Before you read this blog, we recommend that you read, “Part 1. Explaining The Vital Difference Between Social Needs and Healthcare Needs.”
There are a number of different tools available to measure frailty in the elderly, including the Clinical Frailty Scale (CFS) or electronic Frailty Index (eFI) – simple scoring tools used to measure the health status of older individuals (aged 65+). The CFS serves as a proxy measure to identify ageing and those elderly who are the most vulnerable and are at highest risk of poor outcomes such as falls, deteriorating mobility, disability, admission to hospital, or the need for long-term care.
The CFS essentially describes people in nine categories, grading them as to frailty, with simple visual descriptions. Those who are very fit are at one end of the scale, going all the way through the spectrum to those at the other extreme, who are very severely frail and terminally ill. A score of 0 indicates no frailty; a score of 1-3 indicates frailty risk; and a score of 4 or greater indicates frailty. See the CFS scale below:
(Click Image for larger version)
Although not intended as a tool to determine eligibility for CHC Funding, hopefully, the CFS will help you visualise what sort of care needs are likely to fall into the social needs category (and be funded by the Local Authority and subjected to means-testing) and what sort are more likely to be healthcare needs and be assessed for NHS Continuing Healthcare Funding (provided free of charge by the NHS).
- Categories 1 & 2 – have no care needs
- Category 3 to 6 as examples of purely social care needs and would fall under the remit of the Local Authority
- Category 7 & 8 could potentially fall into either social care or healthcare needs, or a combination of both, and therefore an assessment to determine eligibility for CHC funded care should be done.
- Category 8 could also be CHC, as a person is totally dependent. Again, we would recommend an assessment for CHC ought to be carried out.
- Category 9 – may be eligible for Fast Track Funding and an assessment for CHC ought to be carried out.
Read our blog: How To Fast Track The Continuing Healthcare Funding Process
Families, carers and professionals alike must be able to distinguish between social and healthcare needs, as the outcome will make a huge difference as to who ends up paying for your relative’s care. The issue, however, is not straightforward, as those who have been through the CHC assessment process will invariably testify! Especially, as the dividing lines between social vs healthcare needs are often blurred depending on which perspective you are looking at it from.
Most families will genuinely believe that their relative’s care needs are severe and justifies CHC Funding in full by the NHS. Their argument is frequently based on the premise that, without care in place, their relative will simply not be able to survive alone and will die. However, although a truism, that would equally apply to the whole population, and is not how the ‘primary health needs test’ is applied under the National Framework. As we said in Part 1, much depends on the nature, intensity, complexity and unpredictability of those needs and the skilled interventions required to monitor and administer them.
In Part 1, we gave examples of social needs. Here’s an example of some familiar healthcare needs:
Behaviour
Being restive with care interventions (including his food, medication and personal care) and with episodes of physical aggression, hitting staff and constantly shouting for help and requiring staff to provide frequent reassurance.
Cognition
Suffering from a significant cognitive impairment, difficulties word finding, a poor short term memory and problems with recognition, no awareness of needs and staff being required to anticipate all care needs to ensure that needs were managed as far as possible.
Psychological and Emotional Needs
Frequently shouting out for help and requiring staff to provide reassurance, but not responding to that reassurance. Experiencing low moods, feeling lonely and needing regular bed rest due to pain, poor appetite and lack of motivation, resulting in large weight loss.
Communication
Suffering from dysphasia and unable to communicate needs at times and being unable to initiate any input, assistance or expression of need, requiring all care needs to be anticipated by staff.
Mobility
At high risk of falls and being nursed in bed due to immobility and significant pressure sores to sacrum and heel, causing restlessness at times due to pain and cot sides to be used to minimise the risk of falling out of bed, needing frequent checks throughout the night.
Eating and Drinking
High risk of aspiration and requiring assistance from staff with feeding and drinking, suffering from dysphagia and requiring a mashed diet and thickened fluids, suffering from recurrent choking episodes when swallowing, poor fluid intake due to lethargic state, and suffering significant weight loss; paracetamol changed to suspension form.
Incontinence (Elimination)
Doubly incontinent and requiring staff to manage all continence needs, being prone to constipation and requiring regular laxatives to help manage this.
Skin
Excruciating Grade 4 sacral sore (non-responsive to treatment) and a grade 3 sore to heel area, requiring ongoing nursing treatment by registered general nurses and a tissue viability nurse specialist. The severity of the pressure sore conditions necessitated careful repositioning by staff due to the risk of further damage to skin and pain caused.
Medication
Staff required to administer and monitor the effectiveness of medication and closely monitor and administer pain relief for pressure sore pain, experiencing problems swallowing and paracetamol was changed to suspension form, prescribed Butrans patches.
If you are still struggling to understand the difference between what needs are social needs and what are healthcare needs, here’s a really good analogy to help you:
Analogy
We regularly hear comments that elderly relatives:
“couldn’t do anything for themselves”
“had to go into 24 hour care”
“Social Services insisted they couldn’t carry on living in their own home”
“my Mother/Father was doubly incontinent” etc.
None of these factors are necessarily an indicator of CHC eligibility.
If you think of a two or three year old child:-
- They are unable to prepare their own food and drinks to ensure adequate dietary and fluid intake. They need a responsible adult to prepare food and drinks and possibly to feed them as well.
- Some may still be ‘incontinent’ ie still wearing nappies either during the night or day and night, or having occasional accidents which need cleaning up.
- Unable to protect their own skin integrity – if they are still in nappies, they need an adult to clean, dry and change them after wet or dirty nappies and apply moisturising barrier creams.
- Mobility – at risk of falls, unsteady on their feet, tendency to climb and no awareness of risks!
- Not always able to reliably communicate their needs – how many of us have had to use a process of elimination to determine what may be troubling a crying baby or toddler? Even when they can communicate, it can still be difficult to understand what they are trying to tell you.
- Psychological and Emotional Needs – they may be upset or crying but unable to tell you why.
- Cognition – very few two or three year olds have the ability to assess risk, make appropriate decisions as to their day to day care and manage their own care needs. They rely on responsible parents or others to provide a safe environment for them and ensure that they are protected from danger, abuse or neglect.
- Behaviour – this is an interesting one! Ever heard of the ‘terrible twos’ or ‘terrible threes’?
- Medication – can a two year old child administer good old Calpol? Can they always tell you when they are in pain or where that pain is?
Anyone with young children or grandchildren will be able to identify with all of the above points. Sadly, as our parents and grandparents age, many revert to more childlike behaviours and tendencies. But does that mean that they are necessarily eligible for NHS Continuing Healthcare Funding?
Would you consider that your two year old child or grandchild should be eligible for CHC Funding or would you describe them as having a Primary Health Need?
Probably not – you would accept that they need a responsible parent, grandparent or other adult to take care of them and provide a safe environment with provision of all their day to day care needs. You would certainly accept that they could not live on their own or be left in the house alone. All of that is social type care – the child wouldn’t be eligible for CHC Funding and they certainly don’t have a primary health need simply because they need care by a responsible adult of the type listed above.
The same applies to elderly relatives. Not all needs are healthcare needs, even though they may well be as a result of a progressive disease, such as Alzheimer’s Disease/Dementia. Remember that eligibility is not based on a diagnosed illness or disease. It is about the level of healthcare needs as compared to social care needs – for example once an elderly relative starts to lose weight because they are refusing sufficient diet, that presents risks of malnutrition. If they develop nasty pressure sores because of their immobility and double incontinence, that becomes a health need. Once an elderly relative develops physically aggressive behaviour which makes care delivery difficult or impossible, that can become a health need, and so on.
Conclusion
Identifying the point at which an individual has a ‘primary health need’ is difficult and is usually based on many factors all combining to create intense, complex and unpredictable health needs. These factors are known as the 4 Key Indicators or Characteristics. An individual’s needs have to be assessed in the whole, taking a holistic approach, to determine whether they are eligible for CHC Funding. Once you have understood whether the needs fall into the category of healthcare needs, you need to really understand how the NHS will assess those needs when factoring in the 4 Key Indicators. That is a whole separate topic!!
For further information on the subject, read our blogs:
Understanding the four key indicators
‘Take a holistic approach to improve your chances of getting CHC Funding’
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Could anyone please comment on what I have said above? I really need some guidance and answers as the social worker and the CCG refuse to respond. Surely if the person is in a care home 24/7 due to their disabilities and vulnerable with need for constant monitoring of several conditions they have health needs which shield qualify for CHC. Especially if the CCG and social care have already admitted a health allocation of 42%. I would think it should be far more as why is health evening but social care in the day (see above)? Surely all the care needs should be allocated to health. Anyone able to help here??
Hi Tracy, Just from my experience of contesting fees for over three years. I have been through complaints and appeal without success in having my argument accepted, even though I thought it was proven without doubt. What I have found is (don’t take this as advice but somewhere to look for the answers) the LA has a lawful requirement under the Care Act to provide an assessment of need for anyone who is vulnerable. You should quote the Care Act in requesting the details of this. You can also use the data protection act to get all the information you need from the LA or NHS.
If no one is budging, the only people with a legal framework in the limits of health and welfare is the LA. It may be worth writing to see if the LA can take over all the care. If it is beyond their legal remit then you could use Statutory Instrument SI 2996 Clause 21 regulation 5-7, however this was ignored by everyone in my case. I sat in an appeal and repeated for 40 minutes that I wanted this question answering first, with a letter from the CEO telling me it had been considered. The appeal team refused to answer and then glossed over it in their minutes of the meeting. What they do in the assessment process is start looking at shared care plans before finishing the determination of a Primary Health Need. Make sure you record every meeting. What do you do when no one plays by the rules ?
From where you are you are going to have a long struggle. Just my opinion.
If your relative is in a care home for the monitoring and managing of health conditions and needs 1:1 14 hours a day and 2:1 out in the community (say 40+ hrs/week) and is at risk of falls (epilepsy, seizures without warning), has little danger awareness, has limited vision (registered as partially sighted and tunnels vision), poor social skills/cognition so vulnerable when with others as may misunderstand or misinterpret), is generally reluctant to shower and brush teeth and wear clean clothes, constant anxiety linked to health condition leads to sudden incidents such as running off and outbursts with others attacked or threatened, can there be a primary health need? My son keeps getting a joint package even though his health allocation increases each year and health is currently 42.9% even though in 2017 it was apparently 50%. The LA have been unable to explain why 1:1 8am to 8pm is allocated as social care but 1:1 8pm to 10pm its allocated to health. The LA have no legal limit (so they say) and cannot confirm using an objective test. The DST scores have been changed many times over three
years sometimes without explanation and the DSTs are obviously subjective as his underlying needs have remained constant. Can anyone shed any light on these inconsistencies and anomalies and why the LA are refusing to respond and answer over what they have agreed? Thanks. Confused.com
For your next DST :
I would at the start of the DST present the MDT with a letter of your expectations so there is no doubt.
1. Record the DST meeting. The people there will tell you that you cannot. Stick to your guns and if need be say you are only going to record your voice, they cannot stop you doing that. After people have spoken you record in your voice what they said.
2. You will need a social worker at the meeting.
3. For each domain make sure that the actual health needs are documented. I would make your own paper record there and then and before moving to the next domain you want to know the intensity, unpredictability, nature and complexity of each need. Quote the Framework if they won’t do this and say you cannot follow if not.
4. If the patient is resident in a care home then dont allow the DST to discuss social care, you are there to discuss health needs. For every need ask the social worker what the local authority can provide for these health needs. They cannot accept any legally.
5. Have Statutory Instrument 2996 reg 21 clause 5 to 7 to hand and demand that this be considered. You document if it is refused.
Above all do not let the meeting move on unless you are satisfied. Look at the domain scores and if the needs are in totality downgraded, ask how the need is reduced not the delivery of service.
If anyone mentions joint packages or social care remind them that is not part of the process yet.
Use “To consider that you must gave already made your decision on there being no Primary Health Need. Have you done that ?
You will have to be belligerent.
Take two telephone numbers in with you if senior people in the CCG and CSU. Ring and leave a message for them to contact u as u believe the process is not being upheld.
Just my idea of how I would approach.
Many thanks Ian. I have already stated that that LA have exceeded ancillary/incidental. They say there is no legal limit. They rely on the fact that the DST is subjective and open to interpretation. Surely a care need over someone’s behaviour due to a diagnosed condition is health rather than social care? No one can need social care 8am to 8pm and yet still be in a carehome 24/7.
Isn’t there a clear line as to the level of health care that warrants CHC defined in Statutory Instrument 2996 regulation 21 clause 5 to 7 and also mentioned NHS Framework for CHC. Shouldn’t the assessment consider the issue of a Primary Health Need before even approaching Funded Nursing Care. My experience is that FNC is on the table when you walk through the door of the dst and appeal. In principle if social services cant cover all the care then there is Primary Health Need.
Thanks CTBD for expanding on Healthcare needs. This article will certainly help those starting out on CHC to better understand what it takes to prove a Primary Healthcare Need. I know I keep repeating myself about proving a PHN through the key indicators, but I genuinely believe that if you can do this effectively, claimants have a better chance of success, rather than pursuing CHC through due process.
CTBD has a huge amount of information on this website about a PHN but a refresher is always useful. Expanding on the domains would be useful. I understand that it was an overview of each domain but it would be great to have more detail for each & how they interact. So for instance, my father’s irrational behaviour around non-compliance with his medication and routine personal care impacted on his psychological & emotional well being as well as his skin, which potentially left him at huge risk from skin breakdown & sepsis, not to mention the impact on his health from refusing his medication. Behaviour in all it’s different forms can lead to risk in all other domains.
Apathy and withdrawing is just as important as the shouting and aggressive behaviour that most relatives understand.
I look forward to reading “The Whole Different Topic” on the Key Indicators!