NHS fully-funded care for people with primary health needs – part 2

Following his discussion of who can claim NHS Continuing Healthcare funding in part 1 of this article, independent adviser Roger Burgess explains the steps that applicants will go through to make their claim. He provides comment and advice based on his experience of helping others to make claims.

Note: This article was originally published in February 2016, and the Framework it discusses has since been updated. While much of this article is still relevant, there have been some changes. Despite the complications, Roger still believes it is important and worthwhile to make a claim, and continues to be happy to help individuals argue their case. His contact details are at the end of the article.

Step 1: The “Check List”

This is the initial screening process. Every applicant will be required to take part in this stage unless there are special reasons for an individual to be fast tracked through to NHS CHC.

Always ensure that a family member, friend or someone acting for the patient is in attendance. They have a right to be there and be involved in the process to ensure that a fair assessment is provided.

A copy of the Check List can be found online. Otherwise ask the NHS.

Once a recommendation has been agreed then the individual will undergo a full Continuing Healthcare assessment.

Step 2: Multidisciplinary Team (MDT) recommendation

The Care Commissioning Group (CCG) should now implement a Multidisciplinary (MDT) meeting.

The date, place and time of this meeting should be notified to the patient and/or their representatives in plenty of time so that they can prepare their case.

It would be advisable for the applicant to prepare a copy of their own supporting evidence to take to the meeting (example layout can be provided if required).

The MDT meeting can be made up of any number of professionals from different NHS disciplines, i.e. doctors, nursing, social worker, occupational therapy etc. The meeting must include a minimumof two professionals from different NHS disciplinesto establish a multidisciplinary team.

This is where the Decision Support Tool (DST) is completed and an informed decision made as to whether or not a person has a “primary health need”.

What is a Decision Support Tool?

A DST is a document on which decisions are based. It consists of 12 “Health Need Domains” which are systematically discussed in order to assist the MDT to come to a multilateral decision as to whether or not an individual has a “primary health need”.

Remember the patient and/or their representative do have a right to an involvement in the decision-making process and theoretically should always be encouraged to attend.

A copy of the DST can be found online or ask a member of the NHS.

The MDT meeting

It is at this meeting that the DST is completed and an informed decision taken as to whether a person does have a “primary health need”.

All the necessary assessments and investigations into the patient medical history/condition should now be carried out and completed before the MDT meeting takes place. There is normally a 28-day period from the checklist being received to allow for this (see the National Framework p 70 para 26.2f).

The applicant may ask the CCG for copies of any documentation that they will rely on during the course of the meeting and it is obliged to provide them (National Framework p 76 para 33.1b). It’s important to ensure this information is received in plenty of time prior to the meeting, so that the applicant and whoever is representing them have time to read and fully understand its content.

This whole process has been designed to be robust, consistent and above all transparent from the outset.

The DST is not an assessment tool in itself. It is a decision tool, which is why it must be completed at the MDT meeting and must not be altered once it is complete (National Framework p 71 para 27.1). This point is very often misunderstood or sometimes ignored by NHS CHC staff, who may attempt to take the DST away on the basis that they require more information.

Not only is this wrong, it is also contrary to the National Framework, because the CCGs should not make decisions on eligibility in the absence of an MDT recommendation (National Framework p 75 para 31.1). Unless the correct procedures are followed it can sometimes lead to eligible cases being refused unnecessarily.

It would always be advisable to have someone at the MDT meeting taking minutes or notes or use a good-quality voice recorder if that can be arranged.

You may want to observe the wording which is sometimes used in the assessment notes. For example, a person with severe dementia or serious mobility problems may be described in the assessment notes as “needing assistance” with activities such as continence, eating etc, because they cannot do anything for themselves. However, using terms like “needing assistance” implies that a person is able to manage, just needing a little bit of help here and there, when the truth is that they may be entirely dependent and wholly vulnerable – and therefore need “full intervention”.

When the applicant eventually receives their final draft of the DST, usually through the post, some minor changes could have inadvertently taken place and this may also mean the difference between someone qualifying for CHC eligibility or actually being refused it. They may require some evidence in order to challenge a final DST draft. Asking MDT members to sign minutes or notes taken at the time is one way but you may need to produce copies of any recordings – something to consider.

Needs score requirements

Part 1 – The Check List

Once you’ve obtained a copy of the Check List take a look at the needs section. To be put forward for a full assessment for NHS Continuing Healthcare the applicant will require:

2 or more needs in column A
Or 5 or more needs selected in column B
Or 1 in A and 4 in column B
Any box selected in column A that is marked with an asterisk (*) as this is a Priority score.

Part 2 – The DST

If the applicant receives 1 Priority or 2 Severe Needs scores then eligibility can be expected.

However there are many factors to be considered so several High needs and a number of Moderate needs combined could still produce a qualifying result.

Step 3. Ratification

The completed DST and the applicant’s supporting evidence (where applicable) may now go before a commissioning board/panel for ratification.

Some CCGs could use up to as many as five core members to make up the board or panel, whilst others may have less. No decision should be taken unilaterally.

The purpose of the board or panel is to ratify a decision already made by the Multidiscipline Team and recorded on the DST, especially when a case for eligibility has been clearly established, or perhaps consider the case in more depth when there is a borderline situation.

It should be clearly accepted that all needs, even well managed needs, are still needs (DST page 14 para 28) and only when these needs can be proved to have been permanently reduced or removed, will they have any bearing on CHC eligibility.

Distractions

Many people have never been told about this form of NHS funding whilst others have been put off applying because they did not have the necessary help needed to navigate what can sometimes turn into a rather complex issue, especially if procedures are not followed correctly.

In my experience distraction techniques may be used to prevent applications from succeeding. For example an individual’s care needs could be played down by attempting to match them with lower needs scores rather that the more appropriate higher scores. This ignores the fact that the system has been designed as “upwards” scoring. Another distraction technique that may be used is simply the way that the discussion is carried out, with some people being heard and others being talked across. Don’t be put off by this – just be aware that it might happen.

Reclaiming care fees

Successful applicants care may reclaim care fees. You can refer to the Refreshed NHS Redress Guidance for more information (Gateway Ref 03261. Published 1^st April 2015).

Note though that deadlines for NHS CHC were put in place in 2012. Backdated claims before 31^st March 2013 will not be accepted.

What if eligibility is denied?

If the applicant fails to become eligible for NHS Continuing Healthcare they can appeal to the CCG and ask for their case to be reviewed. This is known as a “local review process at CCG level”. They should always ensure that a family member or representative is in attendance.

If they are unable to resolve their case and all local dispute procedure has failed to provide a mutually acceptable resolution, they can apply to their regional NHS England body and ask for the case to be reviewed by an Independent Review Panel. Again the applicant would be expected to attend and provide their own supporting evidence in much the same way as they did at the MDT meeting. The applicant may not automatically be invited, so they should always ask because they do have a right to be there and have an involvement. Remember this whole process is based on transparency.

Finallyas a last resort if all other options have failed and if the applicant still feels they have been treated unfairly they can refer their case to the Parliamentary & NHS Ombudsman (Tel 0345 015 4033).

Navigating the complexity can be worthwhile

Hopefully the information provided here should help to make for a clearer understanding of the NHS Continuing Healthcare service. If the correct procedures are followed and an individual does have a “primary health need” then they should become eligible for 100% NHS funding. If you know someone that may have a “primary health need” and they are currently paying for any part of their care including accommodation then do help them to make an application for NHS Continuing Healthcare (CHC). After all it is their basic right under current NHS policy.

Roger Burgess is happy to answer any questions you might have on NHS Continuing Healthcare. You can contact him by email on [email protected] or by calling 01288 381397 or 07798 902693.

If you found this article useful you may also want to read:

Myths around NHS Continuing Healthcare funding

Applying for Attendance Allowance

Understanding Lasting Power of Attorney

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