“My relative has recently been awarded Continuing Healthcare Funding. I am worried it will be withdrawn at the next review”
If your relative is awarded NHS Continuing Healthcare Funding (CHC), then the Clinical Commissioning Group (CCG) will aim to carry out a review initially at 3 months, and then again 12 monthly thereafter.
A reassessment is a stressful and anxious time
The previous National Framework for NHS Continuing Healthcare (2012), provided that, “Regular reviews should be carried out, the first no later than three months after the initial decision, and then at least once a year subsequently. Some people will need more frequent reviews…….”.
Under the 2012 NHS National Framework, the intended purpose of these reviews was to allow the CCG to reassess the care needs and review whether the individual still met the eligibility criteria for CHC, and to determine whether the individual’s needs have changed.
The 2012 Practice Guidance suggested that a Checklist should be carried out as part of the routine review and look at all of the Care Domains in turn as part of the reassessment (paragraph 139-144) “in order to reassess care needs and eligibility for NHS Continuing Healthcare, and to ensure that those needs are being met”.
It was in the CCG’s interest to carry out the initial 3 monthly (and 12 monthly) reviews promptly (resources permitting!) because the individual’s needs could have “changed” (ie reduced) in this short intervening period. If they no longer met the eligibility criteria, CHC Funding could be withdrawn from individuals who no longer qualified for it – potentially saving the NHS a fortune by needlessly paying for CHC where it was no longer merited.
After all, people’s healthcare needs can go up as well as down over time, and just because your relative obtains CHC Funding at a point in time, doesn’t mean that it is guaranteed for life. Needs can vary, and these reassessments were intended to check whether the funding arrangement was still appropriate.
However, more cynically, these reviews offered the CCGs with a discreet opportunity – ‘second bite of the cherry’ if you like – to revisit the initial decision to grant full CHC Funding and to unilaterally reverse it, and to withdraw existing funding, occasionally without a seemingly robust explanation or rationale.
This potential ‘financial gatekeeping’ opportunity to protect NHS funds, could send families into a state of apoplexy, disbelief, frustration, heightened anxiety, panic and turmoil – at the realisation that they may now have to find huge private funds to pay for care. Being forced to sell the individual’s home to pay for their care was a common scenario. We hear of families who despaired with bewilderment, arguing that their relative’s needs had not changed since the completion of the Decision Support Tool when funding was granted, and if anything, their needs have deteriorated over time – not improved.
In short, how can it be fair that, having gone ’through the mill’ and stress of achieving CHC Funding in the first place, CHC funding can be unilaterally withdrawn in relatively short time after it was awarded?
So what has changed with the new National Framework (revised 2018)?
The new National Framework for NHS Continuing Healthcare and NHS-Funded Nursing Care (revised 2018) has hopefully rebalanced the position back in the family’s favour. But only time will tell as to how each CCG applies the guidance….
New shift in focus….
The focus of the initial three month (and twelve monthly) reviews has fundamentally changed with the revised Framework. The underlying intention of the review is not to undertake a reassessment of care needs and the individual’s eligibility for CHC Funding, but should instead now “primarily focus on whether the care plan or arrangements remain appropriate to meet the individual’s needs. It is expected that the majority of cases there will be no need to reassess for eligibility”.
Note: A reassessment of eligibility should now only take place where there is clear evidence of a change in needs to the extent that it may impact upon the individual’s eligibility for CHC. When carrying out these reviews, it is expected that the recent Decision Support Tool (DST) will be available and indeed the Framework provides it should be “used as a point of reference to identify potential change in needs”. See paragraph 181 to 185, on page 52 of the 2018 NHS National Framework.
Be alert! Despite this positive change intended to reduce unnecessary reassessments and reviews of eligibility, there is still a risk that CCGs may be selective as to how they apply this part of the new NHS National Framework. Much will largely depend on retraining and each individual CCG’s ‘party line’ as to how it approaches the revised guidance.
If applied correctly, the revised 2018 NHS National Framework should provide some comfort for families. The reassessment process should no longer be seen as a ‘green light’ for CCGs to resume battle, challenge eligibility and overturn the decision of a Multi-Disciplinary Team assessment. Instead, reassessments should be used more constructively – to consider whether the care package already in place adequately meets your relative’s ongoing healthcare needs and see what else needs to be put in place to assist them.
If your relative is able to secure CHC funding at the outset, then it is likely to continue, unless those healthcare needs significantly change (i.e. reduce or disappear).
Here’s some of our top tips:
- If you hear that CHC Funding is likely to be withdrawn even prior to the review taking place – then you must object!
- Remember: the review should be fair and impartial, and not be pre-determined without first reassessing the individual;
- Make sure the CCG doesn’t try to use the review process as an invitation to investigate eligibility again. That issue has already been resolved by the Multi-Disciplinary Team.
- If it becomes clear that ‘eligibility’ is the focus of the review, not whether the care package in place is adequate, then ensure that the CCG assessor records the reasons why that is the case and has noted down your concerns.
- Revisiting eligibility “in the majority of cases” – however ‘dressed up’ – is an outdated ‘attitude’ and is contrary to the new Framework (2018).
- Quote paragraphs 181 to 185 of the new Framework above.
- Remember our motto: the reassessment is to “help not hinder”.
In summary, it is early days yet, and we shall have to wait and see how CCGs respond to the new Framework guidance and approach these 3 monthly and 12 monthly reviews.
Spread the word and tell others if your relative has undergone review since 1st October 2018, and you believe the CCGs used this opportunity to undermine eligibility, rather than looking at whether the existing care package is sufficient for your relative’s needs.