What is CHC? An Overview of the Assessment and Appeal Process
What is NHS Continuing Healthcare?
Did you know that if your relative’s primary need is for healthcare, they may have all their care and accommodation paid for in full, free of charge, by the NHS?
This funding is known as NHS Continuing Healthcare (or ‘CHC’ for short) –a pot of funding which is available for individuals with intense, complex and/or unpredictable needs, living in the community.
Unfortunately, most people have never heard of CHC funding – even many medical professionals don’t really know or understand what it is, or how you go about claiming it. Of course, the NHS doesn’t advertise the availability of CHC funding as it comes at a significant cost. Instead, many thousands of unwitting families have been forced to sell their relative’s home or assets to pay for care, which could and should have been fully funded by the NHS.
Make no mistake though, securing CHC funding is not straightforward. The assessment process is complex, and it can be a daunting, uphill struggle.
Here is an overview of the basics steps and terminology that you need to know when applying for CHC funding.
Am I eligible for CHC?
To meet the criteria for Continuing Healthcare funding, an individual must have a ‘primary healthcare need’. In practice, this means that the majority of care interventions are aimed at addressing or preventing health – rather than social care – needs.
NHS Continuing Healthcare funding is described by the Department of Health as a “package of ongoing care that is arranged and funded solely by the NHS where the individual has been found to have a ‘primary health need … Such care is provided to an individual aged 18 or over, to meet the health and associated social care needs that have arisen as a result of disability, accident or illness … Eligibility for NHS Continuing Healthcare is not determined by the setting in which the package of support can be offered or by the type of service delivery”.
The difference between health and social care is critical, as it determines which authority is responsible for meeting and funding the needs – the NHS or the local authority – and if that is subject to means-testing.
Healthcare is provided by the NHS and is not means-tested. The founding principle of the NHS is that healthcare is free to all at the point of delivery: health, not wealth, is the key consideration. While there is no legal definition of healthcare, the Department of Health describes a health need as, “one related to the treatment, control, management or prevention of a disease, illness, injury or disability, and the care and aftercare of a person with these needs”.
Social care is provided by the Local Authority via Social Services and is means-tested – if you have capital assets (e.g. a home, land, buildings, savings) worth more than £23,250, then you will have to pay for all of your care. For the purpose of CHC assessments, social care tends to describe the “activities of daily living” – i.e. the things we all do every day: washing, dressing, toileting, moving around, cooking, cleaning, moving around, going to work, maintaining relationships.
Who carries out the CHC assessment?
The NHS carries out assessments of eligibility for CHC funding through its local Integrated Care Boards (ICBs). Established in 2022 to replace over 200 Clinical Commissioning Groups, there are 42 ICBs in England.
ICBs are responsible for ratifying CHC funding decisions, and commissioning Continuing Healthcare packages. Although the Local Authority plays an important role in the assessment process, the ICB has ultimate decision-making responsibility.
Are there rules about conducting a CHC assessment?
When undertaking assessments of eligibility for CHC funding, ICBs follow the guidance set out in the National Framework for NHS Continuing Healthcare Funding and NHS–funded Nursing Care.
Referred to simply as “the National Framework” or “the Framework”, this guidance was first introduced in 2007 to promote greater clarity and consistency around the process and criteria for determining eligibility for CHC funding. Unfortunately, the “postcode lottery” remains, with some areas known to be far more likely to award CHC than others.
Although the National Framework is not legally binding, ICBs are expected to adhere to its provisions in assessing CHC eligibility. So, it is important to familiarise yourself with the guidance therein to ensure that (a) you know how the assessment process works and what to expect at each stage; (b) you can ensure the ICB carries out a fair and robust assessment; and (c) you can challenge any abuses of process.
An outline of the assessment process
If your relative has significant healthcare needs and has never been considered for CHC funding, you should consider requesting an assessment.
The first step is to ask the GP, District Nurse, Social Worker, care agency or care/nursing home to complete a Checklist.
The Checklist
This is a simple screening tool used to filter out those who clearly do not meet the CHC criteria.
According to the National Framework, the bar is set intentionally low at the Checklist stage to ensure that all those who may qualify for CHC are referred for a full assessment.
Therefore, unless the Checklist is significantly flawed, screening out at this stage indicates that your relative’s primary need is for social care and they will need to consider alternative means of funding their care – e.g. a social care assessment to see if they can get any financial assistance from their local authority, or else, pay privately.
If your relative gets a negative outcome at this stage, they can always request that another Checklist is carried out in the future if their healthcare needs increase.
You will be provided with a copy of the completed Checklist which you should keep safe in case you need to refer to it at any future assessments.
Multi-Disciplinary Team (MDT)
If the outcome of the Checklist is positive, your relative will automatically be referred for a full assessment, which should be completed within 28-days. The full assessment for CHC is carried out by a Multi-Disciplinary Team (MDT), which completes a document called the Decision Support Tool (DST).
The MDT should comprise at least 2 members of different specialisms; ideally a healthcare professional and a social care professional. The National Framework deals extensively with the MDT process and what constitutes a good MDT. We encourage you to read the guidance carefully.
You will be invited to attend the MDT and it is essential that you do so. You may know your relative’s day-to-day care needs better than anyone, so make sure the MDT gets the full and correct picture of your relative’s situation. Don’t be afraid to challenge any misgivings and put your point of view across.
As this is such an important meeting, you may want the support of a a professional advocate to ensure the assessment is conducted properly and to maximise your chances of success.
After the MDT, the completed DST and recommendation will be sent to the ICB for ratification. You should be notified of the outcome within 28 days of the MDT; the letter should enclose a copy of the DST.
If your relative is found not eligible for CHC funding, you have six months to appeal from the date on the outcome letter, which should explain how to instigate this process. The six month deadline is statutory – some ICB’s will try to impose shorter deadlines but generally speaking these cannot be enforced.
If your relative is found eligible for CHC funding, the full cost of their care – including social care and accommodation – should be met by the NHS, and they should not be asked to pay any additional fees on top. Some families are asked to pay a “top-up” but this is plainly unlawful.
For more information on top-up fees, read our blog: Top-Up Fees – Are They Ever Lawful?
Fast Track
If your relative is rapidly deteriorating and needs access to CHC quickly, they may be able to bypass the usual process. The Fast Track Pathway ensures CHC funding is implemented within 48 hours of referral. Fast Track funding is generally applicable in an end-of-life scenario, where the individual has only days or weeks to live.
In some cases, Fast Track funding is granted just to get patients out of hospital more quickly, despite the criteria not being met. It often comes as a shock to the family when funding is withdrawn only three months later, even though their relative has not got any better!
Annual reviews
CHC funding is not guaranteed indefinitely and may be withdrawn. An individual’s healthcare needs can fluctuate, and may increase or decrease over time.
After an award of CHC funding, the ICB is obliged to review the package after 3 months, and then annually thereafter, to ensure it remains appropriate. If the review identifies significant changes in the individual’s needs, a full reassessment will be undertaken and CHC may be withdrawn.
The National Framework makes it clear that the intended purpose of a reviews is to consider the appropriateness of the care package, and that in the majority of cases it is expected that a full reassessment will be not necessary. It is important not to be complacent, however: you should prepare for the review as if it were a full assessment.
Farley Dwek Solicitors can provide expert advocacy at CHC reviews to ensure the process is fair and robust.
Appeal
If your relative is unsuccessful at the MDT and you disagree with the decision, or believe there has been an abuse of process, you have 6 months to lodge an appeal. Check the outcome letter carefully in case it gives any different timescales.
Local Resolution Meeting (LRM)
The first step in the appeal process is for the ICB to consider the decision locally.
This is a two–stage process:
Stage 1 is an informal discussion: you will explain why you are appealing and the ICB will try to explain its assessment and decision. If you remain dissatisfied, you move onto stage 2.
Stage 2 is more formal and may involve a panel of health and social care professionals. The ICB will essentially conduct the assessment again and decide whether the MDT was correct in finding your relative not eligible.
If you remain dissatisfied after Local Resolution, the next step is Independent Review. You must lodge your request for IRP within 6 months of receiving the outcome of Local Resolution.
Independent Review Panel (IRP)
The IRP process is conducted by NHS England.
The Independent Review Panel consists of 3 members – a lay Chair, a representative of NHS (usually a Nurse Assessor) and a representative of the Local Authority (usually a Social Worker); occasionally, the Panel will be supported by a clinical advisor.
Ahead of the Panel, the ICB provides NHS England with a copy of its casefile which contains all the assessments, correspondence, internal documents and evidence relating to your relative’s case. The Panel members will review the file carefully in preparation for the IRP and refer to its content throughout.
You may want to consider instructing a professional advocate to review your case, collate any missing records and information, prepare written submissions and attend the IRP with you for support.
Warning! So many families leave it too late to get professional help. Once you have lodged your request for Independent Review, you have only six weeks to make all final submissions. It is essential, therefore, to enlist professional help well in advance of the deadline.
Farley Dwek Solicitors offer invaluable help with appeals. Don’t delay: good early preparation is essential to give yourself the best chance of success!
Parliamentary Health Service Ombudsman (PHSO)
If you believe the IRP did not adhere to the provisions of the National Framework in considering your appeal, you can complain to the Parliamentary & Health Service Ombudsman (PHSO). The HSO can only consider the conduct of the IRP.
Farley Dwek Solicitors can offer support at any stage of the CHC assessment or appeal process.
For more information, download our FREE GUIDE and do call us on 0161 272 5222 or 0800 011 4136 for a free initial chat or email to: help@farleydwek.com to see how we can help you.