We are often asked “what is the ‘well-managed need’ principle?”
This remains a difficult and highly controversial topic that is generally misunderstood and misapplied by both Clinical Commissioning Groups (CCGs) and families alike. You can use this principle to support or decline an application for NHS funded care, and your approach to the issue largely depends on which side of the fence you are on.
The different interpretations and application of this principle are directly attributable to the distinct lack of clarity in the National Framework.
So what is the ‘Well-Managed Need’ Principle?
The National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care (revised 2018) seeks to provide clearer guidance on the ‘well-managed need’ principle, but in reality, does no better than the previous 2012 edition of the National Framework.
The National Framework, as it is known, sets out the processes and principles of NHS Continuing Healthcare Funding (CHC). It consists of 167 pages of practical guidance and support to CCGs when carrying out their assessments of an individual’s eligibility for CHC Funding.
When making a decision about eligibility for CHC Funding, the National Framework states that CCGs should not ‘marginalise’ (ie undervalue or minimise) a health need just because it is successfully managed. In short, just because a need is under control doesn’t mean that you can disregard it when assessing an individual’s eligibility for CHC. Otherwise, any intense, complex or unpredictable healthcare needs could be overlooked or underrated upon assessment, just because they are being better managed. This outcome could result in a lower score in one of the 12 Care Domains (usually “Behaviour’ ‘Nutrition’ or ‘Medication’), and in turn affect the overall outcome and chance of the individual being awarded CHC Funding.
Remember: Just because a need is under better control (ie well-managed), doesn’t necessarily mean that it has gone away – it may still exist, but is just better handled – that’s all.
The National Framework establishes that only if the healthcare need has been permanently reduced or removed entirely, such that active management of the need is no longer required, should it have a bearing on CHC eligibility.
Tip: If the CCG seeks to play down or dismiss your relative’s needs at a CHC assessment on the basis that they are ‘well-managed’:
i) Ask them exactly what they mean by this in terms of your relative’s specific needs?
ii) Ask them to define the phrase ‘well-managed’?
iii) Quote Paragraph 63 of the revised 2018 National Framework which says that a well-managed need is still a need – see below:
“NHS Continuing Healthcare may be provided in any setting (including, but not limited to, a care home, hospice or the person’s own home). Eligibility for NHS Continuing Healthcare is, therefore, not determined or influenced either by the setting where the care is provided or by the characteristics of the person who delivers the care. The decision-making rationale should not marginalise a need just because it is successfully managed: well-managed needs are still needs (refer to paragraphs 142-146). 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.”
The concept of ‘well managed’ needs is also dealt with in more detail in Paragraphs 142 – 146 of the National Framework, which we have set out below for your convenience. The key phrase that “well-managed needs are still needs” is repeated again:
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).”
Unfortunately, Paragraph 143 above gives only one flimsy example of well-managed needs! In our opinion, this example is grossly inadequate for such an important and controversial topic, and does not really go far enough to assist CCGs or families in explaining the concept clearly. Given that this is such a widely quoted principle, the revised 2018 edition of the National Framework missed a great opportunity to clarify the issue beyond doubt. In fact, the 2012 National Framework example in Practice Guidance Note 11 was marginally better, but also lacking in detail and definitive examples as to how the concept is to be applied practically.
More clarity, please!
Due to the lack of clarity and explanation, this is where it gets tricky. For example:
1) The ‘well-managed needs’ principle is most commonly discussed in the ‘Behaviour’ Domain. If an individual displays challenging behaviour but is prescribed anti-psychotic medications to successfully manage their symptoms, is this a well-managed need?
2) If an individual is resident in an EMI Dementia Unit with specially trained staff who are better able to deal with their challenging behaviour, is this a well-managed need?
There is no straightforward answer to either of these questions.
Both CCGs and families will often refer to the ‘well-managed needs’ principle when it suits their own position:
- CCGs use it to reject claims for NHS Continuing Healthcare Funding on the premise that the needs are less complex, intense or unpredictable because they are being better-controlled (ie well-managed).
- Whereas, families will quote it to support their relative’s claim for free NHS fully-funded care (ie just because the need is being contained and well-managed, doesn’t make it a lesser need). They will argue that, unless the condition hasn’t been permanently reduced or eradicated completely, then there is still a justifiable need for ongoing care intervention (to keep it under control).
We recommend that you consider whether the challenging behaviour has been removed completely, and also, what level of skill/intervention is needed to keep it ‘well-managed’. Ask yourself, if the either the medication was withdrawn, or if the specially trained/skilled staff were removed, would the problematic behaviour would return? If the answer to each question is undoubtedly “yes”, then, in that sense it is a ‘well-managed need’.
However, due to a common misconception, many families believe that their relative must be entitled to CHC Funding, arguing that if you removed their existing care intervention (eg didn’t manage their diet, feed them or assist with mobility etc), then they wouldn’t be able to survive unassisted. But, doesn’t that apply equally to anyone in a care facility?
For example, take the ‘Nutrition’ Domain. If a patient was not fed by staff, they would be unable to feed themselves and would almost certainly starve to death. The Care Plan provides for a carer to assist or feed the patient, and that results in an adequate dietary intake, stable weight and no nutritional risk. Is that a well-managed need justifying CHC Funding? Yes, it could be. However, beware! The CCG may take a contrary view and argue that the provision of diet and fluids is probably more of a social care need than a healthcare need, and the management of the need is unlikely to involve particular skill or require nursing input.
Similarly, it is commonly raised by families, specifically in the ‘Medication’ Domain, that it is only prescribed medications which are managing the patient’s needs. However, millions of people take prescribed medications every day to manage various healthcare conditions – the medication is keeping the symptoms under control and there are no healthcare needs arising from the diagnosed condition. So the ‘well-managed need’ argument would probably not apply here either.
When applying the ‘well-managed needs’ principle you cannot ignore management of the individual’s underlying daily routine healthcare needs which also have to be considered. So, for example, if an individual is taking anti-psychotic medication to help control their unpredictable physical and mental behaviours, hallucinations, talking to objects and imaginary people – the fact that the medication still has to be prescribed and administered by a healthcare professional to control behaviour does not take away the underlying challenging care need. On the contrary, the need still subsists, but is now better managed. Hence the slogan – “a well-managed need is still a need.”
In addition, Paragraph 188 states that, “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.”
Therefore, CCGs should not ignore ongoing routine Care Plans, support and interventions needed to provide controlled care for an individual. Nor should they try and argue that a reduction in the care needs means that the situation is now well-managed and so can be discounted or ignored, when assessing eligibility for CHC.
In short, just because a need is well-managed, it does not necessarily entitle the CCG to refuse or withdraw CHC Funding. It is only one factor of many to be considered as part of the overall CHC assessment process.
One other such factor is the care setting which may influence the level of care required. Paragraph 145 above, and repeated in Practice Guidance Note 23, “How should the well-managed need principle be applied?” states:
“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.”
Both these sections of the National Framework recognise that an inappropriate care environment may be a contributing (exacerbating) factor to be considered when assessing needs. Sometimes, an inappropriate care setting can produce a false reading by increasing anxiety levels (eg disorientation) and the need for increasing care. For example, an individual with cognitive impairment may exhibit worsening behavioural issues in an acute hospital setting or unfamiliar surroundings. But, what would happen if the stressor was removed or the care setting changed for a different, more familiar environment? Once back in more familiar surroundings, is any reduction in their challenging behaviour due to the fact that their needs are now better controlled and being ’well-managed’ (ie are there still healthcare needs that should be CHC funded by the CCG)?
Instead, the National Framework appears to encourage CCGs to look beyond this and consider whether the change in environment has actually reduced or even removed the challenging needs entirely – in which event, it may no longer be a case of a ‘well-managed need’ (suitable for CHC funding) – but one of low or no needs. This outcome depends on which side of the fence you approach the issue and the result will, of course, have a direct bearing on the eligibility assessment for CHC.
The latest version of the 2018 National Framework only adds to the confusion of what is a ‘well-managed need’.
The NHS created this phrase, and should either make the principle much clearer for everyone, with a full explanation of what it entails with worked examples, or else, just abandon this phrase, as it currently serves no real benefit. A mere few paragraphs dedicated to such an important concept, which is used as a trump card by both CCGs and families, surely needs much greater clarity and detail, so that it doesn’t remain highly contentious and frequently misapplied.
Remember: Unless the healthcare needs have been permanently reduced or been removed completely by the better-controlled (‘well-managed’) care intervention, then stand your ground if the underlying healthcare needs still subsist. Quote Paragraphs 63 and 142 of the National Framework that a “well-managed need is still a need!”
Let us know if the CCG have used the ‘well-managed needs’ argument to try and justify ineligibility for your relative’s CHC Funding, and if so, how did you respond?