will pay both the costs of care and the accommodation costs.
However, this also means that ‘top ups,’ as allowed by social services when meeting the costs of a care home resident, are not allowed under the rules relating to CHC. This is because the CHC must be seen to be satisfying their statutory duties to provide the necessary care to the individual. The concept of topping up to provide ‘better’ care would be a tacit admission by the NHS that they are not doing all they can to meet the needs for which CHC is required.
Therefore, although an award of CHC would be very welcome, it must be borne in mind that there might be less choice available as a result.
Yes. The NHS will conduct a review of the award 3 months after the initial award, and then annually thereafter. It is not uncommon for CHC packages to be removed and an award of CHC funding must never be seen as irrevocable.
If the CCG panel find that an individual is not eligible for CHC, then there are two choices. Either the refusal can be accepted, or the non-eligibility decision can be appealed providing that the appeal is lodged in writing within 6 months of the decision.
Upon receiving a letter of appeal, the CCG will convene a local Dispute Resolution Meeting with a CCG representative to explain the reasons why the finding of non- eligibility has been given. It is an early chance for the individual or their representative to decide whether or not to proceed with their appeal or accept the CCG reasons.
The Dispute Resolution Co-Ordinator does not have any power to reverse the initial decision, their role is simply to advise on the reasons for non-eligibility and to hear the individuals own views, perhaps with a view to obtaining more evidence if it is established that this is required.
The next stage is to proceed to an independent review panel at the CCG, made up of a representative of the local authority, a health care professional (usually a Doctor) and a lay representative. The CCG appeal panel would have been provided with the evidence in advance of the appeal hearing and the individual or their representative will be given an opportunity to discuss the evidence and their own perspective with the panel.
The panel will make a decision following the hearing and advise the individual of their decision in writing within 21 days.
If the result of the panel remains a finding of non-eligibility, then the individual or their representative is free to apply to the Parliamentary Ombudsman for a final review. If a representative is making an application to the Ombudsman, that person must have ‘legal standing,’ which means they must be lawfully acting in a representative capacity, rather than informally.
Humphries Kirk can assist applications for CHC in several ways as follows:
We are always happy to meet for one off interviews for those considering making an application or for those that are dealing with CHC applications for a relative or friend themselves and wish to receive some guidance and direction as to the process and the merits of their own application. Such interviews can be held at any of our offices or at home on request.
For more information, contact one of our specialists.
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