RELEVANT INFORMATION

National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care (Department of Health and Social Care)

NHS Continuing Healthcare Decision Support Tool

NHS Continuing Healthcare Checklist

NHS-Funded Nursing Care Practice Guidance

NHS Continuing Healthcare Fast-Track Pathway Tool

August 2019: This chapter was amended to reflect the National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care guidance which was revised in October 2018. Section 1, Introduction has been updated and links and some text updated throughout.

1. Introduction

NHS Continuing Healthcare is a package of ongoing support which is arranged and funded by the NHS for someone who has been assessed as having a ‘primary health need.’ Some people will also need support from the local authority and so will require a joint package of support. Some people will not have a primary health need, and are therefore not eligible for CHC but do have some health needs and some social care needs. These people will require a joint package of support.

The principles and processes for the implementation of NHS Continuing Healthcare and NHS-funded Nursing Care are set out in the National Framework. The determination of eligibility for NHS Continuing Healthcare has been integrated so that the same framework for eligibility determination and care planning for NHS Continuing Healthcare also applies for NHS-funded Nursing Care. It uses the same assessment and decision support tools to reach the determination for the funding stream. NHS Continuing Healthcare is the responsibility of the Clinical Commissioning Group (CCG) and NHS England but Hull City Council will work collaboratively to deliver an integrated approach to assessing people’s needs and for commissioning support to meet those needs. In doing so, we will support a consistent approach leading to fair and equitable access to NHS Continuing Healthcare in accordance with the National Framework and will uphold the principles underpinning the framework which are to:

  • actively work together within the National Framework statutory requirements and best practice guidance;
  • actively promote the empowerment of staff in exercising their roles and responsibilities and promoting effective partnership working in day to day practice;
  • act in a way which supports the rights of the individual to lead an independent life based on self-determination and personal choice;
  • make sure that people who are unable to make their own decisions are considered in line with the principles and requirements of the Mental Capacity Act 2005 and Safeguarding protocols;
  • recognise that the right to self-determination can involve risk and ensure that such risk is recognised, understood by all concerned, and minimised whenever possible through open discussion between the person and the agencies about the risks involved and the options for reducing them;
  • ensure that assessments for eligibility for NHS Continuing Healthcare and NHS-funded Nursing Care are organised so that the person being assessed and their representative understand the process and receive advice and information that will maximise their ability to participate in informed decision making about their future care. Decisions and rationales that relate to eligibility should be transparent from the outset for individuals, carers, family and staff alike.

The National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care (Department of Health and Social Care, 2018) was revised in October 2018. The updated framework includes updates to practice guidance and checklist, decision support and fast track pathway tools. It also clarifies key areas of policy and practice including:

  • most CHC assessments should be done outside acute settings in order to ensure more accurate assessments and avoid unnecessary hospital stays;
  • when no screening is needed;
  • that reviews should look at the appropriateness of care packages rather than reassessing eligibility; and
  • new principles for clinical commissioning groups (CCGs) to resolve local disputes.

This policy sets out the roles and responsibilities of social care staff for the implementation of the National Framework in Hull and provides the process for determining eligibility for NHS Continuing Healthcare.

The numbers in brackets correspond to the references in Section 9, References.

2. Primary Health Need

There is no single, clear definition of what a primary health need is. Identification of a primary health need should include consideration of the nature, intensity, complexity and unpredictability of all of the person’s needs, the nature and quality of the services required to meet them and the quality and continuity of such services. Local authorities are able, in law to provide some health related services if they are incidental or ancillary to the provision of accommodation or they of a nature which a local authority could be expected to provide but if someone has needs for health-related care which goes beyond this, they are in fact, eligible for NHS continuing healthcare; the local authority is prohibited from meeting them. These people may be eligible for CHC or other NHS funded support, and so a checklist should be completed to begin the process of ascertaining this.

When assessing these, case law has established that the following factors need to be considered:

  • nature and type: the characteristics of the needs of the individual, the overall effect of them on the individual and the type of interventions required to manage them;
  • intensity: both extent (quantity) and severity (degree) of the needs, and the support required to meet them, including the need for sustained care (continuity);
  • complexity: how the needs arise and interact to increase the skill needed to monitor and manage the care / condition;
  • unpredictability: the degree to which needs fluctuate, creating difficulty in managing needs, and the level of risk to the person’s health if adequate and timely care is not provided (1).

3. Determining Eligibility

The first step is for a social worker or clinician to complete either a CHC checklist (see section 4 below) or a fast track form if the person’s condition is rapidly deteriorating and they may be entering a terminal phase. The checklist, together with any supporting evidence, should be sent to the CHC team.

If the person is entitled to be considered for CHC, a multi-disciplinary assessment will be scheduled. This will draw together all available evidence from other assessments and monitoring information as well as testimony from the person and others who know the person well. This will be summarised using the decision support tool.

Information to inform the decision making about eligibility for CHC funding should be gathered by using the Decision Support Tool (DST), to gather evidence from multidisciplinary assessments of someone’s need.

Eligibility for CHC funding must be determined by the CCG, acting on the recommendation of a multi-disciplinary panel which has considered the findings of the DST.

The CCG cannot delegate the decision making function in relation to eligibility decisions, although in Hull, a multi-agency panel is convened to advise on decision making. (2) It may choose to use a panel to ensure consistency and quality of decision making, but would only decide not to accept the recommendation in exceptional circumstances. It should not refer a case back for further work, or decide not to accept the recommendation simply because it would have made a different decision to multi-disciplinary team based on the same evidence (3) and the decision not to accept the recommendation should never be made by a single person acting unilaterally. (4)

Decisions on eligibility should never be based on:

  • the person’s diagnosis;
  • the care setting;
  • the ability of the care provider to manage care;
  • the use (or not) of NHS staff to provide care;
  • the need for ‘specialist’ staff in care delivery;
  • the fact that a need is well managed;
  • the existence of other NHS funded care;
  • any other input related (rather than needs related) rationale (5).

4. The Continuing Healthcare Checklist

For most people, the first step in determining eligibility will be a screening process using the NHS Continuing Healthcare Checklist. The checklist can be completed by a qualified doctor, nurse or social worker and will show whether someone is eligible to be considered for CHC funding via a fuller assessment collated by the use of the Decision Support Tool (DST). If someone is eligible, the assessment should take place as soon as possible, as the final decision on funding should take place within 28 days of the checklist being completed (6).

The aim of the checklist is to identify whether or not someone has a primary health need and therefore requires a full assessment using the DST. Where it can reasonably be expected that the person’s needs will increase in the next three months, for example because of an expected deterioration in their condition, this should be reflected (7). Where the extent of need may appear to be less because good care and treatment is reducing the effect of a condition, the need should be recorded in the checklist as if that care and treatment was not being provided (8).

A full assessment for continuing healthcare is triggered if there are:

  • one domain selected in column A where that domain is marked with an asterisk (behaviour, breathing, drug therapies: symptom control and altered states of consciousness);
  • two or more domains selected in column A;
  • five or more domains selected in column B or one selected in A and four selected in B (9).

If someone has been assessed using the checklist and the decision is not to proceed to a full assessment, they should be advised of their right to ask the CCG to reconsider (10). Whatever the decision, the assessor should record in writing the reason for the decision and should sign and date the checklist. The person and their representative should be informed of the decision, given a clear rationale for it and be given a copy of the completed checklist (11).

5. The Decision Support Tool

The Decision Support Tool (DST)has been developed for use by practitioners to help them get a full picture of the person’s needs. It is not an assessment in itself, but should draw information from all assessments previously completed by both the NHS and the local authority. This, combined with the practitioner’s professional judgement, should enable them to identify whether the person has a primary health need.

The DST should be completed by a multi-disciplinary team, which, will usually include a health professional and a social worker or designated care manager (12). Specialist staff and mental health staff should be involved if the person’s needs show this may be helpful.

The multi-disciplinary team will make a recommendation about someone’s eligibility for NHS Continuing Healthcare to the CCG.

Prior to assessment, the person should have completed any active relevant treatment and have reached their optimum potential for any rehabilitation. Services provided to support rehabilitation are not the same as services provided to treat or manage someone’s long term needs and include:

  • reablement (active recovery and independence);
  • rehabilitation programmes;
  • extended period of assessment placements.

It must be borne in mind by assessors that well managed needs are still needs. Only where the successful management of a healthcare condition has permanently reduced or removed a need will it no longer need to be considered when determining eligibility (13). It therefore follows that if there no reasonable expectation of a permanent reduction or removal of need (such that the support to manage it may be withdrawn), the full assessment should not be delayed while an effective programme of support is being identified. For example, where psychological or similar interventions are successfully addressing behavioural issues, consideration should be given to the need which would exist if that support was withdrawn and this should be reflected in the behaviour domain (14). However, well controlled physical conditions should not be recorded as if as if medication or other routine care was not present. For example if someone’s skin condition is not aggravated by their incontinence because good continence care is being given, it would not be appropriate to weight the skin domain as if the continence care was not being provided (15).

A decision about someone’s eligibility for continuing healthcare must be based on their overall need, the interactions between needs in different care domains and the evidence from risk assessments. The overall judgement about whether someone has a primary health need must be based on the nature, complexity, intensity and unpredictability of their needs. However, a recommendation of eligibility would be expected if:

  • a priority need was recorded in any of the four domains which carry this level (behaviour, breathing, drug therapies: symptom control and altered states of consciousness);
  • two or more incidences of severe needs were recorded;
  • one domain was recorded as severe together with needs in a number of other domains;
  • a number of domains with high and / or moderated needs (16).

Before the process begins, the person’s informed consent should be obtained. If someone does not consent, the potential risks to them of not receiving appropriate support should be explained. If someone does refuse an assessment for continuing healthcare funding, this does not mean that the local authority has an additional responsibility to meet their needs and the local authority must not attempt to meet needs which arise from a primary health need, as by their nature these are beyond those which a local authority could be expected to meet. The local authority therefore has no power in law (17).

If there is a concern that the individual may not have capacity to give consent, this should be determined in accordance with the Mental Capacity Act 2005 (see Mental Capacity) and the associated code of practice. A third party, such as a family member, friend or carer cannot give consent on behalf of someone who lacks capacity unless they hold a valid power of attorney or welfare deputyship (18) and a decision should be reached on the person’s behalf by following the best interest decision making process.

6. Hospital Discharge

Safe discharge from hospital remains the responsibility of the discharging hospital, as set out in Schedule 2, part 2 of the Standard NHS Contract for Acute Services and before giving notice to the local authority that the person is to be discharged, hospital staff should take reasonable steps to ensure that an assessment for continuing healthcare is carried out if it appears that the person may have a need for such care (19). Hospital staff must be sure that appropriate provision will be available to meet the person’s needs after discharge, including:

  • rehabilitation support;
  • care provision;
  • a safe environment;
  • moving and handling equipment;
  • medication;
  • continence supplies;
  • wound dressing if required;
  • advance notice to the District Nursing Team and GP.

An assessment for continuing healthcare will not usually be carried out until the person has exhausted their potential for recovery and reablement and care must be taken to distinguish between support which is there to aid recovery and that which is there to manage needs. If the support is being provided to manage needs which will recur essentially unchanged if the support were to be withdrawn, then this is not treatment and the assessment for continuing healthcare can take place, taking full account of the needs which would be there if the support were not being provided. If it is reasonably anticipated that the support will cause the needs to disappear or to recur in a reduced form should the support be withdrawn, than it is reasonable that the assessment for continuing healthcare takes place after the full beneficial effects of the support have been felt. However, if an assessment does then take place, it must consider the needs as they would be if the support was not being provided (20).

If the person appears to have needs for social care support, the hospital will notify the social work team who will arrange for any necessary assessments and provision of support. If it seems to the social work team that the person may be eligible for continuing healthcare, they should complete the checklist and notify the continuing healthcare team, sending a copy of the checklist and detailing the reasons why they believe the person is eligible. While awaiting a decision, the necessary support must be provided. If the person is later found to be eligible, reimbursement must be sought.

7. Reviews

Eligibility for continuing healthcare will be subject to regular review. If it is believed that the person may no longer be eligible, a joint assessment of the person must be carried out between the continuing healthcare team and the local authority and future funding must be agreed and put into effect before any withdrawal of existing funding (21). If agreement cannot be reached between the NHS and the local authority, the local disputes procedure must be invoked and current funding and care management responsibilities should remain in place until the dispute has been resolved (22).

8. Disputes

If the person has been screened out from full consideration for continuing healthcare following use of the checklist, or if funding has been refused or withdrawn they can ask the CCG to reconsider its decision. If they are not satisfied with the response, they can write to the NHS Commissioning Board and ask for the application to be reconsidered.

Part of the management structure surrounding continuing healthcare funding is a requirement for the CCG and the local authority to agree a local disputes resolution process. (23) If the local authority and the CCG disagree about responsibility for funding, the disputes resolution process should be invoked.

9. References

National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care (Department of Health and Social Care)

  1. The National Framework for NHS Continuing Healthcare and NHS funded nursing care para 35
  2. The National Framework for NHS Continuing Healthcare and NHS funded nursing care Part 1 (Executive summary) para 3
  3. The National Framework for NHS Continuing Healthcare and NHS funded nursing care para 92
  4. The National Framework for NHS Continuing Healthcare and NHS funded nursing care para 91
  5. The National Framework for NHS Continuing Healthcare and NHS funded nursing care para 58
  6. The National Framework for NHS Continuing Healthcare and NHS funded nursing care para 95
  7. DH guidance on the NHS Continuing Healthcare checklist para 20
  8. DH guidance on the NHS Continuing Healthcare checklist para 20
  9. DH guidance on the NHS Continuing Healthcare checklist para 21
  10. DH guidance on the NHS Continuing Healthcare checklist para 24
  11. DH guidance on the NHS Continuing Healthcare checklist para 23
  12. DH guidance on the decision support tool summary para vii
  13. The National Framework for NHS Continuing Healthcare and NHS funded nursing care para 56
  14. DH guidance on the decision support tool para 28
  15. DH guidance on the decision support tool para 29
  16. DH guidance on the decision support tool para 31
  17. The National Framework for NHS Continuing Healthcare and NHS funded nursing care para 47
  18. The National Framework for NHS Continuing Healthcare and NHS funded nursing care para 50
  19. The National Framework for NHS Continuing Healthcare and NHS funded nursing care para 62
  20. The National Framework for NHS Continuing Healthcare and NHS funded nursing care para 56
  21. The National Framework for NHS Continuing Healthcare and NHS funded nursing care para 143
  22. The National Framework for NHS Continuing Healthcare and NHS funded nursing care para 143
  23. The National Framework for NHS Continuing Healthcare and NHS funded nursing care para 159.

Appendix 1: What is Continuing Health Care and What is it not?

Click here to view Flowchart: What is Continuing Healthcare and what is not?

Appendix 2: Is a Checklist Required?

Click here to view Flowchart: Is a Checklist Required?

Appendix 3: Completing the Checklist

Click here to view Flowchart: Completing the Checklist

Appendix 4: Completing a Decision Support Tool

Click here to view Flowchart: Completing a Decision Support Tool

Appendix 5: Panel

Click here to view Flowchart: Panel

Appendix 6: Appeals

Click here to view Flowchart: Appeals

Appendix 7: Disputes

Click here to view Flowchart: Disputes