Do you really understand the “Well-Managed Needs” argument? – 2018

Do you really understand the “Well-Managed Needs” argument? – 2018

Well-managed Needs

Well-managed needs – still a hot topic of conversation and controversy that is generally misunderstood by families and the Clinical Commissioning Groups (CCGs) alike. We explain the issues in this article that follows on in our 27 top tips series. Tip 24…

Both sides will often quote the “well-managed” needs principle to suit their cause: CCGs use it to reject claims for NHS Continuing  Healthcare funding; whereas families quote it to support their claim for free funding for their relative’s care home fees.

So how can both parties be at odds on this issue and who is right?

The issue of well-managed needs tends to raise its head when undergoing a Multi-Disciplinary Team Meeting. The CCG assessors may seek to underplay the individual’s health needs by suggesting that they are “well-managed” – arguably a commonly used metaphor for basically saying that the individual simply won’t qualify for NHS Continuing Healthcare Funding.

Don’t be put off disheartened by these comments as the National Framework states that “well-managed needs are still needs” regardless (see below), and should still be taken into account as part as the overall decision–making process.

However, with all the controversy surrounding the subjective interpretation over the phrase “well-managed needs”, grasping the concept is not quite as simple as it seems at first blush. Of course, your interpretation can largely depend on which side of the fence you are coming from.

The 2018 National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care deals with the well-managed needs principle on page 43.

Take a look at paragraph 142 which states, “This Framework provides that the decision-making rationale should not marginalise a need just because it is successfully managed: well-managed needs are still needs”. Ie don’t exclude or ignore the need as part of the assessment process just because it is being well-managed.

This is good news! What this means in practical terms for you, is that just because the need is well-managed does not necessarily entitle the CCG to play their ‘get-out card’ to decline NHS Continuing Healthcare funding.

But, and this is often overlooked by both families and the CCG, you still have to look at the underlying health needs. You can’t simply trot out this quote and expect the CCG to roll over. Read on…

The NHS National Framework also refers to the Decision Support Tool for NHS Continuing Healthcare Amended (Revised 2018) and paragraphs 28 and 29 deal with how this (well-managed needs) principle is applied.  The salient paragraphs have been copied below for your convenience.

“28.Needs should not be marginalised because they are 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 will this have a bearing on NHS continuing healthcare eligibility. However, there are different ways of reflecting this principle when completing the DST. For example, where psychological or similar interventions are successfully addressing behavioural issues, consideration should be given as to the present-day need if that support were withdrawn or no longer available and this should be reflected in the Behaviour domain.

29.It is not intended that this principle should be applied in such a way that well-controlled physical health conditions should be recorded as if medication or other routine care or support was not present. For example, where needs are being managed via medication (whether for behaviour or for physical health needs), it may be more appropriate to reflect this in the Drug Therapies and Medication domain. Similarly, where someone’s skin condition is not aggravated by their incontinence because they are receiving good continence care, it would not be appropriate to weight the skin domain as if the continence care was not being provided.”

Critical – and you need to understand this – just because the individual is receiving care and their health needs are being better managed, it does not mean that the underlying need has actually gone away. It is simply just that – ie they are being better managed. The National Framework seems to suggest (although it could perhaps give a clearer example) that only if the needs are reduced or disappear entirely as a result of care intervention can the CCG argue that they have been better managed.  The fact the health needs still exist but are better taken care of  – has not eradicated the need. It still subsists but is better managed by the care in place.

Take the example provided at Practice Guidance Note paragraph 23.1 of the National Framework where an individual’s challenging behavioural needs might be considerably improved and be better managed (if not eradicated entirely) by changing their environment eg moving them from a hospital setting (where they might feel disorientated or anxious), to a more relaxed environment at a care home or even their own house. That would be an example of a well-managed need.

But, suppose as an alternative example that same individual has hallucinations, displays physical and verbal aggression, is a danger to themselves and others around them, is disorientated and wanders around outside at night time, exhibits inappropriate behaviours (eg smears faeces on themselves and the walls), and generally exhibits other the challenging behaviours – if those behaviours continue to persist in the care home environment, but are better controlled eg by anti-psychotic or other medication, the needs are still there and haven’t gone away; and so whilst they may be well-managed, you cannot ignore the underlying challenging behavioural need which still subsists.

We often hear families saying that their relatives must be eligible for NHS Continuing Healthcare funding because if you take away the 24 hour care package in place, remove medication and other essential needs and don’t feed the individual, they wouldn’t survive.  Yes, that is true, but it equally applies to the majority of people in a care home or nursing environment as well.  The point is when quoting the “well-managed” needs principle, you cannot ignore basic routine nursing needs either.  The individual should still be assessed as if their routine care is still in place, using that as a base-line.  It is the management of their underlying health needs over and above the routine that you need to look at and how they are being managed.  That is the key.

Otherwise, everyone in a care home or nursing environment would invariably be eligible for free NHS Continuing Healthcare funding, and that is not how it works.

Furthermore, well-managed needs still have to be considered in conjunction with the four key indicators, namely, nature, complexity, unpredictability and intensity of the health needs.

To summarise:

These are the common opposing positions adopted by families and CCGs

  • Families will argue that just because the CCG say their relative’s needs are well-managed – they are still needs – and so it does not excuse the CCG from paying for their relative’s care home fees as they are still needs.
  • Conversely, the CCG will argue that as the needs are well-managed, there is no entitlement to free NHS Continuing Healthcare funding (CHC).

Our TIP:

  1. Look at your relative’s underlying health needs first.
  2. Take away routine base-line care required to manage those needs.
  3. Have the underlying needs been reduced or removed entirely by the nursing intervention or is it just a case that they are better controlled?
  4. Even if the underlying needs still subsist regardless, then even though they may well be better -managed, they are still needs – so stand your ground!

Let us know if the CCG have used the “well-managed” needs argument against you, and if so, what you has been your response – and has it changed their mind?

Tip no. 23: Attending the Multi-Disciplinary Team meeting – some useful guidance

11 Comments

  1. Chris Gallagher 10 hours ago

    Given the successful Coughlan argument/conclusion….. That all care provision to someone incapable, is nursing care and that social services cannot really provide any required Registered Nursing care and that the cost of any registered nursing care should reflect the actual cost, then the same would apply to anyone not wishing to go private and to self fund.

    A baby is nursed by way of feeding at the very least by it’s parent because it cannot yet do it for itself.
    What is obvious here is the need for some years of continuity of care in this instance.
    If that continuity is withdrawn then the well met needs provided for, at even the most basic level to the baby, prove to be more than needs of so called daily living because the baby would die.

    The whole matter of well met needs might be to be looked at in conjunction with the fifth and almost hidden criterion of ‘continuity of care’ which I believe resides within the intensity criterion.
    Then what must be addressed is….. what is intensity?…. Five minutes being slowly shot at in a trench might seem intense…… five months at risk of being shot at whilst preparing to be shot at for five minutes in a trench could equally seen as intense.

    Continuity of necessary care over a long period is a display of intensity in meeting what many assessors wrongly view and then disregard as ‘needs of daily living’ that they ,when challenged, equally dismiss as well met even though there is almost always intensity by virtue of repeated long term provision of necessary care….
    Beware the word ‘assist’. Doing something for some one might assist them but it is not to assist them to do it. So often used to imply that needs are easy to meet well because the patient helps themselves too, when in fact they are much more complex etc.
    Repeated and necessary continuity of care and therefore intense care provision, even if the needs appear ‘well met’ is still intensity in the provision of that care.

    Now repeat with variations, the thoughts above whilst using the other eligibility criteria.

    However, just for a laugh, also always ask what the assessors and decision makers have used to compare against the legal tests of a LAs remit to provide care. They will likely make no logical reply…… Most likely they will argue that they have compared needs against the CHC eligibility criteria, which have little or no basis in law at all.
    If the standing rules regulations etc. are read, these two tests relating to LAs are in fact the only law regarding eligibility.

  2. Tom Yarwood 2 days ago

    Hi! I have read this fairly quickly, but it is still very unclear to me. I’m not sure anyone understands this issue, in fact…. But if you think you do understand it, can you find a way to explain it more clearly? It seems to me there’s a completely absurd problem of defining terms going on — the NHS is playing Alice-in-Wonderland-style games with language. The entire thing is just a simple problem of logic:

    1. All applicants for NHS CHC funding have private funds, otherwise they would just go to social services for help
    2. A need is “well-managed” when it is “managed” roughly as well as modern technology, medicine and care methods allow — that is, as well as money can buy. (Thus someone might be in terrible pain, but if they have all the best painkillers on the market as well as physiotherapy and massage and soothing words from the best carers, then their need is “well-managed”)
    3. Private funds and NHS CHC funds are able to “manage needs”in this sense equally well — the colour of my money and the NHS’s is the same
    4. Therefore all applicants for NHS CHC funding have “well-managed” needs at the time of making their application (unless they’re simply not spending enough on care, in which case they should just cough up)

    It follows EITHER that the NHS should not give CHC funding to ANYONE, or that the whole question of “well-managed” needs should be dropped, and instead judgments about who to fund should be made based on the relative severity/ extremity of their needs.

    Can you explain to me where I’ve gone wrong here? Big thanks if you can! I had an initial meeting over NHS CHC funding for my mother in which this “well-managed” term was bandied about, and when I tried to explain to the other side that they were being completely illogical, they could neither grasp the point I was making nor explain the principle at stake clearly to me. Tom

  3. Sue 2 weeks ago

    My mum cannot do anything for herself. She is bed bound and has to be turned by care staff. She can only move her eyes and mouth. Speech is limited. She is doubly incontinent, has to be fed, offered fluid. She would never say she was hungry or thirsty. She has severe cognitive impairment, has had pressure sores in the past due to bad care, cannot assist in washing, changing etc. Where do you think she sits on the “managed need” argument? We have another DST soon because the first one was a complete sham.

    • Care to be Different 7 days ago

      Hi Sue – it is hard to say with limited information. I suggest you contact us if you would like some initial free advice on it.Kind Regards

    • Care to be Different 5 days ago

      Hi Sue – it does sound as though you mother has significant needs which may lead to eligibility for CHC funding but it is difficult to be sure without more information. It may be worth a call to Farley Dwek who provide an initial free advice and work with CHC nurses who may be able to assist you. Kind regards

  4. Hannah Hardy 2 weeks ago

    Where in the Care Act 2014 and statute does it say this about “manage Needs” etc?

  5. Jeannette 3 weeks ago

    This is an excellent evaluation and explanation however, it is difficult to apply and follow this re the revised October 2018 Framework as the page and paragraphs references are different.

    • Care to be Different 3 weeks ago

      Hi Jeanette – thanks for your feedback. Kind regards

    • Care to be Different 3 weeks ago

      Correct. The new 2018 NHS National Framework only comes into effect on the 1st October. However, the principles and concepts are virtually identical to the 2012 Framework and equally apply (although we prefer the layout in the 2018 Framework!). So don’t worry. But for further reading and comparison, we suggest you look at the 2018 NHS National Framework – particularly paragraphs 63, 65, 141 to 146, and Practice Guidance Note 23 – which you will find of assistance here. Kind regards

  6. Craig 3 weeks ago

    Thanks. A useful summary. What constitutes routine nursing care though and when does that routine care tip over from FNC to CHC ? For example, does prescribing anti-psychotics on a routine and PRN basis, and monitoring for side effects constitute routine FNC or CHC care ?

    • Care to be Different 3 weeks ago

      Hi Craig – thanks for your comments. CHC is about having a totality of need over an d above what can be expected to be provided by a Local Authority not just in one area – Medication. It is difficult to say without more detailed information. Regards

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