If your relative has a ’primary health need’ i.e. the main purpose of their care is for health needs (as opposed to social care needs), then they may be eligible for NHS Continuing Healthcare Funding.
NHS Continuing Healthcare Funding (‘CHC’) is a package of fully-funded care, paid for by the NHS, and which is ’free at the point of need’. CHC is paid, regardless of the setting where the care takes place and irrespective of the recipient’s wealth (as it is not means–tested).
Without CHC funding, your relative may end up self-funding their care and paying for it out of private savings or even be forced to sell their home.
In order to be considered for CHC your relative will need to engage with the CHC assessment process to determine their eligibility for NHS funding.
Here are some quick Questions and Answers to help you:
What is the purpose of the Assessment?
The assessment process has 2 key objectives, namely to establish:
1) what your relative’s care needs are (crucially, so that the right care is in place); and
2) whether that care is the legal responsibility of the NHS or the Local Authority to fund.
It should never be an assessment of your relative’s money, nor is it an assessment of Clinical Commissioning Groups’ (‘CCG’) budgets, or their willingness to pay.
When does the assessment process start?
The assessment process should ideally begin as soon as your relative needs full time care, or in any circumstance that would suggest they may be potentially eligibility for NHS Continuing Healthcare. If it does not, they risk being means-tested and told to pay for their care before anyone has explored whether the NHS may have a duty to pay.
What is the Checklist?
The process to determine eligibility for CHC starts with an initial Checklist – a preliminary screening tool used by the NHS to help practitioners assess a basic level of need and determine whether an individual is eligible to move forward to a full assessment for NHS Continuing Healthcare Funding.
Families often get confused and wrongly believe that the Checklist is the actual final decision. It isn’t. It’s simply a process designed to screen out individuals who aren’t eligible for CHC funding and to enable those who may be, to move on to a full assessment.
Where do I begin?
Firstly, you need to establish whether an assessment (for NHS Continuing Healthcare) has already been carried out.
If it has, ask for a copy of the completed Checklist as you need to find out exactly what type of assessment took place. It may have in fact been a financial assessment to assess affordability to pay for care home fees, and not a Checklist assessment to determine eligibility for NHS Continuing Healthcare (remember, which is free).
WARNING! If your relative is already in a care facility and no assessment for CHC has been done, they could be paying thousands of pounds a month for their care unnecessarily!
Where does the Assessment take place?
The Checklist assessment used to take place in hospital, but that changed under new guidance in the revised edition of the National Framework for NHS Continuing Healthcare Funding and NHS–funded Nursing Care (2018).
Preferably, the Checklist assessment should now take place once the individual is back in their own environment or appropriate community care setting where they are going to be living i.e. back in their own home or at a care home facility. That way, a more accurate picture of their long-term healthcare needs and requirements can be obtained away from an acute hospital setting.
How do I start the assessment process?
If your relative is about to be discharged from hospital, ask your local Clinical Commissioning Group’s NHS Continuing Healthcare Department/Team to start the ball rolling and set up a Checklist assessment for your relative.
If they are going into a care home for the first time, you can ask the care home manager to arrange the Checklist assessment.
If they are living in their own home, you can ask their GP, therapist, social worker, community or district nurse to set up the Checklist assessment with the NHS.
If your relative is already paying care fees and you believe they may be eligible for NHS Continuing Healthcare, as above, you can ask a health or social care professional or care home manager to arrange an assessment.
How does the NHS arrange the Checklist assessment?
The CCG has a duty to carry out an assessment even if your relative is currently paying for their care out of private funds (self–funding).
As your relative’s representative, whether acting under a Lasting Power of Attorney or in their ‘best interests’, the CCG should contact you directly to advise you of the proposed appointment date for the Checklist assessment.
If your relative is living in a care home, then they may notify you of the appointment.
Can the NHS refuse to do the Checklist assessment?
Yes. There are circumstances set out in Paragraph 91 the National Framework where the NHS can refuse to carry out a Checklist assessment. These include the following:
- Where it is plainly obvious that there are simply no health needs;
- If the NHS considers the individual’s needs are so obvious that they should bypass the initial Checklist and move straight to a full assessment;
- If the individual has a rapidly deteriorating condition and may be entering a terminal phase, in which case the Fast Track Pathway Tool should be used instead. Read, “How To Fast Track The Continuing Healthcare Funding Process.”
- The individual is already receiving services under Section 117 of the Mental Health Act to meet their assessed needs.
Tip: If you feel that the NHS have wrongly declined to undertake a Checklist assessment, then you must complain immediately to the NHS Continuing Healthcare Department/Team.
Who attends the Checklist assessment from the NHS?
The CCG will appoint an assessor to carry out the initial Checklist assessment.
The assessor will be a health or social care practitioner such as: a registered nurse employed by the NHS, GP, other clinician or local authority staff such as a social worker, care manager or social care assistant.
They should be trained in the National Framework and using the Checklist Tool, and also been involved in assessing or reviewing individuals’ needs as part of their day-to-day work. They must understand how to apply the CHC eligibility criteria against the scoring system when carrying out the Checklist assessment.
Some CCGs will delegate completion of the Checklist to the care home or other organisation under an agreed protocol.
How much notice will I get of the Checklist taking place?
You have every right to be present at the Checklist assessment, so you should be given reasonable notice as you need time to prepare for the appointment.
However, sometimes, if an urgent decision is needed, the Checklist assessment can be arranged at short notice, which, understandably, may be inconvenient for you.
If so, ask for it to be postponed to a more convenient date, as ideally, you need to be there and be involved in the process.
Quite often, we hear from families that the Checklist assessment took place (behind their backs) without them or their relative being notified; or else, even if notified, were then excluded from being involved in the process. That is contrary to the National Framework which puts the person at the centre of the process.
If the Checklist assessment took place without your knowledge or involvement and your relative was not successful, then ask for it to be redone.
Do I have to be present At the Checklist Assessment?
In short, yes! It’s vital for you to attend.
Don’t let your relative be wrongly filtered out of the assessment process before it has even begun!
Whilst it is not a mandatory requirement, we strongly recommend that family representatives get involved and contribute to the assessment process.
You are best placed to know your relative’s healthcare and daily needs better than anyone. Use that advantage to explain their needs to the CCG assessor (who may be meeting your relative for the first time) and to ensure that the assessment process is conducted in a fair, open and transparent manner.
You must try and make every effort to be at this initial assessment in order to support your relative’s case for CHC funding and at least get on to the next rung of the ladder – which is a full assessment.
How do I prepare for the Checklist Assessment?
Good preparation and planning are essential at this stage of the assessment process.
We recommend that you go through the Checklist yourself and score your relative’s needs against the prescribed criteria/descriptions for each Care Domain. That way, you will know in your own mind whether the assessor’s scores are fair and can argue the case if you disagree with them and correct any misinformation they have.
A lack of preparation can prove costly and end up with your relative paying for their care!
Can I have someone to attend with me?
The National Framework provides that you are entitled to have any person you choose to be with you at the Checklist assessment, and they can also act as an advocate, take notes for you, be another pair of ‘eyes and ears’, or simply just be with you to give you encouragement and support.
What happens at the Checklist assessment?
The CCG’s appointed assessor will review your relative’s healthcare needs and score them against the Checklist.
The assessor will look at 11 main Care Domains, namely:
- Nutrition – food and drink
- Skin integrity (including tissue viability)
- Psychological/emotional needs
- Drugs/medication/symptom control*
- Altered states of consciousness *
Each Care Domain is divided into 3 levels and scored A, B or C – with ‘A’ being the highest level of needs and ‘C’ being the lowest.
In order to pass on to the next stage i.e. to a full assessment, your relative will need to achieve a minimum aggregate score of:
- 2 or more As
- 5 or more Bs (or 1A and 4Bs), or
- at least one A in a domain with an asterisk*
How long do I have to wait for the Checklist outcome?
The Checklist will usually be completed within 14 days from the date of request.
Paragraph 100 of the National Framework states that whatever the outcome of the Checklist, it should be communicated clearly and in writing to the individual or their representative as soon as “reasonably practical”.
So, if you do not receive any communication from the CCG within 14 days of the assessment, then we recommend you contact them to chase their outcome decision.
What are the possible outcomes of the Checklist assessment?
There are 2 possible outcomes:
- A negative Checklist; or
- A positive Checklist
Let’s explore both scenarios below.
What happens if the Checklist is positive?
As above, you should be notified of the successful outcome in writing and be given a copy of the Checklist and reasons for the outcome decision (usually contained within the Checklist).
Your relative will now be passed on to a full assessment which is carried out by a Multi-Disciplinary Team (MDT).
Important! A positive Checklist does not necessarily mean that your relative will be found eligible for CHC funding at the MDT stage. Indeed, many applications are turned down (whether correctly or incorrectly) by the MDT assessors.
Keep the Checklist outcome handy as it may become a useful comparator in due course if your relative is reassessed and CHC funding is subsequently withdrawn.
What happens if the Checklist is negative?
As above, you should be given a copy of the Checklist with written reasons for that negative outcome decision, together with information about how to ask the CCG to reconsider their decision (ie complain!).
Beware! You have 12 months to challenge the outcome and to lodge your complaint.
When reviewing the matter, the CCG should take into account all the information available at the assessment and any additional information that is supplied. However, according to Paragraph 102 of the National Framework, the CCG are not obliged to undertake a further Checklist.
You must adhere to the timescales to challenge the outcome, otherwise you may be stuck with it (even if it’s blatantly wrong).
According to Paragraph 85 of the National Framework, the threshold for passing on to a full assessment “has intentionally been set low, in order to ensure that all those who require a full assessment of eligibility have this opportunity.”
Therefore, a negative outcome suggests that your relative’s healthcare needs are not considered sufficiently high enough to pass forward to a full assessment at an MDT meeting.
If you don’t agree with the outcome, or there has been an abuse of process (eg you weren’t included), you can request another Checklist assessment. Contact the local NHS Continuing Healthcare Department/Team in writing, stating your reasons and insist that you would like the Checklist to be repeated.
Keep the Checklist safe. Even if your relative doesn’t qualify, it may still prove a useful exercise and give you peace of mind that their healthcare needs have been properly assessed and are not at a sufficiently high level to trigger a full assessment.
It may also become a useful benchmark for comparison purposes should their needs change (increase) and a further reassessment is required in due course.
When can I request another Checklist Assessment?
If you believe that the Checklist has been completed incorrectly, or the process was not carried out robustly, complain and insist that the Assessment be repeated.
If your relative’s healthcare needs change or fluctuate as time goes by, you can always request that another Checklist assessment is carried out, as and when appropriate.
Alternatively, if the change in needs clearly warrants it, a decision could be made to bypass the Checklist and go straight to full assessment for CHC.
Remember, the Checklist assessment is just a preliminary screening tool to see if a full assessment is required. It is not the actual assessment for eligibility for CHC itself.
Share your experiences of a Checklist assessment below and help others avoid any pitfalls you have encountered…