We know that certain parts of the country are more likely to award NHS Continuing Healthcare (CHC) than others. This is often referred to as the ‘postcode’ lottery. Where you live can increase or decrease your chances of receiving CHC Funding from the NHS.
CHC Funding is assessed and paid for by the NHS, via its local Clinical Commissioning Groups (CCGs). CHC Funding is free of charge and is not-means tested. If you are 18 years or older, have had an accident, disability or illness, CHC will pay for your all your long-term assessed healthcare and social care needs as well as your accommodation – providing, of course, that you meet the eligibility criteria. Those criteria and guidance are set out in the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care.
Don’t make the mistake of confusing healthcare needs and social care needs! Social care needs are paid for by the local authority and are subject to means-testing, whereas healthcare needs are paid in full by the NHS, are not means-tested, and are free at the ‘point of delivery’ (ie need). Specifically, the National Framework, states:
35. Where individuals receive care, treatment or support from the NHS this is normally under the provisions of the National Health Service Act 2006, referred to from this point onwards as the NHS Act. This support is provided free at the point of delivery to the individual.
180. NHS care is free at the point of delivery. The funding provided by CCGs in NHS Continuing Healthcare packages should be sufficient to meet the needs identified in the care plan.
For more information read: Part 1. Explaining The Vital Difference Between Social Needs vs Healthcare Needs.
Families ask us…Why?
Why is the bar to obtaining CHC Funding set very high and why is the whole application process so tortuous, subjective and complex?
Why do so many families struggle to get this vital long-term CHC Funding for their relative in need of care? And more critically, once they have it, how do they keep it?
Why do we hear so many stories of funding being withdrawn following a review – causing untold anxiety, anger and frustration?
The most likely answer is perhaps due to a combination of:
a) budgetary constraints and money ie rationing care and/or;
b) incompetent or inadequately trained assessors, and;
c) being able to recruit highly proficient quality assessors due to a high staff turnover.
If correct, it is hardly surprising that so many individuals who are absolutely entitled to CHC Funding are being failed by the system and the application of the National Framework guidance which is designed to protect them.
No wonder there is an obvious anomaly, that despite an ageing population, so few people by comparison qualify for CHC funding. Read our blog: “Care crisis fear as over 85s to double by 2043”.
The NHS are under pressure to save £855m by 2021. Although paragraphs 37 and 41 of the National Framework categorically state that ‘financial gatekeeping’ should never be a factor when determining eligibility for CHC Funding – in the absence of other explanations, it is hard to find a plausible reason why so many individuals are not awarded CHC funding, or those that are, can have it wrongly withdrawn without robust justification. The National Framework states:
37.3. CCG decision-making processes should not have the function of:
- financial gatekeeping
41.2. CCGs do not have to use a panel arrangement as part of their process for ratifying eligibility recommendations, but if they do the panel should not be used for financial gatekeeping.
Contrary to the guidance, it appears that some CCGs are more aggressive in seeking to withdraw existing CHC funding than others. But again, perhaps that could be a symptom of the ‘postcode lottery’ rather than any calculated policy on protecting funds.
Yet, when an individual is perfectly entitled to receive CHC funding (and has been receiving it for many years to help with their long-term care needs), it is hard to understand how it can possibly be withdrawn – especially, if due to the nature of their illness or injury, there is no possibility of a reduction in the level of need over time, or their needs have remained constant since the last assessment, if not increased!
Annual Reviews – an opportunity to withdraw funding:
Paragraph 181 of the National Framework provides that CCGs are obliged to carry out reviews of CHC funded care packages, initially after 3 months from when the eligibility decision is made, and then every 12 months thereafter. According to the National Framework:
183. These reviews should primarily focus on whether the care plan or arrangements remain appropriate to meet the individual’s needs. It is expected that in the majority of cases there will be no need to reassess for eligibility.
142. The decision-making rationale should not marginalise a need just because it is successfully managed: well-managed needs are still needs. Only where the successful management of a healthcare need has permanently reduced or removed an ongoing need, such that the active management of this need is reduced or no longer required, will this have a bearing on NHS Continuing Healthcare eligibility.
In short, the 3 month or annual review is a safety mechanism to ensure that the individual’s needs are still being met by the care package in place. If their needs remain as before, then the care should continue unabated. However, if they have increased, the CHC care package should also be enhanced to meet those higher demands. However, unless there has been a substantial reduction in the individual’s needs, there should be no need to reconsider their eligibility for CHC funding at the annual review: review and reassessment are separate entities and one does not naturally follow the other in every case. Of course, where the need has been permanently removed and no longer exists, then the CHC Funding should be withdrawn upon reassessment.
However, what is clear is that CCGs should not try to use the 3 month or annual review as an opportunity to remove an individual’s CHC Funding when, in fact, their eligibility should never have been in question. This is entirely in contravention of the National Framework and there is no justification for it. What is more galling for families, is when their relative has obvious ongoing continuing care needs – which have not significantly changed – but face the daunting prospect of them being referred to a reassessment and funding being withdrawn.
It is no wonder that families going through the application or review process become so stressed. The fear of vital funding being withdrawn could throw their relative into the open arms of the local authority and subject them to a means-tested assessment for social care funding. If they don’t meet the local authority assessment criteria, they will then have to pay for their own care out of private funds and savings. Families will then be forced to appeal and join the back of the queue, and potentially face years of delay whilst having to finance their relative’s care.
Here are some examples where it would be unjustified for a CCG to conduct a reassessment of CHC eligibility following an annual review, eg where there has been:
- Failure to review the care arrangements;
- Failure to conduct annual reviews;
- Conflated annual review combined with reassessment where there is no justification to do so;
- Failure to identify any significant change in needs to justify full reassessment;
- Failure to make any comparison with the most recently completed Decision Support Tool (DST);
- Failure to apply the ‘well-managed need’ principle;
- Failure to accurately summarise the patient’s needs;
- Too much reliance on written records, over verbal staff testimony, despite being aware that the care home records were not reflective of needs;
- Minimising and marginalising the patient’s needs;
- Improperly analysing the four Key Indicators (Characteristics);
- Failure to ensure consistency of assessment;
- Failure to provide adequate procedural and clinical training for its staff;
- Failure to take the family’s or patient’s view of needs into account;
- Failure to recognise/correct clinical failings in its assessment when informed by the staff/family;
- Expressing the view that it doesn’t matter if CHC is withdrawn because the individual will be funded by the local authority anyway!
There are various ways a CCG can go about the annual review, but here’s an example where it would be justified to conduct a reassessment of CHC eligibility following an annual review:
Scenario: The CCG’s Nurse Assessor visits Mr A to conduct a review of his care package. The DST or CHC review template is completed and, when compared with the DST from the previous review/assessment, Mr A’s needs are evidenced to have reduced in a number of key domains. For example: Mr A, who was assessed as meeting the CHC criteria on the basis of the complexity and intensity of his behaviour, has subsequently fractured his hip and is now bedbound; his dementia has advanced and he no longer resists necessary care or presents as distressed; all psychotropic medications have been withdrawn with no negative effect on his behaviour, psychological state or presentation; Mr A has been discharged by the Community Mental Health Team and is no longer under the care of the Community Psychiatric Nurse.
In this scenario, the CCG would be justified in proceeding to a full reassessment of CHC eligibility. The Nurse Assessor should make a recommendation to the CCG that Mr A’s needs have changed and a full MDT, with a local authority representative, should be convened to reconsider CHC eligibility.
Remember, if your relative’s CHC funding is withdrawn, they are most likely to be passed over from the NHS to their local authority and with it, the financial burden. Your relative with then be subjected to a local authority means-tested assessment, and if they have assets or capital (including a home) valued in excess of £23,250, they will end up self-funding and having to pay for their own care privately.
We applaud Admiral Philip Mathias’ pioneering public campaign to bring the NHS to task and create a fairer and more transparent process. For more information watch his recent TV interview with Victoria Derbyshire https://www.youtube.com/watch?v=Fc3fsSEnEBo and visit his website here: www.nhschcscandal.co.uk
Here are some other useful blogs for additional reading around the subject:
Over the years, we have been contacted by many families facing the worry and anxiety of an annual review, especially as they are already aware that critical CHC Funding for their relative could be referred for reassessment and possibly withdrawn. If you need specialist advocacy help visit our 1-2-1 Support page.
If you feel your relative has been the victim of a poor or biased review and has then had CHC Funding unfairly or wrongly withdrawn, share your details below and let others know how you went about getting it reinstated, whether you were successful, and how long it took…