If you or a family member have experienced major trauma and are struggling to meet your daily needs, you may be eligible for support from statutory services (social services or the NHS).
Our Community Care page (www.majortraumagroup.co.uk/how-we-can-help-you/community-care/) gives an overview of the support that may be available. This article looks in more detail at NHS Continuing Healthcare.
What is Continuing Healthcare?
NHS Continuing Healthcare (“CHC”) is care that is arranged and funded by the NHS to meet the health and social care needs of an individual aged 18 or over who has a “primary health need”, which has arisen as a result of disability, accident or illness.
CHC is free at the point of delivery, which means that you could receive this type of funding, regardless of your own financial circumstances.
In order to be eligible for CHC funding you must have needs that are primarily health-related, which go beyond the care and support that could be provided by social services.
What does “primary health need” mean?
There is no legal definition of a “health need” in the context of CHC, but the guidance indicates that a health need relates to the treatment, control, management or prevention of a disease, illness, injury or disability, and the care or aftercare of a person with these needs.
An individual has a primary health need if, taking into account all of their needs, it can be said that the main aspects or majority of the care they require is focussed on addressing and/or preventing health needs.
The focus is on an individual’s need for support and not on a specific diagnosis.
How does the assessment work?
The purpose of the assessment is to determine whether an individual has a primary health need.
There is a two stage assessment process.
- The first stage is for a CHC checklist to be completed to identify individuals who may need a full assessment of eligibility.
- The second stage is for a full assessment to be completed.
Stage 1 – CHC Checklist
The checklist looks at the different categories of need and a level of need will be allocated to each category: A, B or C (where A represents a high level of need and C represents a low level).
Whether or not a full assessment is required will depend on the number of As, Bs and Cs identified. The threshold is low.
The checklist can be completed by a variety of health and social care practitioners, which can include a registered nurse, GP or social worker.
Stage 2 – The Full Assessment
A decision support tool (“DST”) document is used by an assessor to gather and record evidence of an individual’s needs. A decision about whether the individual is eligible for CHC funding is then made by a multidisciplinary team.
The DST breaks down a person’s needs into different categories, or “domains”, similarly to the initial checklist, as follows:
- Nutrition – Food and Drink
- Skin integrity
- Psychological and Emotional Needs
- Drug Therapies and Medication: Symptom Control
- Altered States of Consciousness
- Other significant care needs
An assessor will consider the level of a person’s needs within each of the above categories and will give each category a rating, ranging from “no additional needs” to “severe” or “priority”. There are descriptions for each level of need within each of the above categories in the DST.
The DST indicates that a person will be eligible for CHC funding where they have one “priority” level need or two “severe” level needs and that they may be eligible for CHC funding where they have one “severe” level need combined with needs in a number of other domains or a number of domains with “high” and/or “moderate” needs. However, this is not intended to be prescriptive, and assessors should consider the nature, complexity, intensity or unpredictability of a person’s needs in their totality.
I have been told that I’m eligible for CHC funding – what happens next?
Once confirming eligibility for CHC funding, the Clinical Commissioning Group (“CCG”; the healthcare body responsible for arranging CHC care on a local level) should then arrange for a care plan to be drawn up for the individual. The individual should be involved in this process.
Care can be arranged by the CCG directly. Alternatively, it might be possible for the CCG to provide the funds by way of a personal health budget, to enable the person receiving care to have more control over the care that is provided. There are rules and guidance about the circumstances in which a personal health budget can be given and the way in which it can be managed.
A NHS CHC care package will be subject to regular review (usually at 3 months, and then every 12 months) to consider whether the care arrangements remain appropriate.
I have been told that I’m ineligible for CHC funding – what are my options?
There is a two stage process to “appeal” or to seek a review of the decision and you should be informed of the process and the relevant timescales at the time of being informed of the outcome of the CHC assessment:
- Stage 1: An individual has the right to ask the CCG to review its eligibility decision. The CCG will have a local resolution process, which will often involve the individual being invited to a meeting, where the decision should be explained and the individual should have the opportunity to provide any further information not already considered and to put forward reasons why they are dissatisfied with the CCG’s decision.
- Stage 2: If unsatisfied with the decision following the local resolution process, the individual can apply to NHS England for an independent review of the decision. An independent review panel will be convened to review the decision reached and to consider any representations made by the individual and/or their representative
Specialist advice can be sought to support you through this process and/or to advise on the likelihood of an appeal succeeding.
The CCG should also consider whether you or your family member are eligible for NHS-funded Nursing Care (a set amount that can be paid towards nursing care where a person resides in a care home and is ineligible for full CHC funding but nevertheless has a need for additional nursing support), or a joint package of care, with some funding provided by the NHS and some funding provided by a local authority.
Your local authority should also consider whether you have eligible needs that should be met by social services instead.
How can I improve my chances of being awarded CHC funding?
Probably the best thing you can do is to provide as much information and evidence as possible about your or your family member’s needs.
It can be helpful to look at the decision support tool form and to read the descriptions for each level of need under each category, in order to understand the sorts of needs that are considered.
The assessor shouldn’t disregard a person’s needs just because there is support in place at the moment to meet them which is working well: the guidance is clear that well-managed needs are nevertheless needs.
How can Major Trauma Group help?
Major Trauma Group is a network of specialist serious injury law firms, experienced in dealing with claims following major trauma. We can provide assistance to clients throughout England and Wales and we are supported by a medical clinician who can advise on rehabilitation, independent financial advisers and case managers who are all highly experienced in this field.