Jargon busting CHC… here’s a quick refresher guide to some of the key phrases that you will frequently encounter when applying for NHS Continuing Healthcare Funding and some helpful commentary:
NHS Continuing Healthcare Funding (or ‘CHC’ for short):
Is a complete package of free-funded care that is paid for by the NHS if your relative has been assessed as having a ‘primary health need’.
This free package of care should be provided irrespective of whether your relative lives in their own home, a care home or in a nursing home environment. CHC is not means tested. Therefore, regardless of wealth, if you have a primary health need, then all your clinically assessed health needs and accommodation should be met in full by the NHS. You should not be asked to contribute a penny. Remember: It’s a matter of health not wealth.
Primary Health Needs:
Refers to health needs of a nature beyond which Local Authority (Social Services) would ordinarily be expected to provide; and if in a care home setting, “are more than incidental or ancillary to the provision of accommodation which the Local Authority Social Services…are under a duty to provide.” Such LA responsibilities are set out in the Care Act 2014.
Read our blogs:
‘Primary health need’ made simple – what does it really mean?
Apply for NHS Continuing Healthcare Funding if your relative has a ‘primary health need’…
Care Act 2014:
Applies largely to social care and support services provided by Local Authorities – ie means tested care.
Care Domains:
There are 12 Care Domains set out in the Decision Support Tool which are considered when assessing an individual’s eligibility for NHS Continuing Healthcare Funding.
These Domains are: (1) Breathing, (2) Nutrition – food and drink, (3) Continence, (4) Skin and tissue viability, (5) Mobility, (6) Communication, (7) Psychological and emotional needs, (8) Cognition, (9) Behaviour, (10) Medication/drug/therapies, (11) Altered state of consciousness, and (12) Other significant care needs.
Each Care Domain is scored from ‘No Needs’ at the lowest level, to either ‘High/Severe/Priority Needs’ at the top end. The overall score builds up a picture of eligibility for CHC, but this has to be considered in conjunction with the four key indicators.
Four Key Indicators (or Characteristics):
Refers to the ‘nature’, ‘intensity’, ‘complexity’ and ‘unpredictability’ of an individual’s health needs – and particularly what health needs are there, how often they occur, how they are monitored and managed effectively, and what specialist intervention / skills are required to manage them over a sustained 24 hour period.
Each of the four key indicators may on their own, or in combination, demonstrate a primary health need when looking at the impact they have on the quality and/or quantity of care that is required within each of the Care Domains.
Read our blog:
Understanding the four key indicators
Clinical Commissioning Groups (CCG):
There are about 200 CCGs in England and Wales, which are NHS organisations responsible for “planning and commissioning healthcare services” in a designated locality. CCGs perform the NHS’s responsibilities for assessing, decision-making, implementing and carrying out the NHS Continuing Healthcare packages.
Initial Checklist:
A basic screening tool used by CCGs to determine whether an individual should proceed to a full assessment at a Multi-Disciplinary Team assessment.
Read our blog:
Can the NHS refuse to carry out an initial Checklist?
What’s new in 2018 NHS National Framework for CHC? Are you getting an interim care package?
Multi-Disciplinary Team Meeting (MDT):
This is a full assessment of an individual’s health needs carried out by professionals from different disciplines using a Decision Support Tool.
Read our blogs:
What Happens At The Multi-Disciplinary Team Meeting?
Attending the Multi-Disciplinary Team meeting – some useful guidance
Decision Support Tool (DST):
Sets out the 12 Care Domains, and is a scoring ‘tool’ used at the MDT to assess an individual’s health needs across the various Care Domains by reference to a description (or descriptor) which explains what sort of things would give rise to a ‘Priority’, ‘Severe’, ‘High’, ‘Moderate’, ‘Low’ or ‘No need’. The DST is not an assessment in itself, but rather a way of recording your relative’s overall health needs in consultation with the four key indicators.
Read our blog:
Who completes the Decision Support Tool in NHS Continuing Healthcare?
Local Resolution Panel (LRP):
If your relative is not eligible for CHC following a Multi-Disciplinary Team assessment, then consider appealing that decision to a Local Resolution Panel Meeting. There is a procedure for doing this. But beware! A strict 6 month time limit applies to lodge an appeal.
Read our blogs:
Rejected for CHC Funding? Part 1: How To Appeal The MDT Decision;
Appealing A CHC Funding Decision, Not To Grant or To Withdraw Funding
Independent Review Panel (IRP):
If you remain dissatisfied with the outcome of the IRP Decision, then you can appeal to NHS England who will arrange an independent appeal by an IRP. Again, there is a procedure to follow, and the same 6 month deadline applies to lodge your appeal with NHS England.
Read our blog:
Rejected for CHC Funding? Part 2: How to appeal the Local Resolution Decision
NHS England (NHSE):
Responsibilities include providing strategic leadership, planning, day-to-day operational running of the NHS, NHS budgeting, adherence to the NHS National Framework, holding CCGs directly accountable and ensuring that they discharge their functions properly, arranging and convening IRPs.
NHS-Funded (Nursing) Care (FNC):
(also known as Registered Nursing Care Contribution (RNCC):
Is a funded package of care “provided by the NHS to care homes with nursing, to support the provision of nursing care by a registered nurse…”
Palliative Care:
Is a package of specialised holistic care provided to individuals with advanced, progressive or terminal illness to enable them to have a better quality of life.
Note: In some cases, NHS CHC Funding is only awarded ‘magnanimously’ by CCGs during the terminal weeks of an individual’s life; but also be aware that existing CHC can be declined at this stage too. Even though an individual may have acute health needs, they can often be better controlled, become more manageable and less intense as the individual’s health rapidly deteriorates. (See four key indicators above).
Personalised Health Budget (PHB):
Is a sum of money provided by the NHS, that enables an individual in receipt of CHC more freedom of choice and control over how they wish to pay for their healthcare needs. Rather than the care home dictating how the CCG’s budgeted funds are spent to meet the individual’s clinically assessed healthcare needs, they are given a lump sum (usually monthly) instead, and can decide how they wish to spend money on their own care.
Read our blog:
What are Personal Health Budgets?
Advocate:
Whether attending Multi-Disciplinary Team assessment, an LRP or IRP, you should be notified well in advance of the meeting, so that you can prepare for it in good time.
You are entitled to take along someone to assist you, who can provide emotional support, take notes at the meetings, or even act as an advocate on your behalf to present and argue your case. Don’t forget, you are fighting the NHS for CHC Funding and they are not eager to part with budgeted funds! Doing a bad job could cost you many thousands of pounds per month in care home fees which might have been avoided if using a professional advocate skilled in CHC Funding.
Read our blog:
Can The MDT Panel Refuse To Proceed If I Have An Advocate?
Early preparation is key to success. Visit our Need one-to-one help webpage if you need help with your individual case.
Fast Track Tool:
This is an abbreviated short-cut process which can be used if your relative has a rapidly deteriorating condition that may be entering into a terminal phase. Your relative will be ‘fast tracked’ along a different process using the Fast Track Pathway Tool. If successful, CCGs should implement a package of care within 48 hours.
Read our blog:
How To Fast Track The Continuing Healthcare Funding Process
National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care (otherwise known as the ‘National Framework’):
Recently revised with effect from 1st October 2018, the National Framework is a practitioner’s ‘bible’ containing 167 pages of core values, principles, guidance, and details of the assessment processes for NHS Continuing Healthcare and NHS-Funded Nursing Care. It is designed with NHS professionals in mind, but is your essential starting point when tackling the NHS. Familiarise yourself with the rules by which the NHS assess an individual’s eligibility for CHC Funding.
However, if you find it is too daunting, Care To Be Different provides a website filled with lots of handy tips, free information and resources, to help you along the way.
Read our e-book, “How To Get The NHS To Pay for Care” and “The 7 Costly Mistakes Most Families Unwittingly Make With Care Fee” which we are confident you will find very helpful indeed.
Top-up Fees:
The whole point of NHS CHC Funded Care is that it is “free at the point of delivery” ie when you need it. That is one of the core principles of the NHS National Framework.
The NHS CHC package should be adequate to meet all your relative’s healthcare needs set out in their care plan – and that includes accommodation. Care homes are not allowed to charge individuals for additional payments (ie top-up fees) towards the cost of their clinically assessed healthcare needs (and critically, that includes accommodation as well), however cleverly covert top-up fees may be described or disguised!
So, if there’s a shortfall because the cost of residency in a more luxurious care home exceeds the CHC Funded package being paid by the CCG, then insist that the care home seeks increased funding from the CCG to meet all those healthcare needs. You should not be charged, unless the top-up fees relate to ‘hotel style’ services such as beauty treatments eg chiropody, hairdressing etc.
Read our blog:
TOP-UP FEES – Unfair Care Home Practices Now Face Government Sanctions
Are You Paying Top-Up Fees Unnecessarily?
‘Well-Managed Needs’ principle:
A term often banded around by the NHS to justify not paying NHS CHC Funded care. This is a complex area.
The CCG argument runs as follows: because an individual’s needs are ‘well-managed’, they don’t have a ‘primary health need’, and so are ineligible for CHC Funding. However, that argument only succeeds if the healthcare need has either been permanently reduced or removed altogether.
What you need to do is assess the baseline level of routine care needed, and if an individual still has health needs over and above what ordinarily would be expected, even if those needs are ‘well-managed’, they may be eligible for CHC Funding. Remember: Well-managed needs are still needs!
Read our blogs:
Do you really understand the “Well-Managed Needs” argument? – 2018
Care is routine” – misleading NHS Continuing Healthcare information
Local Authority Social Services:
In the event that an individual does not qualify for NHS CHC, they may be entitled to funding from the Local Authority provided through Social Services. This, however, is means tested. If your relative has capital or assets of more than £23,500, then they may be asked to contribute, in whole or in part, to their care.
Joint Packages of Health and Social Care:
If an individual is not eligible for CHC Funding, the NHS may still potentially have a liability to provide a joint package of care in conjunction with the Local Authority. Both organisations are supposed to work together in partnership to provide care or a supportive package.
Read our blog:
What is a joint package of care?
Mental Capacity:
Describes whether an individual has the mental capacity (as set out in the Mental Capacity Act 2005) to consent to an assessment for eligibility for NHS Continuing Healthcare. It is important the individual is involved in the CHC process, understands what is going on, and gives their permission for the assessment to proceed. In the event that they do not have mental capacity, decisions can be taken in their ‘best interests’.
Read our blog:
Cognition and mental capacity – what’s the difference?
Best Interests:
Occasionally, it will be necessary for an independent third party (the ‘decision maker’) to take a decision on behalf of an individual if it is genuinely felt to be in their ‘best interests’. That can cause problems, especially if family members do not agree with the decision maker’s views! A Lasting Power of Attorney can be useful to empower families to deal with such situations.
Read our blog:
Lasting Power of Attorney (LPA):
There are two types of LPA: (1) Property and Financial Affairs, and (2) Health and Welfare. An LPA can only be made if an individual is 18 years or older, and has mental capacity to make decisions themself. Under an LPA an individual can appoint a designated Attorney(s) to act in their best interests and make decisions on their behalf – either before, or once they have lost mental capacity.
TIP: If you don’t have an LPA, then you ought to consider setting one up as soon as possible to cater for life’s unknown contingencies.
Read our blogs:
I have a will, so why do I need a Lasting Power of Attorney?
Lasting Power of Attorney: 4 ways to start the conversation
Essential: Have You Got A Power Of Attorney
Wills:
A Will is a legal document that enables you to decide how your Estate (eg property, assets, money and any personal belongings) will be distributed after you pass away. It can have tax advantages, and moreover guarantees that your wishes (and any ‘legacies’ ie gifts) will be carried out as instructed by your Executors. Otherwise, in the absence of a Will, Intestacy rules apply, and your acquired personal belongings and assets may be distributed to family members in a ‘pecking’ order which you had not intended, and others may miss out.
Coughlan Case:
This is the most important landmark court ruling in NHS Continuing Healthcare Funding (CHC). Pamela Coughlan made a claim for CHC against North and East Devon Health Authority and won in the Court of Appeal.
The Court’s decision drew a critical distinction between Local Authority Funding (which is means tested) and NHS Continuing Healthcare Funding (which is free at the point of need).
Essentially, the outcome meant that Local Authorities could only legally provide healthcare services that were:
- Merely incidental and ancillary to the provision of accommodation which a Local Authority is already under duty to provide;
- Of a nature, which it can be expected that an authority whose primary responsibility is to provide Social Services can be expected to provide
In short, the Coughlan ‘test’ essentially held that where an individual has a primary health need (ie requires nursing services that are over and above or beyond lawful remit of Local Authority Services), then it is the responsibility of the NHS to fund that care (CHC) free of charge.
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I,am currently awaiting my DST for continuing healthcare, l now realise that this DOH sections in the DST are not online with the, Coughlan judgement. The judge said only if the nursing needs are mearly incidental and ancillary, can the LA ‘s fund them,the judge further said,if the person has health needs then the NHS is fully responsible for,their care. So it’s not decided on the 4 DOH criteria of complexities,its a matter of law, it’s some that,you should point out to the MDT at the beginning stating l expect this assessment to be fully Coughlan compliant.
Regards valerie
S
Thank you for that advice. Who would my first port of call be ? We seemed to have had quite a few staff dealing with my mother.
My mother aged 96 was moved out of Hospital into a Nursing Home in November 2017.
She was totally unable to do anything for herself plus advanced Altzheimers and lack of communication due to a stroke. We continually asked fot the Assessments to be done whilst she was in hospital and we were continually being put off and then told it would be done in the Nursing Home. She died 5 weeks after her transfer. She never left the bed, was not aware of where she was and had to have everything done for her. She was unable to communicate. No one came to carry oit the promised assessment !
We paid £5000 + to the Nursing Home for her Care, and obviously were then just written off by the NHS.
Mandy – sorry to hear this. It is no too late to pursue this. Why not contact the CCG and ask tell them that you would like them to to do a retrospective review. Kind regards