28.07.16

A major concern for many people and their families is the potentially high cost of care. With weekly care fees reaching £1,000 in some areas, it is understandable that people worry about this issue.

The reason for someone needing care will establish how these services are provided and, quite importantly, who pays.  If a person requires social and personal care, this will often be provided by the local authority and means testing will be carried out to determine whether the individual has to pay themselves.

However, for those people requiring care who have a ‘primary health need’, a package of relevant care can be arranged that is funded solely by the NHS and not by the individual.  This care can be provided in a residential setting or can be care in your own home. This package of NHS care is known as Continuing Health Care (CHC) and it will be provided to an individual aged 18 or over to meet needs that have arisen as a result of disability, accident or illness.

Who qualifies to receive Continuing Health Care?

It is often difficult to separate someone’s personal and health needs, and therefore determine whether the local authority or the NHS has responsibility for them.  To help decide if CHC is applicable, a process of assessment has to be followed to determine eligibility and  show that a person has ‘a primary health need’.

The decision about eligibility for CHC must be based on the needs of the person.  It does not matter if that person already has a carer, they live at home or they can afford the costs of care.

How does the assessment process work?

A CHC assessment will be arranged by the person’s local Clinical Commissioning Group (CCG) and they should follow a set procedure.  This often involves two stages; a screening process and then a full assessment.

The screening will usually involve a checklist being completed by a nurse, doctor, qualified health professional or social worker and the aim is to identify if someone might be eligible for Continuing Health Care.

The assessment will involve the use of a Decision Support Tool (DST) to record a person’s care needs and determine whether or not they have a primary health need.  The DST records a person’s needs across 12 areas, known as ‘domains’.  These are:

• Behaviour
• Cognition
• Communication
• Psychological and emotional needs
• Mobility
• Nutrition – food and drink
• Continence
• Skin and tissue viability
• Breathing
• Drug therapies and medication
• Altered states of consciousness
• Other significant care needs

The assessor will score the needs in each domain as either Priority (only available for four domains), Severe, High, Medium, Low or None.  The assessor should also consider a range of indicators across each domain.  These are:

• Nature – characteristics of the individual’s needs i.e. physical health, mental health or psychological needs, the effect these have on the person and the treatment they need.
• Intensity – quantity, severity and continuity of needs
• Complexity – level of skills and knowledge required to care for the person’s needs
• Unpredictability – the degree to which needs fluctuate and are therefore challenging to support

What determines the outcome?

On reviewing the above points, a person is considered as having a primary health need and be eligible for CHC if:

They have priority needs in any of the four domains for this level; or

They have severe needs in two or more domains

If the individual has severe needs in one domain, and needs in a number of other domains or a number of domains with high and/or moderate needs, then that might also indicate a primary health need.

What if the person already has a diagnosed disability?

A diagnosis of a particular illness or disability will not automatically entitle someone to CHC and, in every case, it will be necessary to assess the person’s particular needs to show that they have a primary health need.

Here is an example scenario:

A person with dementia won’t automatically qualify for CHC and it can be difficult to show they have severe needs when looking at the domains that have that rating.  However, if a person with dementia has a number of lower level needs over a number of domains, it might be possible to show they must always be supervised and require full time care.  It might therefore be possible to show sufficient needs to qualify for CHC.

CHC is a complex area and the assessment process can prove difficult for individuals and families because the criteria is applied based on personal circumstances. As we have explored here, every individual is different and the scoring against the key domains can differ between individuals with the same, or similar, illnesses or disabilities.

It is important to point out that it is possible to apply retrospectively for someone who has been paying for care that ought to have been provided free of charge.

Additionally, even if an assessment is made and the outcome is that CHC is not available, a later change in the needs or condition of the person who requires care might make a difference. So, the possibility of asking for the assessment to be re-visited should not be ruled out.

We feel strongly that Continuing Health Care is an important issue for our clients to understand as it will play a key part in planning for the future, particularly for elderly clients and the disabled and vulnerable with care needs.

If you would like to discuss any of these issues, please do not hesitate to contact us.