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:
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:
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.
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.
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.
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.
Doubly incontinent and requiring staff to manage all continence needs, being prone to constipation and requiring regular laxatives to help manage this.
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.
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:
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.
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: