In response to requests for more information about the 4 Key Indicators, we are developing a series of blogs aimed at addressing some of the important issues you need to know.
In order to meet the eligibility criteria for NHS Continuing Healthcare Funding (CHC) your relative must have a ‘primary health need’. In short, this means that the primary or overriding reason for their care must be due to healthcare, rather than social care, needs.
Understanding the basic distinction between health needs and social needs is essential as it underpins the whole ‘primary health need’ approach. If you are not familiar with these concepts, we recommend that you read these helpful articles:
The Assessment Process
In order to be awarded CHC, there is an assessment process which NHS Clinical Commissioning Groups (CCGs) have to follow, starting with an Initial Checklist assessment. The Checklist is a scoring tool to determine whether the individual will pass on to the next stage: a full assessment.
For more information about the Checklist assessment, read: Understanding the Checklist Assessment
The full assessment is carried out by a Multi-Disciplinary Team (MDT) using the Decision Support Tool (DST). The DST is not the assessment itself, but is merely a useful ’tool’ to gather together and record the evidence of needs in one document, and assist the MDT to reach a conclusion as to eligibility for CHC Funding. The DST looks at certain areas of need, called Care Domains, namely: Breathing*, Nutrition – Food and Drink, Continence, Skin integrity (including tissue viability), Mobility, Communication, Psychological and emotional needs, Cognition, Behaviour*, Drugs/Medication/Symptom control*, Altered states of consciousness* & Other.
Below is a copy of the image taken from the National Framework listing all 12 Care Domains and shows the interaction between the intensity, complexity and/or unpredictability of needs:
Each Care Domain is broken down into a number of levels. The levels represent a sliding scale from the lowest to highest, with: ‘N’ (No needs) at the bottom end of the scale, increasing to ’L’ (Low), ‘M’ (Moderate), ‘H’ (High), ‘S’ (Severe) and ’P’ (Priority) needs at the highest possible level of need and support required.
Completion of the DST should result in a comprehensive picture of the individual’s needs that captures the nature, intensity, complexity and/or unpredictability of their needs and indicates the quality and/or quantity (including continuity) of care required to meet those needs.
The DST contains a summary sheet to provide an overview of the levels chosen and a summary of the individual’s needs, along with the MDT’s recommendation about eligibility or ineligibility. The guidance gives a clear recommendation (and decision) that eligibility for NHS Continuing Healthcare would be expected in each of the following cases:
- A level of ‘Priority’ needs in any one of the four Domains that carry this level (also marked * above).
- A total of two or more ‘Severe’ needs across relevant Care Domains.
You can learn more about the MDT assessment in the blogs at the end of this article.
The MDT’s Approach
When carrying out a full assessment to determine whether the individual has a primary health need, and is therefore eligible for CHC Funding, the MDT are supposed to take a holistic approach and consider the totality of the individual’s care needs.
Eligibility for CHC Funding is not contingent on any particular diagnosis or medical condition, but rather on the daily needs of the individual and whether these fall into the category of health or social care. To correct a common misunderstanding, a diagnosis of Dementia or Alzheimer’s alone, does not guarantee CHC Funding. The MDT have to look at the whole picture of overall needs (holistic) and consider their interaction as a whole (totality). We will explore the interrelation of healthcare needs in more detail later in the series.
While the distinction between health and social care can be difficult to define, social care needs are often thought of as being assistance with the things we all need to do every day: washing, dressing, eating, drinking, moving around, going to the toilet, taking routine medications, applying prescribed creams. The NHS refer to them as Activities of Daily Living (ADL). If a person’s primary need is for social care, i.e. assistance with such routine daily activities of living, responsibility falls to the Local Authority, who carry out means-testing to gauge the individual’s ability to fund that care.
CHC Funding, however, is concerned specifically with the health needs of the individual; i.e. those needs that can only be met by a registered nurse or other similarly skilled professional. Health needs must be such that a registered nurse, or similarly skilled professional, is required 24-hours a day to provide necessary care. If the individual’s primary (overriding) need is for healthcare, then all of their care (including accommodation and daily social needs) should be funded in full by the NHS, free of charge, via an NHS Continuing Healthcare package. Unlike social care, CHC is not means-tested and is paid by the NHS irrespective of wealth and savings.
Such needs that require the sustained input of a registered nurse, or other similarly skilled professional, might include:
- Severe behavioural problems, such as unpredictable physical aggression, absconding or self-harm – such that there is a serious risk of harm to self or others.
- Severe psychological disturbance, requiring regular pharmacological intervention and referrals to Mental Health Services.
- A physical condition such that there is serious risk of injury upon movement or transfer, or whereby the positioning of the patient is crucial – e.g. to aid breathing.
- Problems with swallowing food/drink/medication, requiring regular monitoring by Speech and Language Therapy. Even with such intervention, the patient may still aspirate (inhale liquids/food particles into the lungs), requiring skilled intervention and/or suction to clear the airways.
- Problems with continence beyond routine care; for example, a problematic catheter requiring frequent changes/washouts, or severe constipation requiring the frequent administration of enemas and/or performance of manual evacuations (manually removing faeces from the rectum/sigmoid colon).
- Significant tissue breakdown caused by pressure sores or other skin conditions, such that the integrity of the underlying tendons/muscles/bones is compromised or at risk. The patient requires regular dressing changes – daily or more frequently – and supervision by Tissue Viability Nurses to ensure the wound does not degrade further.
- Sustained difficulty in breathing, requiring the regular administration of oxygen or other inhalants. Even with such intervention, the patient continues to have difficulty in breathing and all Activities of Daily Living are affected.
- A complex or frequently changing medication regime, requiring regular oversight by the GP or Consultant. The route of medication may be complex – intravenous – or the type of medication may be high-risk, e.g. licenced painkillers, such as morphine.
- Severe and unrelenting pain, such that frequent in-the-moment decisions regarding the administration of licensed analgesics need to be made, and the patient’s mental and physical wellbeing are affected.
- Frequent (weekly, daily or several times each day) episodes of Altered States of Consciousness – e.g. transient ischaemic attacks, cerebrovascular accidents, epileptic seizures – requiring skilled intervention or A&E admission to minimise the risk of harm.
Eligibility for CHC Funding is not contingent on a certain combination of levels of need across the 12 Care Domains within the DST, (except as above, in cases of automatic award when an individual has one ‘Priority’ level of need or two ‘Severe’ levels of need), but rather on the fulfilment of one or more of the Key Indicators (sometimes referred to as ‘Characteristics’), namely: Nature, Intensity, Complexity and Unpredictability.
A description of the 4 Key Indicators is set out in paragraph 59 of the National Framework for NHS Continuing Healthcare and NHS funded Nursing Care (revised October 2018), and are summarised below:
NATURE: The nature of the patient’s needs addresses the necessary quality of the service to be provided to the patient, and whether a local authority should lawfully be expected to provide it.
INTENSITY: Intensity of needs evaluates the quantity and degree of needs, as well as the continuity of care necessary to treat those needs. Where a Local Authority funds aspects of healthcare, the primary need must be for accommodation and/or social care.
COMPLEXITY: The complexity of needs is concerned with how the needs present and interact to increase the skill needed to monitor the symptoms, treat the condition(s) and/or manage the care. This can arise with a single condition or can also include the presence of multiple conditions or the interactions between two or more conditions.
UNPREDICTABILITY: The unpredictability of needs addresses the degree to which needs fluctuate, creating challenges in managing them, and the degree of risk to the person’s health if adequate and timely care is not provided. For the purposes of this indicator, someone with an unpredictable healthcare need is likely to have either a fluctuating, or unstable or rapidly deteriorating condition.
Each of these 4 Key Indicators 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.
A ‘Priority’ level of need in the Domains of Behaviour*, Breathing*, Medication* or Altered States of Consciousness* would, in and of itself, fulfil at least one of the Key Indicators and demonstrate a primary health need (see Paragraph 141 of the NHS National Framework); either because staff require specialist knowledge to meet the needs (think of a person on invasive mechanical ventilation, or someone whose behaviour is a mortal danger to self or others, or someone who is suffering life-threatening seizures on a daily basis), because interventions take a long time or an increased number of staff, or because the condition is rapidly changing such that Care Plans must be updated weekly, daily or even hourly.
Two ‘Severe’ levels of need in any of the Domains that carry this weighting would result in inherent complexity, due to the interrelation of needs and their impact on one another. It would also likely result in some intensity in terms of the frequency of intervention, the length of time this takes and the number of staff required.
Whereas, Activities of Daily Living – such as eating/drinking, routine toileting/changing of continence pads, changing position/moving around and taking routine medication are considered social needs – none of which require the continued input of a registered nurse or similarly skilled professional. This type of predictable 24 hour care intervention, assistance and support can be delivered routinely by unskilled staff. Even if a person requires full assistance with all activities of daily living, and providing there is no complexity, intensity and/or unpredictability arising from those needs (should they be severely cognitively impaired, unable to communicate, immobile and doubly incontinent), this is classed as social care that can be met by the Local Authority (subject to means-testing).
For example, take an individual who requires full assistance to wash, dress and maintain personal hygiene; who is doubly incontinent and relies on care staff to change their pads regularly and ensure good skin integrity; who is unable to weight bear and requires the use of a full hoist to transfer; who relies on staff to administer their non-complex medication regime, which is routinely prescribed; who is compliant with all care and is described as having a “happy and cheerful outlook”; who does not experience any difficulty in breathing and does not suffer altered states of consciousness; who does not appear to be in any pain. Let’s say, the only Care Domain in which there is some evidence of complexity is ‘Nutrition’ – where the individual has been assessed as being at risk of aspiration and requires their fluids be thickened to assist swallowing; but, there is no evidence of frequent choking episodes requiring skilled intervention to maintain their airway and the individual maintains a healthy weight. A risk of choking is not sufficient to indicate eligibility for CHC Funding, unless there is evidence of a severe impact on wellbeing and the provision of care (i.e. nutritional status at risk; skilled interventions to clear the airway frequently required). In this hypothetical example, the individual’s care interventions would not present with a primary need for healthcare, and as such, they would not eligible for CHC Funding.
For more reading around the subject, look at this selection of articles from our website: