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NHS Continuing Healthcare Procedure

1. The National Framework

The National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care is a document that sets out:

  1. The principles and legislative context of NHS Continuing Healthcare; and
  2. The processes of applying for and making a decision about NHS Continuing Healthcare eligibility.

All practitioners must have regard for the framework when carrying out any action in relation to NHS Continuing Healthcare.

Click here to access the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care.

2. An Introduction to NHS Continuing Healthcare Funding

Defining NHS Continuing Healthcare

NHS Continuing Healthcare (sometimes called fully funded NHS care) is care outside of hospital that is arranged and funded entirely by the NHS.

NHS Continuing Healthcare can be provided in any setting, including:

  1. A care home;
  2. A hospice; or
  3. The person's own home.

Where NHS Continuing Healthcare is provided the NHS must fund all of the services and support that the person requires to meet both their:

  1. Health needs; and
  2. Associated Care and Support needs; which includes
  3. Accommodation related costs of a care home.

If a person receiving Care and Support from the Local Authority under the Care Act is found to be eligible for NHS Continuing Healthcare all legal responsibilities for arranging, funding and reviewing their care transfer to the NHS.

Eligibility for NHS Continuing Healthcare

NHS Continuing Healthcare is only available for people:

  1. From the age of 18; who
  2. Need ongoing healthcare as a result of disability, accident or illness; and
  3. Have a 'Primary Health need', as determined by a comprehensive eligibility assessment process (as set out in the Framework).

The local Clinical Commissioning Group (CCG) must determine if a person is eligible for NHS Continuing Healthcare.

Primary Health need

This is the threshold that must be met in order for a person to be found eligible for NHS Continuing Healthcare.

Under the Framework a Primary Health need exists if, having taken into account all of a person's needs, it can be said that the main aspects or majority part of the care they require is focussed on addressing and/or preventing health needs.

It is the responsibility of a multidisciplinary team to recommend to the CCG whether or not the threshold is met.

Personal health budgets

If a person receives NHS Continuing Healthcare they should be provided with a Personal Health Budget, in much the same way as they would be provided with a Personal Budget if the Local Authority were meeting their needs.

The health care manager should then plan with the person how best to use this budget to meet their needs, which could include through a health Direct Payment. This process is similar to Care and Support Planning in adult Care and Support.

3. Roles and Responsibilities

The role of the Clinical Commissioning Group

Following a referral the local CCG must:

  1. Decide whether a full assessment of eligibility is required; and
  2. Notify the person of their decision.

If a full assessment is required the CCG must appoint a suitably qualified practitioner (normally a health professional) to co-ordinate the process set out in the Framework.

After the assessment process is completed and the multidisciplinary team have made their recommendation the CCG must then make a decision about whether or not the person is eligible for NHS Continuing Healthcare.

If a full assessment of eligibility is carried out and the person is deemed not eligible for NHS Continuing Healthcare the CCG should consider whether the person may be eligible for either NHS-funded Nursing Care or a joint package of health and social care.

If a full assessment of eligibility for NHS Continuing Healthcare is not required the CCG should consider whether the person may be eligible for NHS-funded Nursing Care.

The role of the Local Authority

Practitioners carrying out Local Authority functions should, through any assessment or review process:

  1. Identify when a person may be eligible for NHS Continuing Healthcare; and
  2. Provide information to the person (and their family) about NHS Continuing Healthcare (whenever it is requested or would be beneficial); and
  3. Obtain the person's consent to complete the NHS Continuing Healthcare checklist (of if they lack capacity decide whether it is in their Best Interests to continue); and
  4. Complete the NHS Continuing Healthcare checklist; and
  5. If a full assessment is required, make a referral to the CCG; and
  6. Provide relevant information about the person's needs (for example a needs assessment, Care and Support Plan or risk assessment); and
  7. Where requested, be part of the multidisciplinary team; and
  8. If NHS Continuing Healthcare is awarded, take steps to transfer Local Authority funded services and support to the health professional that will be assuming care management responsibilities.

Note: Under section 9 of the Care Act where it appears that a person may be eligible for NHS Continuing Healthcare the Local Authority must refer them to the CCG.

The role of the co-ordinating practitioner

The practitioner appointed by the CCG to co-ordinate the process set out in the framework should:

  1. Explain the NHS Continuing Healthcare assessment process to the person (and/or their representative);
  2. Obtain the person's consent to the assessment process (and if they lack capacity decide whether it is in their Best Interests to continue);
  3. Decide who should be part of, and establish the multidisciplinary team;
  4. Ensure the process is completed in a timely way;
  5. Present the recommendation of the multidisciplinary team to the CCG; and
  6. Notify the person (and/or their representative) and the Local Authority of the CCG's decision.

Note: Under the Framework the co-ordinator may also assume a role as part of the multidisciplinary team if they deem this to be appropriate.

When the MDT recommends that the person is not eligible for NHS Continuing Healthcare the coordinator should also make a recommendation to the CCG about the person's eligibility for NHS-funded Nursing Care or a joint package of health and social care.

Maximising participation of the person A core value and principle of the Framework is to maximise the involvement and participation of the person at all stages of the process, from completing the checklist to the point where a decision is made about eligibility and beyond.

As a minimum the MDT should:

  1. Ensure that the person and/or their representative is fully and directly involved in the process and any decision making;
  2. Take full account of the person's own views and wishes, ensuring that their perspective is the starting point of every part of the process;
  3. Address communication and language needs;
  4. Obtain consent to assessment and sharing of records;
  5. Deal openly with issues of risk; and
  6. Keep the person (and/or their representative) fully informed.

Practitioner skills and knowledge

The Framework requires that practitioners involved in the process have received the necessary training to fulfil their role and meet their responsibilities.

You should speak with a line manager if you are concerned about your skills or knowledge around the NHS Continuing Healthcare framework.

4. Identifying when a Person may be Eligible

Why it is important to identify possible eligibility

As a social care practitioner it is important that you understand when a person may be eligible for NHS Continuing Healthcare, for both person centred and statutory reasons.

Person centred benefits

It is unlikely that practitioners based in the Local Authority will:

  1. Understand how best to meet complex health needs; or
  2. Have access to appropriate services to meet the needs.

Statutory implications

Under section 9 of the Care Act where it appears that a person may be eligible for NHS Continuing Healthcare the Local Authority must refer them to the CCG.

In addition to this requirement under section 22 of the Care Act the Local Authority is not permitted to provide services and support to people when it is the legal duty of the NHS to provide them unless:

  1. The support being provided by a health professional is merely incidental or ancillary (secondary) to doing something else to meet Care and Support needs; or
  2. The support is of a nature that the Local Authority could be expected to provide.

People that may be eligible

It is important that no assumptions or generalisations are ever made about a person's possible eligibility for NHS Continuing Healthcare. However, people requiring a care home placement, or people with the following health conditions may have needs that are complex enough to meet the Primary Health need threshold of eligibility, and the need to complete a NHS Continuing Healthcare checklist should therefore normally be considered:

  1. Advanced Dementia;
  2. Parkinson's Disease;
  3. Cancers;
  4. Acquired brain injury;
  5. Severe learning disability;
  6. Complex personality disorders; and
  7. Enduring mental health illness.

Identifying when a person may be eligible

Possible eligibility for NHS Continuing Healthcare can be identified by considering the person's needs in the context of their:

  1. Nature;
  2. Intensity;
  3. Complexity; and
  4. Unpredictability.
Caption: nursing 1
   
Nature This describes the particular characteristics of an individual's needs (which can be physical, mental health or psychological needs) and the type of those needs. This also describes the overall effect of those needs on the individual, including the type ('quality') of interventions required to manage them.
Intensity This relates both to the extent ('quantity') and severity ('degree') of the needs and to the support required to meet them, including the need for sustained/ongoing care ('continuity').
Complexity This is concerned with how the needs present and interact to increase the skill required to monitor the symptoms, treat the condition(s) and/or manage the care. This may arise with a single condition, or it could include the presence of multiple conditions or the interaction between two or more conditions. It may also include situations where a person's response to their own condition has an impact on their overall needs, such as where a physical health need results in the person developing a mental health need.
Unpredictability This describes the degree to which needs fluctuate and thereby create challenges in managing them. It also relates to the level of risk to the person's health if adequate and timely care is not provided. Someone with an unpredictable healthcare need is likely to have either a fluctuating, unstable or rapidly deteriorating condition.


If you are not sure of a person's possible eligibility you should seek the support and advice of your line manager.

When a need to consider eligibility is identified

If you have identified that a person may be eligible for NHS Continuing Healthcare you should:

  1. Provide information to them (or their representative) about NHS Continuing Healthcare (see Section 5, Providing Information and Advice about NHS Continuing Healthcare); and
  2. Obtain their consent to complete the NHS Continuing Healthcare checklist (see Section 6, Obtaining Consent); and
  3. Complete the checklist to determine whether a referral for a full assessment of eligibility by the CCG is required (see Section 7, Completing the NHS Continuing Healthcare Checklist).

5. Providing Information and Advice about NHS Continuing Healthcare

You are expected to be able to provide accessible information and advice about NHS Continuing Healthcare whenever:

  1. A person/carer asks for it; or
  2. You have identified that a person may be eligible.

The following is a list of all the information that you should be able to provide:

  1. What NHS Continuing Healthcare is;
  2. What factors might make a person eligible for NHS Continuing Healthcare;
  3. The process of completing a NHS Continuing Healthcare checklist;
  4. Who is responsible for making decisions about eligibility;
  5. How decisions about eligibility are made;
  6. The implications of an 'eligible' decision; and
  7. The implications of an 'ineligible' decision.

It is important when providing information about NHS Continuing Healthcare you make clear the checklist is not a determination of eligibility, nor is it a guarantee that a full assessment will be carried out.

If the person who is requesting information (or for whom it would be beneficial) is a person with a learning disability the NHS has produced easy read information that can be given to them. Click here to access it.

You should speak with a line manager if you are concerned about your skills or knowledge around the NHS Continuing Healthcare framework before providing advice about it.

Obtaining consent

It is important to obtain informed consent from the person prior to completing the NHS Continuing Healthcare Checklist.

Consent should be sought to:

  1. Complete the Checklist; and
  2. Provide a copy of the Checklist to the CCG; and
  3. If positive, make a referral for full assessment by the CCG; and
  4. Provide information to the CCG during the assessment process.

Consent should be:

  1. Explicit;
  2. Specific;
  3. Informed; and
  4. Freely given.

For further information about consent, please refer to the Framework.

The nature of the consent given must be clearly recorded on:

  1. The person's file;
  2. The checklist; and
  3. Where required, the referral.

Refused consent

If the person does not consent you should:

  1. Provide them with further information about NHS Continuing Healthcare as required; so that
  2. Any anxiety they have about the process or possible implications for services can be alleviated.

If the person continues to refuse to provide their consent you should:

  1. Explain the possible implications of refusing consent; and
  2. Explain the benefits of providing consent (in terms of access to more appropriate services and a case manager who understands their health needs); and
  3. Explain to them that you will need to discuss the situation with your manager; and then
  4. Discuss the most appropriate course of action with your line manager.

There are a range of possible actions that may be decided, depending on the specific circumstances and the person's likely eligibility for NHS Continuing Healthcare. A decision could be made to:

  1. Take no further action under the NHS Continuing Healthcare framework;
  2. Request a health professional already involved with the person supports them to understand the benefits of the NHS Continuing Healthcare framework;
  3. Discuss the situation with the CCG to agree a joint organisational position; or
  4. Seek legal advice.
Need to know

Under section 22 of the Care Act the Local Authority is not permitted to provide services and support to people when it is the legal duty of the NHS to provide them unless:

  1. The support being provided by a health professional is merely incidental or ancillary (secondary) to doing something else to meet Care and Support needs; or
  2. The support is of a nature that the Local Authority could be expected to provide.

Mental capacity and consent

If you believe that the person may lack capacity to consent this must be formally established through a proportionate Mental Capacity assessment. If the person is found to lack capacity a Best Interests decision must be made about proceeding to complete the NHS Continuing Healthcare checklist or make a referral.

Information and practice guidance regarding the requirements and processes of mental capacity assessment and Best Interests decision making can be accessed in the Mental Capacity Act 2005 Resource and Practice Toolkit by clicking here.

7. Completing the NHS Continuing Healthcare Checklist

Using this section of the procedure

This section of the procedure should be used when:

  1. The person may be eligible for NHS Continuing Healthcare; and
  2. Information about NHS Continuing Healthcare has been provided to them (or their representative); and
  3. Consent has been provided to complete the checklist; or
  4. The person has been assessed as lacking capacity to consent, and a Best Interests decision has been made to complete the checklist.

The purpose of the NHS Continuing Healthcare checklist

The checklist is a screening tool for use by practitioners who believe that a person may be eligible for NHS Continuing Healthcare to:

  1. Establish whether a referral for a full assessment of eligibility should be made; and
  2. To help the CCG direct NHS Continuing Healthcare resources towards those persons most likely to be in need of them.
Need to know
It is important when providing information about the NHS Continuing Healthcare checklist to the person (or their representative) that you make clear the checklist is not a determination of eligibility, nor is it a guarantee that a full assessment will be carried out.

The person completing the NHS Continuing Healthcare checklist

The person completing the NHS Continuing Healthcare checklist must be trained in its use and familiar with the NHS Continuing Healthcare framework, particularly the role of the multidisciplinary team in agreeing a recommendation about eligibility.

You should speak with a line manager if you are concerned about your skills or knowledge around the NHS Continuing Healthcare framework before completing the NHS Continuing Healthcare checklist.

Advocacy

Under the Framework it is important to maximise the participation of the person in all parts of the process, including the Checklist stage. The minimal requirements of the Framework are explained above in Section 3, Roles and Responsibilities.

You should establish whether the person wishes to have (or needs) representation. If so you should:

  1. Consider whether there is a family member or friend able to represent them; and
  2. If not, arrange advocacy support whenever time allows.

People that should be present when the checklist is completed

When the checklist is completed the following people should be present:

  1. The person; and
  2. Any representative or advocate.

No other person is required to be present but if you feel it would be beneficial to consult with somebody else you may do so, as long as:

  1. The person consents to their involvement; or
  2. The person lacks capacity and a decision is made in their Best Interests.

The NHS Continuing Healthcare checklist

Click here to access the NHS Continuing Healthcare checklist, which can be printed, e-mailed and saved as required.

Deciding the level of need

The NHS Continuing Healthcare checklist is primarily divided into 11 sections, representing the 11 static care domains of the framework. These are:

  1. Breathing;
  2. Nutrition;
  3. Continence;
  4. Skin Integrity;
  5. Mobility;
  6. Communication;
  7. Psychological/Emotional;
  8. Cognition;
  9. Behaviour;
  10. Drug therapies and medication (symptom control); and
  11. Altered states of consciousness.

Each section contains a range of statements (A, B or C), similar to the example below (which is a replica of the Breathing section of the checklist):

  C B A
Breathing*

Normal breathing, no issues with shortness of breath.



OR

Shortness of breath or a condition, which may require the use of inhalers or a nebuliser and has no impact on daily living activities.

OR

Episodes of breathlessness that readily respond to management and have no impact on daily living activities.

OR

A skin condition that requires monitoring or reassessment less than daily and that is responding to treatment or does not currently require treatment.

Shortness of breath or a condition, which may require the use of inhalers or a nebuliser and limit some daily living activities.

OR

Episodes of breathlessness that do not consistently respond to management and limit some daily activities.



OR

Requires any of the following:

  • low level oxygen therapy (24%);
  • room air ventilators via a facial or nasal mask;

other therapeutic appliances to maintain airflow where individual can still spontaneously breathe e.g. CPAP (Continuous Positive Airways Pressure) to manage obstructive apnoea during sleep.

Is able to breathe independently through a tracheotomy that they can manage themselves, or with the support of carers or care workers.

OR

Breathlessness due to a condition which is not responding to therapeutic treatment and limits all daily living activities.

OR

A condition that requires management by a non-invasive device to both stimulate and maintain breathing (non-invasive positive airway pressure, or non-invasive ventilation)

Brief description of need and source of evidence to support the chosen level  

Write A, B or C below:

 


You must:

  1. Circle or highlight the individual statement that best matches the needs of the person; and
  2. Write the corresponding letter (either A, B or C) in the box; and
  3. Provide a brief and concise summary of the person's needs in that domain and the evidence upon which you have based your judgement.

Copies of the evidence used do not have to be provided in any referral made but the manner in which you reference the evidence on the Checklist should make it easy for the CCG to locate if required.

If you are of the view that the person's needs are likely to increase in the next 3 months, this should be reflected by the statement that you select.

The equality monitoring data form

The equality monitoring data form at the end of the checklist should be completed by the person, with your support as required. This form must be submitted to the CCG with the other areas of the checklist.

Deciding whether a referral to the CCG is required

When you have circled a statement in each of the care domains you must record the total number of A's, B's and C's selected in order to establish whether the threshold upon which a referral must be made to the CCG has been met.

A referral to the CCG for a full eligibility assessment must always be made when there are:

  1. 2 or more domains selected in column A; or
  2. 5 or more domains selected in column B, or 1 selected in A and 4 in B; or
  3. 1 domain selected in column A where the domain has an asterisk with any number of selections in the other 2 columns.

If the above does not apply it may still be appropriate to make a referral to the CCG if the overall level of need is deemed to be complex, intense or unpredictable in nature.

In this case you should seek agreement from your line manager and follow local protocols.

Recording the outcome

There are 2 statements at the end of the checklist, one of which you must circle:

  1. Referral for full assessment for NHS Continuing Healthcare is necessary (known in the Framework as a 'positive' Checklist); or
  2. No referral for full assessment for NHS Continuing Healthcare is necessary (known as a 'negative' Checklist).

The rational for the decision should be clearly recorded, especially if the threshold upon which a referral must be made has not been met.

When the checklist is complete you must sign and date where specified, and make a record of your contact details.

A record of the outcome, and the rational should also be recorded on the person's electronic file.

Notifying the person of the outcome

As the person completing the checklist it is your role to notify the person of the outcome, specifically:

  1. Whether a referral to the CCG for a full assessment is required; or
  2. Whether a referral to the CCG is not required;
  3. The rational for the decision; and
  4. Information about how the person (or their representative) can request that the CCG review the decision.

Reviewing the decision

All requests to review NHS Continuing Healthcare decisions must be made to the CCG, even if it was your decision not to make a referral.

It is therefore best practice that if a decision is made not to refer, a copy of the checklist is still provided to the CCG, so that it is available should the person decide to complain.

Providing copies of the checklist

The person (and any representative) should be provided with a copy of the checklist, regardless of whether a referral to the CCG is to be made.

If a referral is to be made to the CCG the original checklist should be sent to the CCG, and a copy should be stored on the person's Local Authority file.

Where a decision is made not to refer the original checklist should be stored on the person's Local Authority file, and a copy provided to the CCG, so that they are aware that NHS Continuing Healthcare has been considered and are able to respond to any complaint that may be made.

8. Making a Referral to the CCG

Secure and timely referrals

It is essential that the checklist and referral form are sent to the CCG is a secure and timely manner to:

  1. Ensure confidentiality; and
  2. Avoid any delays in establishing and providing NHS Continuing Healthcare (or any other health funding provision).

The process for making a referral

All referrals should be made in line with local processes and requirements.

Providing evidence

Copies of the evidence used do not have to be provided in any referral made but the manner in which you reference the evidence on the Checklist should make it easy for the CCG and/or any assessor to locate if required.

Making a record

You must record the following on the person's electronic file:

  1. The date that the referral was made; and
  2. When known, the outcome of the referral.

Notification of the referral outcome

The CCG is expected to make a final decision about eligibility for NHS Continuing Healthcare within 28 days of receiving the referral (or sooner if it is more urgent) unless their reasons for not doing so are both:

  1. Valid; and
  2. Unavoidable.

The need to carry out a full assessment should therefore be established soon after the referral has been provided to them.

It is the CCG's responsibility to notify the person of the outcome of the referral in writing, and advise them of any action they can take if they are not happy with the decision.

The outcome of the referral will be either:

  1. A full assessment of eligibility for NHS Continuing Healthcare will be carried out; or
  2. A full assessment of eligibility for NHS Continuing Healthcare will not be carried out.

If a full assessment is to be completed

If a full assessment is to be completed the CCG must appoint a practitioner to coordinate the assessment process. This practitioner should notify you that a full assessment is to be completed and confirm whether you are required to be part of the multidisciplinary team.

Click here to access the guidance about being part of the multidisciplinary team.

If you are the person's allocated worker and you are not required to be part of the multidisciplinary team the MDT should still consult you as part of the process.

Click here to access the procedure for providing relevant information.

If a full assessment is not required

If the CCG decides that a full assessment to determine eligibility for NHS Continuing Healthcare is not required you should take steps to ensure that the person continues to access Local Authority support and services under the Care Act.

However, if the person lives in a nursing home (or will be moving to one) you should ask the CCG to consider whether or not they may be eligible for NHS-funded Nursing Care (FNC), if the CCG has not already done so.

Complaints and requests to review the decision

If the person (or their representative) is unhappy with the decision of the CCG they should complain about it directly to the CCG, and the CCG is required to review their decision.

The Local Authority is not able to manage any complaints relating NHS Continuing Healthcare.

If you are concerned about the decision of the CCG you should discuss any action that may (or may not) be needed to challenge the decision with your line manager.

9. The Provision of Relevant Information

If the CCG consults with you as part of the NHS Continuing Healthcare process you must, as far as is reasonably practicable provide any evidence and assistance requested within a reasonable timeframe.

You should only provide information in line with the consent given by the person to do so, unless the person lacks capacity and you deem sharing the information to be in their best interests.

10. The Multidisciplinary Team and the Decision Support Tool

When to use this section of the procedure

This section of the procedure should be used by social care practitioners who are part of the multidisciplinary team considering a person's eligibility for NHS Continuing Healthcare. It provides guidance about:

  1. The process of decision making that you will be involved in; and
  2. Your role as a member of the multidisciplinary team.

The role of the multidisciplinary team

The multidisciplinary team (MDT) must consist of at least:

  1. Two professionals from different healthcare professions; or
  2. One healthcare professional and one person with responsibility for assessing Care and Support needs under the Care Act.

It is the expectation in the Framework that the MDT should include professionals from both health and social care, who are knowledgeable about the person's needs and, where possible have been recently involved in the assessment, treatment or care of the person.

The MDT is responsible for:

  1. Carrying out any assessments required (e.g. a needs assessment or a nursing needs assessment);
  2. Maximising the participation of the person in the process (see below);
  3. Consulting with the person, their family and any other person deemed relevant to the decision;
  4. Reviewing all of the information gathered;
  5. Applying the Decision Support Tool; and
  6. Making a recommendation to the CCG about eligibility.

Note: Where the MDT does not contain a Local Authority representative, the CCG is required (wherever practicable) to consult with the Local Authority before making any decision about eligibility.

Under the Framework the co-ordinator may also assume a role as part of the multidisciplinary team if they deem this to be appropriate.

Maximising participation of the person

A core value and principle of the Framework is to maximise the involvement and participation of the person at all stages of the process, from completing the checklist to the point where a decision is made about eligibility and beyond.

As a minimum the MDT should:

  1. Ensure that the person and/or their representative is fully and directly involved in the process and any decision making;
  2. Take full account of the person's own views and wishes, ensuring that their perspective is the starting point of every part of the process;
  3. Address communication and language needs;
  4. Obtain consent to assessment and sharing of records;
  5. Deal openly with issues of risk; and
  6. Keep the person (and/or their representative) fully informed.

Practitioner skills and knowledge

The Framework requires that practitioners involved in the process have received the necessary training to fulfil their role and meet their responsibilities.

You should speak with a line manager if you are concerned about your skills or knowledge around the NHS Continuing Healthcare framework.

The Decision Support Tool

The Decision Support Tool (DST) is the mechanism used to bring together all of the evidence gathered during the assessment process so as to clarify needs and then make a collective professional judgement about eligibility for NHS Continuing Healthcare on the basis of a primary health need.

The Care Domains

There are 12 care domains set out in the Decision Support Tool which are the same domains as in the Checklist:

  1. Breathing;
  2. Nutrition-food and drink;
  3. Continence;
  4. Skin and tissue viability;
  5. Mobility;
  6. Communication;
  7. Psychological and emotional needs;
  8. Cognition;
  9. Behaviour;
  10. Drug Therapies and medication (symptom control);
  11. Altered States of consciousness; and
  12. Other significant care needs.

In each domain the actual health and social care needs of the person should be described, along with the evidence that has informed this judgement.

Determining health and social care needs

Often it can be difficult to determine which needs are health needs and which are social care needs.

A health need

A 'health need' is described in the Framework as:

  1. A need related to the treatment, control, management or prevention of a disease, illness, injury or disability; and
  2. The care or aftercare of a person with these needs (whether or not the tasks involved have to be carried out by a health professional).

Some of the domains in the DST are clearly health needs by nature (breathing, drug therapies, ASC) but the remaining domains are likely to have an element of both health and social care need, and the role of the MDT is to agree whether the nature of the care required indicates a more prominent health or social care need overall.

Social care needs

Under the Framework a 'social care need' is taken to be any need related to the Care Act eligibility criteria:

  1. Managing and maintaining nutrition;
  2. Maintaining personal hygiene;
  3. Managing toilet needs;
  4. Being able to make use of the home safely;
  5. Maintaining a habitable home environment;
  6. Developing and maintaining family or other personal relationships;
  7. Accessing or engaging in work, training, education or volunteering;
  8. Making use of necessary facilities or services in the local community; and
  9. Carrying out any caring responsibilities for a child.

Eligibility criteria a-e clearly fit into the domains of the DST, whereas the others are all social care needs. It is important to make sure that the needs that do not fit into the DST domains are still included in decision making.

Deciding the level of health need

When all relevant health and social care needs in a care domain have been identified the multidisciplinary team must consider and agree the overall level of health need in each domain, which will be one of the following:

N=No needs 
L=Low needs
M=Moderate needs
H=High needs
S=Severe needs
P=Priority needs

This decision should be made having regard for the frequency and intensity of need, unpredictability, deterioration and any instability. Guidance on these characteristics can be found in the table below:

Caption: nursing 2
   
Nature This describes the particular characteristics of an individual's needs (which can be physical, mental health or psychological needs) and the type of those needs. This also describes the overall effect of those needs on the individual, including the type ('quality') of interventions required to manage them.
Intensity This relates both to the extent ('quantity') and severity ('degree') of the needs and to the support required to meet them, including the need for sustained/ongoing care ('continuity').
Complexity This is concerned with how the needs present and interact to increase the skill required to monitor the symptoms, treat the condition(s) and/or manage the care. This may arise with a single condition, or it could include the presence of multiple conditions or the interaction between two or more conditions. It may also include situations where a person's response to their own condition has an impact on their overall needs, such as where a physical health need results in the person developing a mental health need.
Unpredictability This describes the degree to which needs fluctuate and thereby create challenges in managing them. It also relates to the level of risk to the person's health if adequate and timely care is not provided. Someone with an unpredictable healthcare need is likely to have either a fluctuating, unstable or rapidly deteriorating condition.
Need to know

It is important to refer to guidance in the Decision Support Tool when agreeing the level of need in each care domain. This is because:

  1. The description of P, S, H, M and L varies across care domains; and
  2. Not all levels of need can be applied to all domains.

The concept of a 'well-managed' need

Well managed needs are those needs that are currently having little or no impact on the person's health or wellbeing because of the positive effects of the support they are receiving.

The Framework is clear that a well managed need is still a need.

Evidence of the number of recorded incidences of need (e.g. of challenging behaviour) should not be used as the sole factor when determining the overall level of need in the care domain. This could lead to a false level of need being agreed. The MDT should consider whether other factors are impacting on the need, for example environment and whether changes can be made to these factors that reduce or eliminate the need.

If the level of health need is not clear

If it is not clear what the level of health need is, or if there is disagreement about this the co-ordinating practitioner should make a record of any disagreement or difficulties occurred in reaching the decision so that the CCG can discuss this when making a decision about eligibility.

Deciding if there is a Primary Health need

After agreeing the level of health need in each care domain (i.e. P, S, H, M, L or N) the information must be summarised into the following table, which appears on page 39 of the Decision Support Tool:

A key question to ask

After completing the table the multidisciplinary team must agree whether the total effects of all needs across all domains equates to the existence of a Primary Health need (in which case a recommendation of eligibility for NHS Continuing Healthcare would be made).

Indicators of a Primary Health need

Under the Framework a person is deemed to have a Primary Health need if it can be said that the main aspects or majority part of the care they require is focussed on addressing and/or preventing health needs.

A recommendation of eligibility for NHS Continuing Healthcare should normally be made when:

  1. A Priority level of need is identified in any one of the 4 care domains that carry that level; or
  2. A total of 2 or more incidences of Severe level of need across any care domains.

In all other cases the multidisciplinary team must to consider the quality and quantity of care in more detail, using the four characteristics of:

  1. Nature;
  2. Intensity;
  3. Complexity; and
  4. Unpredictability.
Need to know
It is important to remember that each of these characteristics may, alone or in combination, demonstrate a primary health need, because of the quality and/or quantity of care that is required to meet the person's needs.

If the existence of a primary health need is not clear

If there is an occasion when the existence of a primary health need is unclear the coordinating practitioner should:

  1. Make the recommendation to the CCG that they believe is most appropriate; but
  2. Make a record of any disagreement or difficulties occurred in reaching the decision; so that
  3. The CCG can discuss this when making the final decision about eligibility.

Notifying the CCG

The coordinating practitioner is responsible for notifying the CCG of the multidisciplinary team's recommendation, which will be either:

  1. That the person is not eligible for NHS Continuing Healthcare (because they do not appear to have a Primary Health need); or
  2. That the person is eligible for NHS Continuing Healthcare (because they appear to have a Primary Heath need).

If the recommendation is that the person does not have a Primary Health need (and is not eligible for NHS Continuing Healthcare) the lead practitioner should consider and advise the CCG whether:

  1. The person would benefit from on-going health support; and
  2. If so, whether any joint package of health and social care arrangements may apply; or
  3. If the person lives in a nursing home (or will be moving to one), whether they may be eligible for NHS-funded Nursing Care (FNC).

If you are concerned about the recommendation made by the lead health professional you should discuss any action that may (or may not) be needed to challenge the recommendation with your line manager.

11. After Eligibility is Determined

Notification of the outcome

The CCG will consider the recommendation and decide that either:

  1. The person is eligible for NHS Continuing Healthcare; or
  2. The person is not eligible for NHS Continuing Healthcare.

Regardless of your involvement in the multidisciplinary team, if you made the referral the coordinating practitioner should notify you of the outcome as soon as possible after a decision has been made. You should:

  1. Record the outcome on the person's electronic file; and
  2. Answer any questions that the person may ask of you regarding the outcome or implications.

The coordinating practitioner is responsible for formally notifying the person of the outcome in writing, explaining the implications of the outcome to them and letting them know how they can make a complaint about the decision.

If the person is eligible

The timeframe for transfer of services from the Local Authority to the CCG should be agreed at the point that a decision about eligibility is made. This should reflect local policy and should allow for:

  1. Any remaining relevant assessment and planning processes to be carried out by the CCG; and
  2. Services to be arranged.

During any transfer of services you should work as required with the health professional that will be assuming care management responsibilities to:

  1. Introduce them to the person (and their family);
  2. Ensure they have all relevant information about the person's needs (having full regard for consent); and
  3. Ensure they have all relevant information about the current services and support being provided to the person.

If the transfer process is likely to take some time, or is delayed for any reason that is not valid or unavoidable, the Local Authority and the CCG should agree arrangements for appropriate reimbursement.

In no circumstances should the Local Authority cease to provide services to the person until alternative arrangements are in place.

When the transfer of services is completed you should take steps to close the person's case unless there is a need to maintain involvement as part of an on-going safeguarding concern or investigation.

Need to know
If a person is eligible for NHS Continuing Healthcare the CCG also becomes responsible for meeting the needs of any carers.

If the person is not eligible

If the person is not eligible for NHS Continuing Healthcare the Local Authority remains legally responsible for meeting eligible needs under the Care Act, which can include support provided by a health professional when:

  1. It is merely incidental or ancillary (secondary) to doing something else to meet Care and Support needs; or
  2. It is of a nature that the Local Authority could be expected to provide.

However, when making the determination about eligibility the CCG should have considered whether:

  1. The person would benefit from on-going health support; and
  2. If so, whether any joint package of health and social care arrangements may apply; or
  3. If the person lives in a nursing home (or will be moving to one), whether they may be eligible for NHS-funded Nursing Care (FNC).

If you believe that the person may be eligible for alternative heath funding provision and that this has not been considered you should discuss this with your line manager in the first instance.

Funded nursing care

If the CCG has agreed that the person is eligible for NHS-funded Nursing Care, click here to access the NHS-funded Nursing Care procedure.

Joint package of health and social care

If the CCG has recommended that a joint package of health and social care should be arranged, click here to access the Joint Package of Health and Social Care procedure.

Safeguarding responsibility

Regardless of eligibility for NHS Continuing Healthcare the Local Authority maintains all legal responsibility for:

  1. Any ongoing adult safeguarding processes or investigations regarding the person; and
  2. Responding to any new safeguarding concerns that may arise; but
  3. It is expected that the CCG will take a lead role in any new enquiries.

Equipment

If a person is eligible for NHS Continuing Healthcare they assume responsibility for providing any equipment the person may require. However, where all Occupational Therapy services are commissioned jointly no changes will be required.

Reviewing eligibility

Eligibility/non-eligibility for NHS Continuing Healthcare is not indefinite, as needs can change.

The CCG

The CCG have a statutory responsibility to review the person's services 3 months after the transfer of funding responsibility, and then every 12 months after that. If there is any evidence to suggest that the person may no longer be eligible for NHS Continuing Healthcare a referral may be made to the Local Authority to be part of the multidisciplinary team who considers this once more.

The Local Authority

If the Local Authority believes there to be a change in the person's needs in the future, and that they may now be eligible for NHS Continuing Healthcare consideration should be given to completing a further NHS Continuing Healthcare checklist as outlined in this procedure.

Complaints and challenges to the decision

Challenges to the decision

If you disagree with any outcome that refuses NHS Continuing Healthcare funding you should discuss any action that may (or may not) be needed to challenge the decision with your line manager.

It may be necessary to hold a dispute meeting with the CCG.

Complaints about the decision

If the person (or their representative) is unhappy with the decision of the CCG they should complain about it directly to the CCG.

The Local Authority is not able to manage any complaints relating NHS Continuing Healthcare.

If the CCG subsequently reverses its decision they should make arrangements to reimburse the Local Authority for the services that is has provided during that time.

12. The Responsibility of Meeting Needs

During assessment

Inpatient settings

See Section 13, NHS Continuing Healthcare in Acute Hospital Settings.

Other settings

If a person is living in the community or a care home it remains the legal responsibility of the Local Authority to meet the person's eligible needs until:

  1. A decision about eligibility for NHS Continuing Healthcare is made; and
  2. Where eligible, the person's services and support have been transferred to the CCG.

During reassessment

If a person is already receiving support and services through NHS Continuing Healthcare but their eligibility is under review it is the legal responsibility of the CCG to continue meeting the person's needs until:

  1. A decision about on-going eligibility for NHS Continuing Healthcare is made; and
  2. Where ineligible, the person's services and support have been transferred to the Local Authority.

Delays in assessment/reassessment

With the exception of referrals made in acute hospital settings arrangements in place at the point of referral to the CCG should remain in place until a determination is made.

The CCG is expected to make a final decision about eligibility for NHS Continuing Healthcare within 28 days of receiving the referral (or sooner if it is more urgent) unless their reasons for not doing so are both:

  1. Valid; and
  2. Unavoidable.

The Local Authority and the CCG should agree arrangements for appropriate reimbursement if a decision is subsequently made that the person is eligible/ineligible for NHS Continuing Healthcare.

Delays in the transfer of services after a determination

The timeframe for transfer of services from the Local Authority to the CCG (or vice versa) should be agreed at the point that a decision about eligibility is made. This should reflect local policy and should allow for:

  1. Any remaining relevant assessment and planning processes to be carried out; and
  2. Services to be arranged.

If this process is likely to take some time, or is delayed for any reason that is not valid or unavoidable, the Local Authority and the CCG should agree arrangements for appropriate reimbursement.

The Framework is clear that the person should not experience any gaps in care as a result of delays, regardless of the cause. This means that under no circumstances should either organisation cease to provide services to the person until alternative arrangements are in place.

13. Continuing Healthcare in Acute Hospital Settings

Using this section of the procedure

This section sets out the specific considerations and requirements for social care practitioners when the person who may be eligible for NHS Continuing Healthcare is an in-patient in an acute hospital setting.

When eligibility should be considered

Eligibility should not be considered until:

  1. All acute or emergency treatment has been completed; and
  2. The likely outcome of any rehabilitation treatment or therapy is clear; and
  3. The person's needs upon discharge are clear.

The Framework expects that most assessments for eligibility will not take place until after the person has been discharged from hospital.

The requirement of the CCG to consider eligibility

Under the Framework the CCG is required to consider a person's likely eligibility for NHS Continuing Healthcare prior to commencing discharge processes.

If you are aware that a person with social care needs has been admitted to hospital and you feel it would be appropriate to consider their eligibility you should discuss this health colleagues on the ward, whose responsibility it is to consider this.

Discharging to Assess

If, as expected the CCG intends to determine eligibility post discharge they are legally responsible for providing all care and treatment to the person in the interim period. Examples of how this could be arranged include intermediate care, the provision of domiciliary care or a short term placement.

One exception

If the person was in receipt of a Local Authority funded service prior to admission the Framework allows for the CCG to request the Local Authority reinstate and continue funding that service whilst the eligibility assessment takes place.

The Local Authority does not have a duty to do this and before responding to such a request you must be clear about local arrangements that have been agreed between the Local Authority and the CCG.

Furthermore the CCG can only make such a request if:

  1. The same service is still open and available;
  2. The service does not need to be altered to meet the person's post-discharge needs.

Where the Local Authority agrees to reinstate services and the CCG subsequently decides that the person is eligible the Local Authority must be reimbursed for all care costs from the date of discharge.

Assessing in hospital

On occasion the CCG may decide that the assessment of eligibility needs to take place prior to discharge. In this situation they are responsible for making all necessary arrangements set out in this procedure.

If you are requested to provide relevant information, or be part of the multidisciplinary team you should respond to the request in a timely way so as to:

  1. Avoid any delays in establishing and providing NHS Continuing Healthcare; and
  2. Avoid contributing to any unnecessary delays in discharge.

The Fast Track Pathway

There is a fast track NHS Continuing Healthcare pathway, which requires the NHS to assume all care and treatment responsibilities from the point of referral for people who:

  1. Have a rapidly deteriorating medical condition; that may be
  2. Entering a terminal phase (end of life).

The person making a referral through the fast track pathway must be able to comment reasonably on the above and, as such practitioners in the Local Authority are not able to access the pathway.

If you believe that a person may be eligible for NHS Continuing Healthcare through the fast track pathway you should:

  1. Discuss this with a clinician who is authorised to access the pathway; and
  2. If they decline to make the referral, take steps as outlined in this procedure to complete the NHS Continuing Healthcare checklist and make a standard referral.
Need to know
A clinician authorised to access the fast track pathway is a health professional who is responsible (either solely or part of a team) for managing and arranging the person's care and treatment in either a hospital or other approved setting, such as a hospice.

Receiving a Discharge Notice

It should be clearly evident from the discharge notice:

  1. How NHS Continuing Healthcare has been considered;
  2. What decisions have been made and why.

Note: The CCG does not have to complete a Checklist in order to have considered NHS Continuing Healthcare as the Framework recognises that this is not always necessary.

If it is not clear whether NHS Continuing Healthcare has been considered you should liaise with the ward to establish this. If the ward has not considered it you should ask them to do so.

If the discharge notice requests that services are reinstated as set out in Discharging to Assess above, you must:

  1. Be clear about local arrangements that have been agreed between the Local Authority and the CCG; and
  2. Be satisfied that the service is able to continue meeting the person's needs post discharge.

Telford Adult Social Care Procedures