We have spoken to a number of people over the past month who have been refused assessment for NHS Continuing Healthcare Funding (CHC) because their relative is not “optimised”. This seems to be the latest NHS buzzword, as it is not mentioned anywhere in the National Framework.
We told you about the ‘Grogan Gap’, a newly invented NHS phrase in our last article. It seems that the NHS Clinical Commissioning Groups have either had a training session on yet more ways to evade their obligations, or else are trying to compete with the Oxford Dictionary to find some new words to add to their ‘CHC’ vocabulary before the year end.
If your relative has a ‘primary health need’ they may be entitled to a package of FREE care funded entirely by the NHS, known as NHS Continuing Healthcare Funding (often abbreviated as ‘CHC’). CHC is not means-tested, is paid irrespective of wealth, and is not dependent on the setting where the care is provided (eg in your own home or a care home facility).
If your relative is about to go into a care facility (or is already in one), they are entitled to ask the NHS to undertake an assessment of their healthcare needs at any stage to see whether they are eligible for CHC Funding.
This is a two-stage process, starting with the initial Checklist screening tool.
The bar is set low at this stage to ensure that the majority of people applying for CHC Funding are not screened out of the process prematurely. For more information about the Checklist assessment process read our blogs:
If your relative scores positively at this Checklist stage, they will then move on to the second stage – a Full Assessment. This is carried out at a more formal meeting conducted by a Multi-Disciplinary Team of assessors (MDT) who are appointed by the Clinical Commissioning Group (CCG). They will make a recommendation to the CCG as to whether the individual is eligible for CHC Funding.
The MDT is the critical part of the assessment process and the first real opportunity (excluding Fast Track assessments) to secure free funded care for your relative. Good preparation is vital! You need to be fully prepared for this meeting. Otherwise, your relative could end up paying thousands of pounds a month for their healthcare and accommodation, quite unnecessarily!
For more helpful information as to what to expect at the MDT look at these blogs:
The latest NHS delaying tactic – “optimisation”
We spoke to an Enquirer who had recently attended a Multi-Disciplinary Team assessment on behalf of his mother, only to be told that the meeting would not go ahead because she had never had a Dementia Assessment, and so was not “optimised”.
The family were told that she would now need to have this Dementia Assessment first, which might result in a new regime of medication (ie be “optimised”), which, if successful, could result in reduced healthcare needs. Hence, upon review, a further Checklist would need to be completed to see whether a Full Assessment is still appropriate.
So, despite an initial positive Checklist already having been completed, this added ‘optimisation’ stage, not only adds another artificial stage in the assessment process, but, moreover, can have dramatic financial implications for the individual in care.
What does this mean in practical terms?
This added tactical delay means that our Enquirer could be forced into paying another six months full care home fees, maybe longer, without their mother ever having been assessed for NHS Continuing Healthcare Funding by an MDT. In the meantime, the family may be forced to sell their mother’s home to pay for her care, or else dig into hard earned life-time savings or private funds, to prevent her being evicted from the care home.
The National Framework NHS Continuing Healthcare Funding and NHS-funded Nursing Care (revises October 2018) states that patients should not now be assessed in an acute hospital setting, which we accept is quite reasonable. However, if the patient is in a Nursing Home, then the indication is that they have been medically discharged from hospital (i.e. their condition is deemed clinically stable).
In this eventuality, we cannot foresee any reasonable grounds for the NHS to delay arranging the preliminary Checklist assessment or proceeding to an MDT.
There is also an added risk that ‘optimisation’ could ultimately lead to the CCG refusing to carry out a Full Assessment after all, on the basis that the individual’s healthcare needs might reduce in future, once optimised! This is, of course, entirely speculative, as their needs might equally deteriorate.
Turning back to our Enquirer whose mother is awaiting ‘optimisation’ prior to carrying out another Checklist. Supposing, the boot is now on the other foot, and the proposed Dementia Assessment takes place resulting in a different medication regime being implemented. Healthcare needs that were previously stable and well-managed, could now potentially become unstable. Does that change mean that the CCG should automatically agree to fund her care on the basis that her needs might change, regardless of her current identified needs? Somehow, we very much doubt that the NHS would agree to pay for these speculative care needs, which may or may not arise.
The cynical would say that the obvious purpose of inserting an artificial ‘optimisation’ stage into the assessment process (not mentioned anywhere in the National Framework) is simply to try and save funds.
Remember: CHC assessments to determine eligibility for NHS Continuing Healthcare Funding are all about identifying present needs – ‘here and now’ – and not about speculation as to what might (or might not) happen in the future. That is why ‘optimisation’ is flawed.
If the latest NHS tactic is to introduce ‘optimisation’, then at least the NHS should agree to pay for the individual’s care in the meantime whilst this intervention is taking place, as inevitably delays occur. It is simply unfair and unreasonable for individuals to be expected to pay for their own care whilst waiting for the NHS to get their house in order and embark on ‘optimisation’.
By analogy, an individual discharged from hospital but requiring additional rehabilitation (i.e. ‘optimisation’) would have their care funded by the NHS via an interim package of care – either in their own home, a care home or community hospital. Similarly, those individuals who have been identified as requiring Full assessment for CHC, but need optimising ie further medical intervention or treatment before this takes place, should expect their care to be fully funded in the meantime.
We do not agree with ‘optimisation’ and would prefer to see individuals assessed far more quickly for CHC. But, if the NHS insist on ‘optimisation’ to see if more can be done to improve an individual’s healthcare once outside an acute (hospital) setting (and avoid paying for long term care!), then the NHS should fund their care in the meantime. Simple! The NHS can’t have it all ways!
Watch out for ‘optimisation’ as this seems to be purely a delaying tactic by the NHS to defer, or even avoid a Full MDT assessment and having to pay for your relative’s care home fees.
Don’t accept this delay and succumb to ‘optimisation’ or else your relative may end up paying for their care unnecessarily!
Tip: Ask the CCG to point out where ‘optimisation’ is provided for in the National Framework.
For additional reading around the subject take a look at these blogs:
If your relative has been “optimised”, then share your experiences below and tell others: what the NHS said to you to justify ‘optimisation’, what further assessments they needed to do before the Checklist could be carried out (or redone), and how long it took from ‘optimisation’ until the Full MDT assessment, did the matter in fact get to an MDT at all?