Is your relative about to be discharged from hospital into care?
In this article we take a look back over the last 10 years to see how the NHS Continuing Healthcare (CHC) process upon discharge from hospital has changed, and how it can benefit your relative, so they don’t miss out on their entitlement to CHC Funding.
Firstly, a quick overview of the process:
The position in 2013
When posting our blog, What to do if your relative is in hospital and needs full time care (28 March 2013), we wrote that many patients were being discharged from hospital too soon in order to free up hospital beds and in an effort to save the NHS money.
Hospital staff were not always aware that CHC Funding existed i.e. all the patient’s ongoing healthcare needs once back in a community setting could be paid for in full by the NHS, FREE of charge. So a quick discharge often meant patients went without any NHS assessment for CHC Funding being undertaken and then missing out of CHC Funding as a consequence.
Alternatively, patients were effectively told not to worry as they would be assessed for CHC once out of hospital. This deft move by the NHS shifted the responsibility for paying for care over to the patient’s local authority instead where they would be subjected to means-testing. If their means were above the local authority threshold, patients were forced to pay for their own care privately in the meantime until it was decided one day that they needed a CHC assessment and proper arrangements could be put in place to meet their long-term healthcare needs.
So, to avoid being pressured into a quick discharge from hospital and to protect a patient’s right to a CHC assessment, we suggested they ‘bed block’ and insisted on an assessment for NHS Continuing Healthcare as leverage before being discharged from hospital. The message was clear – sit tight and hold on to your hospital bed as a tactical bargaining chip until an assessment for CHC Funding had been done – because, once discharged, it was far harder to get CHC Funding.
However, with the passage of time and the COVID pandemic years later, that tactical thinking has been superseded and is no longer appropriate.
The position in 2018
In October 2018, the NHS National Framework for NHS Continuing Healthcare modified its assessment process. It was no longer considered appropriate to be assessed for CHC Funding whilst in hospital (save in exceptional circumstances).
Assessing in an acute hospital environment at a time of ultimate vulnerability was felt unsafe and unlikely to maximise the patient’s potential for recovery.
If a patient was assessed in hospital before they had reached optimal recovery, it could mean that their longer-term needs might be substantially under or over-prescribed – producing a package of NHS funded care that was either grossly inadequate to meet their intermediate or long-term healthcare needs, or conversely, unduly generous and unnecessary (at the NHS’s wasted expense).
The 2018 National Framework indicated that assessments in an acute hospital setting may not necessarily give an accurate picture of a patient’s intermediate or long-term healthcare needs – especially, as with appropriate support and opportunity, the patient has the potential to recover further in the near future.
So, the updated 2018 NHS National Framework indicated that it would now be more effective to carry out CHC assessments promptly upon discharge and without delay in a community setting e.g. when the patient returned to their own home or were established in a care home and after there was a period of recovery to monitor and assess the situation (known as ‘Discharge to Assess’). Only then, following a period of optimisation, could a clearer and more accurate picture of ongoing healthcare needs be properly ascertained.
Therefore, the old rouse of holding on to your hospital bed as a negotiating leverage to get a CHC assessment done sooner became obsolete and contrary to the new 2018 National Framework.
The position in 2020
However, all that changed again with the onset of COVID in early 2020.
NHS hospitals were inundated with acute cases and were understandably trying to free up hospital beds as quickly as possible to accommodate the number of sick patients needing urgent medical treatment.
From 1st September 2020, the Government introduced an automatic package of free care funding (via the NHS) for up to 6 weeks after discharge from hospital as an incentive to free up hospital beds and give patients reablement, rehabilitation or sub-acute care and arrangements – including intermediate care or an interim package of support – whilst waiting to be assessed for CHC Funding for their longer-term healthcare needs. The rationale, as set out in the National Framework, was that there should be no gap in the care being received. If the assessment and decision-making process took longer than 6 weeks, the NHS (and/or local authority) were obligated to make arrangements to continue to fund ongoing care until the matter had been determined.
Did you know that if you have been discharged from hospital after 1st September 2020 you may be entitled to free NHS care?
As COVID started to subside, key personnel within CHC Departments returned from the front line back to their usual duties to catch up with CHC backlogs, assessments and appeals. With more staff available and the staffing crisis starting to regain normality, with effect from 1st July 2021, the 6-week automatic Government funding package post-discharge was reduced from 6 weeks to just 4 weeks. This put immense pressure on the NHS to carry out their assessments promptly and efficiently in order to avoid being personally responsible for the cost of ongoing care until the patient’s assessment had been finalised.
The position in 2022
The 4-week Government discharge funding finally ended on 31 March 2022.
However, even though it is no longer official Government policy, we understand that some ICBs have continued the policy of providing 4 weeks of funding to assist patients whilst assessment is pending post-discharge from hospital.
The latest edition of the NHS National Framework came into effect on 1st July 2022.
The Discharge to Assess principles are broadly the same as the 2018 National Framework, namely that CHC assessments should not take place in an acute hospital setting (except In rare circumstances). However, the 2022 National Framework also adds that CHC assessments should be delayed until after discharge from hospital in order to provide for a further period of time for timely and appropriate recovery support, e.g. therapy or rehabilitation if needed, to try and reach an end point of recovery before assessment – so that a more accurate picture of the patient’s longer-term needs can be seen.
The key message now is – assessments at the right place and the right time. This means that, in the vast majority of cases, this will be following discharge and after a period of recovery in a familiar setting or intermediate/rehabilitation placement.
Of course, for the NHS that could represent huge savings by not having to pay for a patient’s full-time care and accommodation in a care home, as soon as they leave hospital, if they can be rehabilitated and make a quicker recovery with assistance. As there must be no gap in the provision of appropriate support to meet the individual’s needs, these interim services should continue until it has been decided whether or not the individual has a need for NHS Continuing Healthcare. However, the assessment process has been further modified in the latest 2022 edition of the National Framework.
We recommend you read paragraphs 101 to 108 -“Understanding how NHS Continuing Healthcare interacts with Hospital Discharge”. Set out below, for ease of reference, are some salient paragraphs from the updated 2022 NHS National Framework. It provides for 5 different scenarios (pathways) upon discharge from hospital as follows:
“107. In the vast majority of cases, CHC assessments should take place in community settings. There may be rare circumstances where assessments may take place in an acute hospital environment. In addition, ICBs and their partner organisations should ensure appropriate processes and pathways exist for individuals who may have a need for NHS Continuing Healthcare, for example:
(a) where the individual has an existing package or placement which all relevant parties agree can still safely and appropriately meet their needs without any changes, then they should be discharged back to this placement and/or package under existing funding arrangements. In such circumstances any screening for NHS Continuing Healthcare, if required, should take place within six weeks of the individual returning to the place from which they were admitted to hospital. If this screening results in a full assessment of eligibility and the individual is found eligible for NHS Continuing Healthcare through this particular assessment, then any necessary re-imbursement should apply back to the date of discharge;
(b) a decision is made to provide interim NHS-funded services to support the individual after discharge. This may allow individuals to reach a better point of recovery and rehabilitation in the community before their longer-term needs are assessed. In such a case, before the interim NHS-funded services come to an end, screening, if required, for NHS Continuing Healthcare should take place through use of the Checklist and, where appropriate, the full MDT process using the DST (i.e. an assessment of eligibility);
(c) a ‘negative’ Checklist is completed in an acute hospital (i.e. the person does not have a need for NHS Continuing Healthcare);
(d) a ‘positive’ Checklist is completed in an acute hospital and interim NHS-funded services are put in place to support the individual after discharge until it is either determined that they no longer require a full assessment (because a further Checklist has been completed which is now negative) or a full assessment of eligibility for NHS Continuing Healthcare is completed;
(e) a ‘positive’ Checklist is completed in acute hospital and a full assessment of eligibility for NHS Continuing Healthcare takes place before discharge. In a small number of circumstances, it may be decided to go directly to a full assessment within the acute hospital, without the need for a Checklist. ICBs are reminded that if an individual’s needs change in a short time frame between a positive Checklist and a full assessment of eligibility taking place, it is legitimate to undertake a second Checklist, rather than necessarily proceeding to full assessment of eligibility for NHS Continuing Healthcare. The individual should be kept fully informed of the changed position.”
For further reading:
Hospital discharge and community support guidance (updated 01.07.22)