Continuing Healthcare is when a part of, or all of a person’s needs are medical rather than social, such as washing and dressing. They may then be eligible for NHS funded Care known as Continuing Health Care. Click here for full details: What is a Continuing Care Assessment?
How are decisions to award Continuing Health Care Funding made?
Initially, a small group of multi-disciplinary professionals, (a trained nursing assessor, social worker and usually a 3rd person such as a ward nurse/ residential home carer), use a Decision Support Tool (DST) to determine if CHC should be provided. The DST consists of a number of medical fields with descriptors detailing levels of need, these descriptors are strongly adhered to. These descriptors also have to be considered within medical terminology. If a person is completely bedridden they may score high, but not severe, this is because some people have injuries that mean they can’t be moved, at all, without risk, and it is this level that falls under the severe descriptor. People tend to believe that scoring high enough descriptors in a number of domains is how CHC funding is allocated, however, if the person’s care needs can be proven to be complex and unpredictable this should be adequate to argue for funding irrespective of the descriptors applied in the domains of the DST. The family are usually given an opportunity to voice their opinions but this is more to debate with the professionals why particular descriptors should be applied; if the family dispute an applied descriptor then this would be noted but would not affect the actual descriptors chosen, within the DST, by the professionals.
The meaning of the descriptors are medical in nature and cover a wide scope of disability. A person who is completely bedridden would score high but not severe needs in the mobility domain; the severe descriptor would be used in cases where the movement of a person could result in injury or death, such as a neck fracture. A person who has limited cognition would be considered compliant with medications if they took them without issue; regardless that they have no comprehension of what they are doing so are not actually agreeing in any way to being medicated or being instructed to take medications, which arguably is a more basic dictionary definition of compliance.
The first stage of appealing a decision not to award funding is to inform the Clinical Commissioning Group (CCG) that you do not agree with the decision; this can result in a review which in itself can sometimes be enough to lead to a change in the decision in borderline decisions. You will be allocated a Nursing Assessor who will meet with you and go over any evidence prior to appeal; if a strong case is made at this stage the decision could potentially be overturned.
If not an appeal can be raised to a local panel, usually held at the CCG, chaired by senior CCG, Social Care and Medical Professionals. If this is unsuccessful then there is a right to a further appeal to a regional panel.
Although families have a right to do this it would be hoped that they can bring strong arguments evidencing that incorrect descriptors had been applied or compelling arguments as to why nursing care needs should be considered more than merely incidental or ancillary to what the local authority would be expected to provide. Arguing that someone’s needs are a result of their health is not helpful and the focus should be on the nature of support required by the service user; when shaping an appeal and gathering evidence in support.
If considering making a challenge against CHC decisions it is advisable to seek specialist support, from organisations such as Beacon.