Families often ask us about ‘well-managed needs’ or quote the ‘well-managed needs’ principle, with very little understanding as to how it might apply to their relative’s assessment for NHS Continuing Healthcare (CHC).
The concept of what is a ‘well-managed need’ is admittedly confusing due to a lack of clarity and guidance in the NHS National Framework. As such, its application is frequently misapplied by CHC assessors – leading to incorrect decision outcomes and families being wrongly refused essential free NHS healthcare for their relative’s needs and accommodation.
The guidance in the National Framework for NHS Continuing Healthcare (2018) and the Decision Support Tool and Practice Guidance sets out the following provisions about well-managed needs:
NHS National Framework:
“142. The decision-making rationale should not marginalise a need just because it is successfully managed: well-managed needs are still needs. Only where the successful management of a healthcare need has permanently reduced or removed an ongoing need, such that the active management of this need is reduced or no longer required, will this have a bearing on NHS Continuing Healthcare eligibility.
143. An example of the application of the well-managed needs principle might occur in the context of the behaviour domain where an individual’s support plan includes support/interventions to manage challenging behaviour, which is successful in that there are no recorded incidents which indicate a risk to themselves, others or property. In this situation, the individual may have needs that are well-managed, and if so, these should be recorded and taken into account in the eligibility decision.
144. In applying the principle of well-managed need, consideration should be given to the fact that specialist care providers may not routinely produce detailed recording of the extent to which a need is managed. It may be necessary to ask the provider to complete a detailed diary over a suitable period of time to demonstrate the nature and frequency of the needs and interventions, and their effectiveness.
145. Care should be taken when applying this principle. Sometimes needs may appear to be exacerbated because the individual is currently in an inappropriate environment rather than because they require a particular type or level of support – if they move to a different environment and their needs reduce this does not necessarily mean that the need is now ‘well-managed’, the need may actually be reduced or no longer exist.
146. It is not intended that this principle should be applied in such a way that well controlled conditions should be recorded as if medication or other routine care or support was not present (refer to Practice Guidance note 23 for how the well managed needs principle should be applied). The multi-disciplinary team should give due regard to well-controlled conditions when considering the four characteristics of need and making an eligibility recommendation on primary health need (refer to paragraph 59).”
The National Framework also provides a section entitled ‘Well-managed needs and reviews’ which provides:
“188. When undertaking NHS Continuing Healthcare reviews, care must be taken not to misinterpret a situation where the individual’s care needs are being well managed as being a reduction in their actual day-to-day care needs. This may be particularly relevant where the individual has a progressive illness or condition, although it is recognised that with some progressive conditions care needs can reduce over time.”
The Decision Support Tool also provides information about well-managed needs:
The DST provides at paragraph 27: “Needs should not be marginalised just because they are successfully managed. Well-managed needs are still needs. Only where the successful management of a healthcare need has permanently reduced or removed an on-going need, such that the active management of this need is reduced or no longer required will this have a bearing on NHS Continuing Healthcare eligibility. This principle is incorporated into the domain descriptors of the DST. For example, in the behaviour domain the level of support and skill required to manage risks associated with challenging behaviour helps determine the domain weighting. In such cases the care plan (including psychological or similar interventions) should provide the evidence of the level of need, recognising that this care plan may be successfully avoiding or reducing incidents of challenging behaviour (refer to paragraphs 142-146 of the National Framework and Practice Guidance note 23). For example, where psychological or similar interventions are successfully addressing behavioural issues, consideration should be given as to the present-day need if that support were withdrawn or no longer available and this should be reflected in the Behaviour domain.”
And at paragraph 28: “It is not intended that this principle should be applied in such a way that well-controlled health conditions should be recorded as if medication or other routine care or support was not present. For example, where needs are being managed via medication (whether for behaviour or for physical health needs), it may be more appropriate to reflect this in the Drug Therapies and Medication domain. Similarly, where an individual’s skin condition is not aggravated by their incontinence because they are receiving good continence care, it would not be appropriate to weight the skin domain as if the continence care was not being provided (refer to paragraphs 142-146 of the National Framework).”
The Practice Guidance provides:
PG 23 How should the well-managed need principle be applied?
“23.1 Care should be taken when applying the well-managed need principle. Sometimes needs may appear to be exacerbated because the individual is currently in an inappropriate environment rather than because they require a particular type or level of support – if they move to a different environment and their needs reduce this does not necessarily mean that the need is now ‘well-managed’, the need may actually be reduced or no longer exist. For example, in an acute hospital setting, an individual might feel disoriented or have difficulty sleeping and consequently exhibit more challenging behaviour, but as soon as they are in a care home environment, or their own home, their behaviour may improve without requiring any particular support around these issues.
23.2 Where needs are being managed via medication (whether for behaviour or for physical health needs), it may be more appropriate to reflect this in the Drug Therapies and Medication domain. Similarly, where an individual’s skin condition is not aggravated by their incontinence because they are receiving good continence care, it would not be appropriate to weight the Skin domain as if the continence care was not being provided.”
How does this work in Practice?
Perhaps an easier way of putting the ‘well-managed need’ principle is simply to say: what are the care actions that are being carried out on a day-to-day basis to provide the care and what training does the care provider need to properly carry out this care? The CHC assessor should ask pertinent questions to find out the answers.
The circumstances in which a need is being well-managed and the impact on the presentation of the individual will vary from patient to patient. Therefore, it is difficult to give hard and fast examples of the application of a well-managed need, or the questions necessary to identify the need and how it is being met. However, here are some examples which will help you:
1. Supposing a patient has recently moved from one setting to another, and as a result, their needs have changed. It could be that the previous setting was not meeting the care needs – causing other problems – which have now been resolved. In this event ask:
- What has changed?
- Who is now providing the care, and what is being done differently?
- What is being done now on a day-to-day basis to manage the needs, and what training is needed by carers?
Some/all needs created as a result of being in the wrong setting may have disappeared altogether, so it could be that those needs no longer exist. For example, a person with challenging behaviour around a member of the opposite sex could be moved to a single sex setting; in this case the problem has been resolved and no one is having to do anything now to meet that need; the need has disappeared.
2. Consider a patient who may not be coping alone in their own home because they forget to take their medication. This in turn could cause lots of problems that are resolved once the person is being properly supported with their medication being administered by a carer. In the case of the medication being forgotten, the person now needs support with taking their medication. The need is being managed. The fact that support is needed to take medication, should be measured in the DST. The assessor should ask questions such as:
- Is the medication being given covertly?
- Does the person refuse to take the medication?
- What medication is being administered, and does it need a level of skill to administer it?
- What monitoring is needed to ensure that the medication is effective?
- Are there any side effects?
3. Take a patient who is now in a new setting, and the setting is a specialist provision, where the input of the specialist care has made all the difference. In these instances, it is necessary to ask:
- What exactly is being done now to meet the care needs?
- Is the care that is now being undertaken being properly recorded?
It is the analysis of this care, and the training needed to do it, that is important. As specialist care providers will have specialist staff with specialist skills and knowledge that conduct the care, the type and amount of care that these specialist staff are providing needs to be measured/recorded on the DST. The assessor should consider the skill needed to provide the care and what techniques are being used etc.
4. What if a patient was having lots of epileptic seizures and these have now stopped due to being prescribed new medication? In this scenario, the CHC assessor should ask: what is the care that is now needed day-to-day? The care now prescribed might be: “To administer the anticonvulsant medication as prescribed by the GP/Specialist, and to monitor the patient for further seizures.” Before, the patient might have been having numerous fits and needed a lot of skilled management by carers, but are now seizure free. So, in this case, the needs are now well-managed and the need the being met by administering medication and monitoring – this need should be recorded on the DST.
A ‘well-managed’ need is still a need. This means that the care actions needed to meet the need should be recorded on the DST. So, in practice you should see written in the DST as follows: “Anticonvulsant medication needs to be prescribed by the GP/Specialist and carers need to administer the medication and monitor the patient for further seizures.” This, as long as it sufficiently describes the care now needed, will indicate that it has been properly measured within the assessment.
5. It could be that a patient was displaying lots of challenging behaviour and this has been well-managed with medication i.e. meaning that the challenging behaviour is no longer happening. In this event, the CHC assessor should ask:
- What medication is now being administered?
- Does it require a level of skill to administer it?
- Are there any side effects?’
- Is PRN (as required) medication prescribed? This is relevant as it involves additional monitoring to determine whether and when the medication should be administered, and monitoring for effectiveness and adverse side effects.
What if the patient was aggressive, and still is aggressive, but the need for care to prevent this aggression has become easier to manage e.g because they are no longer independently mobile (which stops them from being a high risk to themselves or others)? In this instance, the need has simply decreased due to other factors rather than being well-managed. This could result in the level of need in behaviour reducing.
The ‘well-managed need’ concept is difficult to grasp for both NHS seasoned assessors and practitioners as well as families, and the questions to be answered will differ from case to case.
Just because there is a well-managed need, it does not follow that there is eligibility for CHC. However, the well-managed need should be identified, and the care required to meet that need should be recorded on the DST.
TIP: It is vital to ask the right questions to figure out what, if any, needs still exist, what training is needed to meet those needs, and whether there have been other changes that now need to be considered as a result of the former needs being met.
For further reading around the subject:
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