In order to establish whether your relative meets the criteria for a primary healthcare need and is eligible for NHS Continuing Care Funding (‘CHC’), they’ll need to undergo a multi-disciplinary team assessment.
If your spouse, relative or friend has a ‘primary healthcare need”, ie needs over and above those which the local authority are legally obliged to provide, then they may be entitled to have all their care fees, including accommodation, paid for free of charge, by the NHS.
The first stage of the assessment process is to have an initial Checklist completed. You can read all about this in our previous article, “The NHS Continuing Healthcare Funding Checklist Explained.”
If your relative passes this Checklist stage, they will then go on to a full assessment, which is carried out by their Clinical Commissioning Group (CCG).
The CCG will appoint at least 2 assessors to meet with your relative in their care setting to carry out a Multi- Disciplinary Team Assessment (“MDT”).
The National Framework provides that the MDT should consist of at least 2 professionals who are from different healthcare professions, or one professional who is from the healthcare profession, and the other is a social worker.
A list of MDT professionals could include the following: Nurse Assessors, Social Care Practitioners, Physiotherapists, Occupational Therapist, Dieticians/Nutritionist, GPs/Consultants/Other Medical Practitioners, Community Psychiatric Nurses, Ward Nurses, Care Home/Support Provider Staff, Community Nurses, Specialist Nurses, Community Matrons and Discharge Nurses.
Important: These appointed professionals should be trained in the National Framework, be knowledgeable about your relative’s health and social needs, and where possible, have recently been involved in their assessment, treatment or care.
We know from experience that it is quite common for the MDT’s assessors to have little or no knowledge of your relative’s daily needs. Indeed, they may never have met them before assessment, or else have very little understanding of the National Framework and the assessment process. This can lead to tainted and poor assessments, with disastrous outcomes for families who are fully expecting their relative to be awarded NHS Continuing Healthcare Funding, and that the process will be carried out thoroughly, fairly and robustly. As you can imagine, if the MDT’s assessors have no direct prior knowledge or input into your relative’s care needs, then even in the most obvious cases where CHC Funding should be recommended, it could become an uphill struggle.
Question what training the MDT’s assessors have had on the National Framework, and also what prior involvement they have had with your relative’s care. Otherwise, proceeding with the MDT might be a pointless exercise and a waste of time, leading to a lengthy appeal.
The MDT assessment is carried out by the assessors looking at your relative’s medical condition, their medical history, in conjunction with the care and other relevant medical records and assessments, to build an overall picture of their healthcare needs.
Unsurprisingly, care home records do not always contain all the necessary evidence to support the case for CHC Funding. Firstly, it isn’t always in their best interests to keep detailed records as that might assist the resident to get CHC Funding, which invariably, will be paid by the NHS at a lower rate than the actual cost of care. Secondly, most care homes have too few staff looking after too many patients, and there’s simply not enough time in the day to write up each and every occurrence as it happens. Staff may write up care records at the end of their shift which, after a long day, can lead to errors and many important entries being forgotten, or else, partially or inadequately recorded.
However, these records can provide vital contemporaneous evidence of actual daily healthcare needs, and are therefore equally, a vital ingredient of the assessment process. Poor records can often result in a poor outcome!
As with the initial Checklist assessment, you should be given plenty of notice of the MDT meeting.
It is essential that you attend to ensure that the assessment is conducted impartially and robustly.
You can provide a vital role by assisting the MDT’s assessors with additional information about your relative’s daily healthcare needs or correcting any errors or misunderstandings they may have.
Don’t assume the MDT assessors have all the facts and are above making reproach. You will know more about your relative’s needs than them. So speak up!
It is also essential that the MDT’s assessors actually see your relative as part of their assessment. This sounds obvious, but we have heard of assessments being carried out, without them even asking to see the resident – ie clearly suggesting that the assessors had already made their minds up to reject funding in advance. How can that be right or fair? If this happens to your relative, you must object and raise your concerns as these are immediate grounds for appeal.
The Multi-Disciplinary Team will score your relative’s needs using the parameters set out in the Decision Support Tool (DST).
The DST contains 12 headings, known as Care Domains, similar to the Checklist, but with the added 12th Domain of’ ‘Other significant care needs’:
1. Breathing 2. Nutrition 3. Continence 4. Skin Integrity 5. Mobility 6. Communication 7. Psychological & Emotional needs 8. Cognition 9. Behaviour 10. Drug therapies and medication 11. Altered states of consciousness 12. Other significant care needs.
Common misconception: The DST is not the assessment of needs itself. It is just a tool to aid the MDT assessors record the level of your relative’s health needs in one document, based on information they’ve gathered, so that they can make a recommendation eligibility for CHC Funding.
Each of the 12 Care Domains contains a description (‘descriptor’) of the level of need ranging from ‘no needs to ‘severe’ or ‘priority.’
Here’s an example of the ‘Behaviour ‘domain…
|Description||Level of need|
|No evidence of ‘challenging’ behaviour.
| No needs
|Some incidents of ‘challenging’ behaviour. A risk assessment indicates that the behaviour does not pose a risk to self, others or property or create a barrier to intervention. The individual is compliant with all aspects of their care.|| Low
|‘Challenging’ behaviour that follows a predictable pattern. The risk assessment indicates a pattern of behaviour that can be managed by skilled carers or care workers who are able to maintain a level of behaviour that does not pose a risk to self, others or property. The individual is nearly always compliant with care.|| Moderate
|’Challenging’ behaviour of type and/or frequency that poses a predictable risk to self, others or property. The risk assessment indicates that planned interventions are effective in minimising but not always eliminating risks. Compliance is variable but usually responsive to planned interventions.|| High
|‘Challenging’ behaviour of severity and/or frequency that poses a significant risk to self, others or property. The risk assessment identifies that the behaviour(s) require(s) a prompt and skilled response that might be outside the range of planned interventions.|| Severe
|‘Challenging’ behaviour of a severity and/or frequency and/or unpredictability that presents an immediate and serious risk to self, others or property. The risks are so serious that they require access to an immediate and skilled response at all times for safe care.|| Priority
Remember: If there is disagreement between members of the MDT about a level of need, the higher level must be applied.
Many families mistake the DST ‘scores’ as being the most important determining factor for awarding funding. However, the DST is just a forum to record the level of need. What is important is how these needs impact upon the 4 Key Indicators (sometimes called ‘characteristics’), namely: Nature, Intensity, Complexity and Unpredictability.
DST scores, whilst of course important, are not always the overriding factor in determining eligibility for CHC Funding. You’ve got to look at the bigger picture and take a holistic approach. You have to consider the totality of the individual’s needs by applying the 4 Key Indicators to see whether there is a primary need for healthcare overall.
Essentially, you need to look at the interaction between the different care needs across the 12 Care Domains and see how they impact upon each other.
It is not simply a question of saying, “My relative has scored ‘1 severe’, ‘3 highs’ and ‘4 moderates’ in their DST, so they must qualify”. If the evidence does not suggest the patient’s needs are complex, intense and/or unpredictable, they will not qualify for funding, whatever the assessed levels of need (excepting, of course, one “priority” level of need or two “severe” levels of need which would fulfil the Key Indicators).
When thinking about the 4 Key Indicators, consider the following:
- How often do care interventions arise over a 24-hour period and how long does it take staff to meet the need on each occasion; how many members of staff are required for each intervention (Intensity)?
- Do the staff need any specialist training, knowledge or skill in order to meet the needs and do needs interact (Complexity)?
- Are the needs unstable and/or rapidly changing (Unpredictability)?
This will build a picture as to whether your relative needs trained staff to manage these healthcare needs with skilled intervention over a sustained 24-hour period to prevent deterioration.
Attending a full assessment in front of a Multi-Disciplinary Team can be a stressful and daunting experience, and often fills families with much anxiety. Most family representatives don’t really understand the National Framework, how the assessment process works, what is expected of them at the MDT, or what they should or shouldn’t say. The MDT’s assessors will be far more experienced and should know the National Framework inside out. They should come with an open mind so that they can conduct a fair and thorough assessment and make an impartial recommendation as to your relative’s eligibility for CHC Funding.
However, listening to families, and what we know from our own experience, we often hear that MDT assessments do not go as expected. Sadly, some assessors appear to come with a predetermined outcome (i.e. to refuse funding) and no matter how much the family try to argue their case, they feel overwhelmed by the assessors’ aggressive or indifferent stance.
The MDT is your first real opportunity to secure long-term fully-funded free care for your relative. It Is therefore critical that you give this meeting your best shot. Otherwise, your relative may end up paying huge sums for their own care and accommodation.
Good preparation for the MDT is the key.
Here are our top 10 tips:
1. Get the MDT in plenty of time and ensure you are at the assessment when it starts. Don’t allow the assessment to start without you. Who knows what’s been done or said in your absence.
2. Speak to the relevant care home staff in advance as they may be questioned by the MDT’s assessors about your relative’s daily care needs. Inaccurate or ‘loose’ phrasing may paint a misleading or entirely different picture of your relative’s needs.
3. Ask the assessors what qualifications they have, what their experience of conducting MDTs is, how they know your relative, and what aspect of their care they have provided.
4. Participate in the meeting and don’t be a bystander! You know your relative’s needs better than the assessors – so stand up, speak up, and don’t be afraid to correct any misinformation they have.
5. Point out to the assessors any of the care records, risk assessments or care plans etc, that you think are particularly relevant and check they’ve been considered by the assessors.
6. Look at Practice Guidance Note 22 of the National Framework which lists the type of information and evidence that the MDT assessors should consider before making their recommendations funding.
7. Don’t ramble on about unimportant matters. Whilst we know that you’ll want to tell the MDT’s assessors all about your relative’s care needs from ‘A – Z’, it is vital that you stick to your key arguments and don’t get side-tracked pontificating about areas of care where there are ‘no’ or ‘low needs’. Focusing on irrelevancies or making poor points, will only serve as an own goal and could severely undermine your relative’s chances of securing funding. We recognise that this is often easier said than done, when you are emotionally involved.
8. It’s a good idea to take someone along with you for notetaking, as a good record may become useful evidence if you need to lodge an appeal.
9. Do not discuss nor engage in any discussion about how your relative’s care will be funded at this stage! It is completely irrelevant and has no place in the assessment. The MDT assessors are there solely to determine whether your relative has a ‘primary healthcare need’ and make a recommendation as to their eligibility for funding. It is not their job to discuss whether your relative can pay privately for their own care.
10. Don’t sign any agreement to the DST. There could be key matters which the MTD assessors have overlooked, misinterpreted, mis-stated or not given sufficient weight to, which could impact upon their recommendations. Signing your agreement to the DST may unwittingly prejudice at any later appeal, if needed.
The NHS assessment process is supposedly designed for families to attend and argue the case for funding themselves. Unfortunately, in our experience, very few families who embark upon this process, successfully manage to get to grips with the National Framework or have the particular skills required to secure funding.
The common error that families frequently make, is thinking that their relative must surely qualify for CHC Funding, when in fact their health needs are not sufficiently high enough. The barriers to getting CHC funding are stacked against you and the bar is set very high.
Farley Dwek Solicitors have a wealth of experience, gained over many years, in dealing with MDTs. We provide advocacy help and support for families, and take the stress and strain of the MDT assessment on our shoulders. We use specialist nurses who have all worked in this particular field for many years, and who understand the National Framework and know how to fight your corner. Farley Dwek can help you at every stage of the assessment or appeals process.
Get our Free Guide or call us on 0161 272 522 or 0800 011 4136 for initial free advice.
For further reading, we recommend that you look at:
Practice Guidance Note 21 of the National Framework: What are the elements of a good multidisciplinary assessment of needs?