Just Caring Legal answers your frequently asked questions in regards to the stages of eligibility assessment for NHS Continuing Healthcare Funding.
What is NHS Continuing Healthcare funding?
Many people don’t realise that if they have a “primary health need” the NHS should pay their full social care fees. This is called NHS Continuing Health Care Funding (NHS CHC). People may be eligible whether they are in residential care or receive home care. Eligibility for NHS CHC is not means tested. This means it does not depend on how much money you have in the bank or whether or not you own your own home.
What is a primary health need?
The term “primary health need” does not appear in primary legislation. This causes many problems in eligibility assessments for NHS CHC. After all, most adults who require a package of care do so for a health-related reason. This could be because they have had an accident or have an illness or disability. However, they do not all qualify for NHS Continuing Healthcare. It is the level and type of care needs that determine whether they have a primary health need. For further information see our Factsheet on this page.
What is the process for assessing eligibility for NHS Continuing Healthcare?
The National Framework for NHS Continuing Healthcare sets out the principles and processes for assessing eligibility and the legal duties that local Clinical Commissioning Groups (CCGs) must meet. There are generally several stages in an eligibility assessment for NHS CHC. They include a checklist stage, a multi-disciplinary team meeting (MDT) stage and an independent review panel (IRP) if necessary to challenge a decision. However, for people who are deteriorating rapidly and possibly approaching the end of their life, a Fast Track process is also available.
What is the NHS Continuing Healthcare “Checklist Tool”?
Health and social care professionals use the Checklist Tool to decide relatively quickly whether you should be referred for a full NHS Continuing Healthcare assessment. It is a screening tool to work out whether your care needs are of a level or type that indicate you may require NHS continuing healthcare.
Any individual can ask for a Checklist assessment and the person you ask should then arrange it. The professionals involved should keep you and your family informed and involved. You should have the chance to contribute if you wish. This way you can make sure the assessor is aware of the full extent of care needs.
Alternatively, a social worker may do the screening when carrying out a community care assessment. Whoever it is, they should have received training in how to apply the tool.
The assessor will use the checklist tool to consider the amount of care and support an individual requires across 11 broad areas of health-related need, or “domains”. These are:
- cognition (how well you can think and understand)
- psychological/emotional needs
- mobility (ability to move around, risk of falling, etc)
- skin (including wounds and ulcers)
- symptom control through drug therapies and medication*
- altered states of consciousness*
They will score care needs on each of these – A for high, B for moderate, or C for low. They must then consider any other care needs not covered by these domains.
A full assessment is triggered if there are two or more domains identified as high-need; five or more domains identified as moderate, or one high and four moderate; or one “priority” domain (marked with an asterisk) identified as high need with any number of levels in other domains.
The CCG should, other than in exceptional circumstances, accept the assessor’s recommendation.
What is a multi-disciplinary team (MDT) for NHS Continuing Healthcare?
If the Checklist Tool establishes that you may be eligible for NHS continuing healthcare, your CCG must arrange a full assessment of your care needs. It should assemble a multi-disciplinary team (MDT) specifically for this purpose. The National Framework says you should receive a full funding eligibility decision within 28 days of a positive checklist.
The MDT should consist of two professionals from different healthcare professions or one professional from a healthcare profession and one person responsible for assessing individuals for community care services. It should include professionals who have an up-to-date knowledge of your needs, potential, and aspirations. This may include GPs, dieticians, psychiatrists, physiotherapists, occupational therapists and many other kinds of professionals involved in your care. It should not include finance officers – the MDT decides on care needs only, regardless of budgetary considerations.
What is the “Decision Support Tool” for NHS Continuing Healthcare?
The MDT should ensure they have complete evidence on your care needs from all necessary and relevant assessments. These should be both comprehensive and specialist.
The MDT should then use the information to populate a detailed document called a “Decision Support Tool” (DST). This is designed to maintain a level of consistency in decision-making across local CCGs. The DST is not exhaustive. It should support the MDT, in combination with the team members’ skills, knowledge and professional judgment, in applying the “primary health need” test. This must be in a way that is consistent with the law and National Framework. For more detail, see our Factsheet on ‘What is a Primary Health Need?’.
The MDT must record the full range and levels of need in the DST. They must then take this into account when making their recommendation on eligibility for NHS Continuing Healthcare. They must consider:
• what help is needed
• whether the needs are complex and what they are
• how intense or severe these needs can be
• how unpredictable they are, including any risks to the person’s health if the right care isn’t provided at the right time.
The complexity, intensity, severity or unpredictability of needs may, in combination or alone, demonstrate a primary health need.
In most circumstances, the CCG must follow the recommendation of the MDT on eligibility for funding.
The CCG should not make decisions on eligibility in the absence of an MDT recommendation unless exceptional circumstances require an urgent decision.
What can an Independent Review Panel do in NHS CHC cases?
The Independent Review Panel (IRP) process has been set up to enable individuals and/or their representatives to challenge a CCG decision on whether someone has a primary health need. It may also check the procedure followed by a CCG in reaching a decision about eligibility for NHS CHC. You may only request an IRP review when all local resolution processes have been exhausted. This might include the CCG complaints procedure, for instance.
At an IRP, the independent Chair will introduce members of the panel, the NHS England representative and the clinical advisor (if applicable). The individual/family representatives and CCG representatives are then invited to make their representations and discuss the CCG’s DST or needs portrayal. The Chair’s job is to make sure everyone has an opportunity to contribute and to clarify any outstanding issues.
The IRP will then ask the parties to leave and will deliberate in private on any differences of opinion. The clinical advisor’s role is to advise the IRP on the original clinical judgments and how they relate to the National Framework; examine the information provided; advise on the wider nature of conditions and how different needs may interact; ensure that no significant clinical issues have been overlooked by the IRP during their deliberations; and provide any other observations on the holistic clinical care needs associated with the condition. An IRP will then make a recommendation on eligibility to NHS England. A report of the IRP findings will be sent to the individual or their representative and to the relevant CCG.
What is the “Fast-Track Pathway Tool” for NHS Continuing Healthcare?
The National Framework on NHS CHC says Individuals with a rapidly deteriorating condition that may be entering a terminal phase, can be fast-tracked for immediate provision of NHS Continuing Healthcare funding. A special Fast Track Pathway Tool exists to facilitate quick decisions about Continuing Healthcare funding so that appropriate end-of-life support can be put in place immediately. It is designed for use only by an appropriate clinician, i.e. a medical practitioner responsible for the individual’s diagnosis, treatment or care such as a consultant, registrar, GP or registered nurse. The clinician should have sufficient knowledge of the individual to be able to able to reasonably comment on whether their condition is entering a terminal phase.
Upon receipt of a Fast-Track Pathway tool, the CCG must accept without question the clinician’s judgment that the person is eligible for NHS Continuing Healthcare and action this immediately based on the care plan. The funding can then only be withdrawn if the CCG carries out a full NHS Continuing Healthcare eligibility assessment first.