Four key indicators.
Families often tell us that they find the NHS Continuing Healthcare assessment process – emotional, difficult, lengthy and immensely frustrating. For many, it appears that the whole assessment process to determine eligibility for NHS Continuing Healthcare Funding (CHC) is ‘slanted’ against them, or else, designed to frustrate their relative’s entitlement for free funded care.
The process is clearly not as straightforward as it is perhaps intended to be – whether you’ve wrongly been told that ‘it’s a waste of time because your relative simply won’t qualify for CHC’; or been given misleading information, such as, ‘you can’t bring an advocate along with you’; or have been subjected to inaccurate or incompetent assessments; or lengthy and unreasonable delays which cause families frustration whilst the NHS drag out the eligibility assessment process.
Sometimes, the process can be so lengthy, that, often what starts out as a current assessment for CHC Funding for an individual going into a care home, ends up becoming a retrospective claim, as the individual has passed away whilst trying to secure funding. In the meantime, they may have had to sell their home to pay for their care.
We thought it would be helpful to look at matters from the NHS’s perspective, and consider how their assessors might argue the case against an individual seeking NHS Continuing Healthcare Funding.
Here is an example to help you understand some of the common arguments that might be raised by Clinical Commissioning Group assessors.
As you will know from reading our many other blogs, in order to obtain free funded NHS care (known as NHS Continuing Healthcare Funding), your relative first has to demonstrate that they have a ‘primary health need’. In simple terms, that is clinically assessed nursing or healthcare needs of a nature over and above what the Local Authority (Social Services) could ordinarily be expected to provide, and are more than just incidental or ancillary to accommodation needs which the Local Authority are under a duty to provide. For further reading: ‘Primary health need’ made simple – what does it really mean?
Those families who have already been through the assessment process, will know that it is not just about reviewing the 12 Care Domains (Breathing, Nutrition – Food and Drink, Continence, Skin integrity (including tissue viability), Mobility, Communication, Psychological and emotional needs, Cognition, Behaviour, Drugs/Medication/Symptom control, Altered state of consciousness & Other). You have to take a holistic approach and consider the totality of the individual’s needs when applying the Four Key indicators/characteristics (Nature, Intensity, Complexity and Unpredictability) to see whether there is an overall primary healthcare need that justifies fully funded NHS Continuing Healthcare. Read our blog: Understanding the four key indicators
According to the NHS National Framework, “Each of these characteristics may, alone or in combination, demonstrate a primary health need, because of the quality and/or quantity of care that is required to meet the individual’s needs.”
If your relative does not meet the eligibility criteria for fully funded NHS care, then they should automatically be considered for NHS-Funded Care instead to meet the nursing element of their care needs in a care home. Read: Have you considered NHS-Funded Nursing Care (FNC)?
Fictional Case study; Mary’s claim
Background – a brief summary of Mary’s daily care needs:
Mary has suffered two strokes and is in cognitive decline with vascular dementia; is immobile and requires use of a hoist for transfers; needs full time assistance of two carers; help with her mobility; frequent repositioning to maintain skin integrity and prevent pressure sores; cannot use her left arm due to weakness and has to use a spouted beaker when drinking to prevent spillage and burns from hot drinks; has difficulty swallowing – her food has to be pureed and her drinks thickened for consistency; is doubly incontinent and relies on staff to meet her needs in a timely manner in order to maintain her dignity and protect her skin from damage; has behavioural difficulties; limited awareness of her surroundings; is unable to reliably communicate her needs; and is totally reliant on her carers to anticipate her needs.
Here’s a selection of phrases that CCG assessors may use to argue the NHS case to refuse CHC Funding
Mary has routine care to maintain her safety and to ensure that her needs are met.
The care plans are reviewed routinely and the care records indicate that staff can manage her needs on a consistent and predictable basis.
Her nursing care and other needs are not of a nature entirely beyond which the Local Authority could lawfully provide.
Although Mary is immobile, unable to assist with her care, requires her skin monitoring for pressure sores, medication administering, nutritional needs monitoring and oversight of a Registered Nurse 24 hours a day, those needs were routinely met and should have been funded by NHS-Funded Nursing Care instead.
Primary health need is not about the reason why someone requires care or support, nor is it based on diagnosis, it is about the overall picture of care needs taken in their totality i.e. about the impact of the illness and disability.
The nature and quality of Mary’s health and care needs do not demonstrate a level of eligibility of NHS Continuing Healthcare, and do not produce a primary health need.
The quality of interventions required, are not in themselves, over and above that which a Local Authority could legally provide with the assistance of outside organisations e.g. GP/District Nurses etc.
Furthermore, any element of nursing care required to look after Mary in the care home has been incidental and ancillary to the provision of accommodation, which the Local Authority Social Services are duty-bound to provide in line with the Care Act 2014, anyway.
There is no evidence of any unmet needs, and all the care provided to Mary is predominantly of a routine and pre-planned basis and linked to her activities of daily living.
Her care is delivered routinely by care staff with access and oversight of a Registered District Nurse, as required. NHS Funded Care is more appropriate.
Although Mary developed cognitive and physical impairment, which impacted upon her behaviour, communication, continence, mobility, nutritional and psychological domains, she declined food, fluids and medication, resulting in a large amount of weight loss, was immobile and required assistance to re-position her every two hours both day and night, there is nothing based on the available evidence to suggest that her care needs would warrant them being described as complex – whether taken in isolation or totality. Interactions between the various care domains do not make Mary’s needs for care delivery complex.
There is no evidence to support a level of complex needs – either individually, or in their interaction, or totality. Care providers are able to use their skill and judgment to monitor and intervene in Mary’s needs, which are not complex, and are within the remit of social services’ responsibility to provide. Her needs can be met through routine pre-planned care.
Whilst Mary undoubtedly has needs in many of the Care Domains, the totality of those needs do not combine to create a quantity or intensity of need or care which will lead to a primary health need. She does not require sustained care intervention or continued care and monitoring.
Intensity is about the quantity or length of care interventions. Care is being delivered in a timely manner by two carers in line with say moving and handling guidelines. The records do not show a sustained or intense level of need, or that the care delivery was taking a lengthy period.
Is about the degree to which needs fluctuate and thereby create challenges in managing them.
Mary’s needs do not fluctuate, are settled, stable and care is provided on a routine basis within the remit of pre-planned care plans. Care is delivered by two members of the care team together with the oversight and access to a Registered District Nurse. Her needs could readily be anticipated, even though she is unable to inform her carers of her needs.
The care provided was maintained and does not fluctuate at short notice.
Whilst timely care, monitoring and supervision is required around the Care Domains, her need for monitoring and supervision is not unpredictable and remains of a nature and extent which a local authority could lawfully provide.
The CCG’s assessor might conclude by saying something like:
Having considered the nature, complexity, intensity and unpredictability of the totality of Mary’s healthcare needs, and the interaction between those needs, together with all supporting evidence, the CCG’s conclusion of the assessment, indicates that Mary does not have a primary health need and would therefore not meet the criteria of NHS Continuing Healthcare Funding. Despite evidence of a health need in various Care Domains, which interact and impact upon each other, Mary’s care is routine, managed and monitored successfully in accordance with the care plans, and does not justify an award for NHS Continuing Healthcare Funding, as those needs could be met by the Local Authority. Alternatively, any nursing needs element could be met by the NHS-Funded Nursing Care Package.
This scenario might be a typical example of a CCG’s position. You can now understand, how, even in cases where it may seem obvious that NHS Continuing Healthcare Funding ought to be awarded, that some CCG assessors can subjectively interpret the Care Domains, 4 Key Indicators and totality of needs, to present an entirely different picture, and effectively undermine an individual’s chances of securing CHC Funding.
When you consider that so many people are in care, it is often quite staggering to learn that so few people actually qualify for CHC Funding. Our message is – don’t give up. Fight on! Perseverance is the key, and if you feel that you have a strong case, you must Appeal.
Don’t forget, you can always seek specialist advice whether it is general advice, help with assessments or appeals, or even advocacy support.
Sounds familiar? Tell others below if you’ve had a similar experience to Mary’s case and how you successfully argued the 4 Key indicators/characteristics…
For further reading consider: