Am I Eligible For CHC Funding?

Misconceptions – My Relatives Needs Are “Well Managed” And Therefore I Am Told They Are Not Eligible For Nhs Continuing Healthcare Funding Is This Correct?

In previous blogs we have discussed what is a ‘Primary Health need’ and what may be classed as a ‘social care needs’. The former is free at the point of need and is provided by the NHS; whereas social care is means tested and is provided by the Local Authority Social Services.

We discussed that eligibility is scored by reference to the 12 Care Domains as to the level of need, and those needs are then referenced to the four key indicators or ‘characteristics’ (ie the nature of needs, intensity, complexity and their unpredictability).  Each of these characteristics may alone, or in combination, demonstrate a primary health need.

Too often we hear however the eligibility for NHS Continuing Heatlhcare Funding (CHCF) has been refused because the CCG will contend that the patient’s needs are “well-managed” and therefore because they are under control, do not meet the eligibility criteria for funding.

Not always true. Therein lies a huge misconception.

The NHS can use this simple ruse as a means of justifying their rejection for CHCF. This can be a very contentious area which is often misunderstood by all parties – both claimants and the NHS.

The NHS National Framework says that a “well-managed” need does not of itself, mean that the individual is eligible or not eligible for CHCF, but should be taken into account as part of the overall decision-making process.

To assist, The National Framework for NHS Continuing Healthcare and NHS funded Nursing Care indicates that the decision–making rationale should not marginalise a need just because it is successfully managed. “Well-managed” needs are still needs”.  So don’t be fobbed off by the NHS if they say your relative doesn’t qualify for CHCF as their needs are well-managed.  More investigation is required.  The reasons given for a decision on eligibility should not be based on the single fact that the need is “well-managed” as grounds to refuse Continuing Healthcare funding, but is a factor that should form part of the overall decision-making process.

It is the nature, intensity, complexity and unpredictability of the underlying healthcare need that is the crux of the matter, and which should be assessed.

Just because the individual is receiving care and their needs are being better managed does not mean that the underlying need has actually gone away.  Take for example a patient with cognitive impairment (eg dementia), who experiences hallucinations, who has falls regularly, needs constant watching and medicating for various other health problems, exhibits other inappropriate behaviours (aggression), who may be prone going out of their house and wandering in the street, thereby putting themselves (and possibly others) in danger, etc. Just because that patient has been moved into a care home setting to help manage these various conditions – ultimately, does not remove the underlying medical conditions, it is just better managed in a different environment.  The assessment of the individual’s needs must reflect the serious nature of the underlying need and risk, and the fact that it is now being better managed may be irrelevant.  It is the basic health need that is paramount. This is where the NHS often get it wrong.

So, if you are told that your relative’s needs are “well-managed” and that is the end of the matter as they don’t qualify for CHCF, there may be a lot more to it than that, and you should be prepared to raise a challenge, where appropriate.

Equally, families quote the “well-managed needs” principle to us, to argue that of course their relative must qualify for CHCF – take away the 24 hour care, remove medication and their special diet (or stop feeding them) and they wouldn’t survive! Yes, that is true, but equally it would be true for the majority of people in a care/nursing environment as well. The argument is obviously not quite as simple as that, otherwise 99% of people in care would receive CHCF. The patient should still be assessed as if their routine care is still in place. You have to judge the individual assuming that this baseline care is still in place and you cannot simply ignore it.

The National Framework states that, “only where the successful management of a healthcare need has permanently reduced or removed an ongoing need, such that the active management of this need is reduced or no longer required, will this have a bearing on NHS Continuing Eligibility”.

Furthermore, The NHS National Framework issues a word of cautions and states that, “Care should be taken when applying this (well-managed) principle. Sometimes needs may appear to be exacerbated because the individual is currently in an inappropriate environment rather than because they require a particular type or level of support – if they move to a different environment and their needs reduced this does not necessarily mean that the need is now “well-managed”, the need may actually be reduced or no longer exist”.  For example, in an acute hospital setting, an individual might feel disoriented or have difficulty sleeping and consequently exhibit more challenging behaviour posing a risk to themselves or others, but as soon as they are in a care home environment, or their own home, their behaviour may improve without requiring any particular support around these issues”.  So, this scenario, their needs may become well-managed by a change of environment and the underlying challenging behavioural problems reduced or removed entirely, and as such, should be recorded and taken into account in the eligibility decision”.

In summary when considering what is a well-managed need you have consider the needs in conjunction with the four key indicators of need when making a determination of eligibility on primary health needs, and a well-managed need is only one such factor that should affect eligibility for CHCF if that need is reduced or removed.