Compass Will Writers has supported many families over the years to ensure that they receive the financial support that they are eligible for from the NHS.
This is because families are paying for care when in fact they have a ‘primary health need’ which means that they are eligible for NHS Continuing Healthcare (CHC) which covers 100% of care fees.
The problem is that many families do not know that CHC exists. To get a better understanding of what CHC is, who is eligible for it and how to claim it, have a look through this overview taken from whentheygetolder.co.uk. You can link to the full article here.
NHS Continuing Healthcare (CHC) is funded by the NHS for people who need care and have a primary health need.
CHC covers 100% of their care fees including accommodation and food where appropriate for people who require full-time care primarily for health reasons, and it is available in any setting whether they are in a care home, in their own home, in a hospice or anywhere else.
This is one of the NHS’ best kept secrets – it is sometimes referred to as the “secret fund”. The NHS has a duty to promote Continuing Healthcare at key locations. You would perhaps expect to see this information freely available in your surgery waiting rooms, hospitals, health centre, care and nursing homes, but you would be mistaken, because strangely enough the information is unlikely to be there.
The one vexed question that the NHS wants to avoid is who pays when someone has a “primary health need”? It is of course the NHS, but very few people are aware of the term CHC, let alone how to make an application. This article is designed to help that process:
Who can apply for NHS Continuing Healthcare (CHC) Funding?
Anyone can ask for a Continuing Healthcare assessment. CHC services are for people who, because of primary health needs, are eligible for NHS CHC funding.
Upon hospital discharge
In accordance with section 2 (2) of the Community Care Act (Delayed Discharges etc) the NHS must take reasonable steps to ensure that an assessment for NHS Continuing Healthcare is carried out in all cases where it appears that the patient may have need for such care.
What is the function of the service?
NHS CHC ensures that people with complex health needs have their care and support funded by the NHS.
A “primary health need” is determined by a number of factors, each of which may in combination or alone demonstrate a “primary health need”.
How can we access the service?
To access the NHS CHC service individuals need to be screened. Anyone can ask their doctor, social worker or any NHS professional to start the process. They may try to discourage the application, but if you believe that someone does have a “primary health need” you should not be put off.
There is no means testing and it is free from all budgetary restraints. Financial issues should never be discussed or play any part in the application process to access the NHS CHC system, so applicants shouldn’t allow themselves to be drawn on this subject.
Read on to find out about the steps that applicants will go through to make their claim.
Step 1: The “Check List”
This is the initial screening process. Every applicant will be required to take part in this stage. Always ensure that a family member, friend or someone acting for the patient (Advocate) is in attendance to ensure that a fair assessment is provided.
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.
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.
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.
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 Not only
It would always be advisable to have an Advocate or someone at the MDT meeting taking minutes or notes.
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.
The completed DST and the applicant’s supporting evidence (where applicable) may now go before a commissioning board/panel for ratification.
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 and only when these needs can be proved to have been permanently reduced or removed, will they have any bearing on CHC eligibility.
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.
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.
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.