Do you have questions about NHS Continuing Healthcare, funding, eligibility or disputes? Read on to see Sharon Lamerton of Care or Not answer some of your questions in our second Q&A instalment.
What is NHS Continuing Healthcare funding, and can all people receiving care apply?
“NHS Continuing Healthcare funding is funding from the NHS for somebody who has what is known as a primary healthcare need. Only people with a primary healthcare need are eligible. Not all people will be eligible, but anybody can apply, those who are definitely not going to be eligible can be screened out of the process using an NHS Continuing Healthcare checklist. If the checklist stage is passed, then the NHS carry out a full Decision Support Tool or ‘DST’ assessment and the NHS nurse assessors and social worker make a recommendation. They are what is known as the multi-disciplinary team or ‘MDT’ and they make a recommendation to the CCG, the Clinical Commissioning Group and the decision will be based on the recommendation”.
Is it perceived as difficult to receive NHS Continuing Healthcare funding? And if so, why?
“It is absolutely incredibly difficult to receive NHS Continuing Healthcare eligibility because the NHS framework guidance and the Decision Support Tool are extremely subjective. Unfortunately, the leading case of ‘Coughlan’ can also be interpreted in various ways and this has made it very difficult to be able to obtain funding from the NHS, which is free at source and non-contributory. It is not impossible however; you just need to know the law and to be able to argue the appropriate points with the CCGs”.
We have not heard of the Coughlan Case; please could you explain this case?
“The leading Continuing Healthcare case of Rv North and East Devon Health Authority exp Coughlan is a Court of Appeal case which reinforced the finding that entitlement to NHS Continuing Healthcare support arose, not merely when a patient’s healthcare needs were complex, but also when they were substantial – the so called ‘quality/quantity’ criteria. Pamela Coughlan was seriously injured in a road traffic accident in 1971. The court described her healthcare needs in the following terms:
She is tetraplegic; doubly incontinent; requiring regular catheterisation; partially paralysed in the respiratory tract, with consequent difficulty in breathing; and subject not only to the attendant problems of immobility but to recurrent headaches caused by an associated neurological condition.
However, in many respects her nursing needs are comparatively modest (when compared with many residents of nursing homes) she is able to move her upper body (including her arms); she leads a relatively full and busy life, being able to study, campaign and use her electric wheelchair. Nevertheless, when applying the Court’s ‘quality/quantity’ formulation, it concluded that her needs were “wholly different category” to that which social services authority could fund”.
What can you do if you do not agree with the decision made that your loved one is not deemed eligible for NHS Continuing Healthcare?
“If a Decision Support Tool assessment has taken place and the CCG has made a decision that your relative is not eligible, you can lodge an appeal with the CCG. At first stage a local resolution appeal meeting is held, where you attend a meeting with the CCG and discuss why you think your relative should be eligible for NHS Continuing Healthcare. This can be time-consuming and take around two months to complete. If you are still unsuccessful at the local appeal stage, then you can make a further appeal which is known as an Independent Review Panel (IRP) request to NHS England. An independent panel will be put together by the NHS who will then hear what you have to say on why you think the CCG have got it wrong and the IRP will then make a decision which could overturn the CCG’s decision on eligibility. This is not a quick process and NHS England is inundated with work and you can be waiting for six months or longer to be able to get a date for an IRP”.
Is there anything a relative can do to keep document of their loved one’s well-being to supplement official documentation in preparation for an appeal?
“Absolutely there is. Records should be kept of any need that you are helping to support with your relative and loved one including and not limited to challenging behaviours. Sometimes families find it really difficult to talk about their relatives when they are being challenging, but it really should be documented. This can include anything from yelling and shouting, to aggressive behaviour, to striking out. It can also include being abusive during personal care, trying to run across the road without looking when you are out and about, it can be really anything. You should document how much food and fluid are being consumed, how long it takes to do personal care, how long it takes to help a relative with their food. How difficult it may be to provide personal care, such as changing incontinence pads, changing the bedding, getting dressed, showering or washing. Absolutely anything. While some of this is easier if your relative is in a care home, NHS Continuing Healthcare can be provided at home, but you do need the records to back-up what you are saying”.
Who funds the cost of care if it is required but cannot be afforded and is not considered as eligible for NHS Continuing Healthcare?
“If somebody has capital of over £23,250 they are considered by social care as a self-funder and would be expected to fund their own care. If somebody had between £14,250 and £23,250 they would receive some help from social services, who would do a financial assessment and they will take into account income and capital. People are expected to make a contribution from their income and if it is residential care that could be the majority of their income. If it is home care, then there is a slightly different calculation, however if there are savings between £14,250 and £23,250 people will be making a contribution from both their income and capital. If you own the property you live in, the property is disregarded in a financial assessment if you receive care at home. If you are moving into a care home, the property can be disregarded if you have spouse or a partner living in the property, or for a small number of other reasons. If none of these reasons apply and there is no discretionary disregard, the property may have to be sold to pay for your care.”.
If NHS Continuing Healthcare has been provided, how does the timescale apply? Will the individual always be eligible? What if the individual was eligible prior to the assessment?
“Well when someone has an NHS Continuing Healthcare checklist assessment, the NHS has 28 days in which to complete a full Continuing Healthcare assessment and make a decision. If the decision is that the individual is eligible, the funding will be dated to either 28 days from the date of the checklist or if a checklist was not carried out it will commence on the date the assessment took place. However, if somebody thinks they might have been eligible prior to that assessment and there has been no previous assessment, regardless of whether that person is alive or has passed away, a claim for a previously unassessed period of care can be carried out and then the NHS go back and look at the whole period which at this moment in time can go back as far as April 2013”.