Focus: Looking at the four key indicators (characteristics) from the NHS’ perspective
Four key indicators.
Families often tell us that they find the NHS Continuing Healthcare assessment process – emotional, difficult, lengthy and immensely frustrating. For many, it appears that the whole assessment process to determine eligibility for NHS Continuing Healthcare Funding (CHC) is ‘slanted’ against them, or else, designed to frustrate their relative’s entitlement for free funded care.
The process is clearly not as straightforward as it is perhaps intended to be – whether you’ve wrongly been told that ‘it’s a waste of time because your relative simply won’t qualify for CHC’; or been given misleading information, such as, ‘you can’t bring an advocate along with you’; or have been subjected to inaccurate or incompetent assessments; or lengthy and unreasonable delays which cause families frustration whilst the NHS drag out the eligibility assessment process.
Sometimes, the process can be so lengthy, that, often what starts out as a current assessment for CHC Funding for an individual going into a care home, ends up becoming a retrospective claim, as the individual has passed away whilst trying to secure funding. In the meantime, they may have had to sell their home to pay for their care.
We thought it would be helpful to look at matters from the NHS’s perspective, and consider how their assessors might argue the case against an individual seeking NHS Continuing Healthcare Funding.
Here is an example to help you understand some of the common arguments that might be raised by Clinical Commissioning Group assessors.
As you will know from reading our many other blogs, in order to obtain free funded NHS care (known as NHS Continuing Healthcare Funding), your relative first has to demonstrate that they have a ‘primary health need’. In simple terms, that is clinically assessed nursing or healthcare needs of a nature over and above what the Local Authority (Social Services) could ordinarily be expected to provide, and are more than just incidental or ancillary to accommodation needs which the Local Authority are under a duty to provide. For further reading: ‘Primary health need’ made simple – what does it really mean?
Those families who have already been through the assessment process, will know that it is not just about reviewing the 12 Care Domains (Breathing, Nutrition – Food and Drink, Continence, Skin integrity (including tissue viability), Mobility, Communication, Psychological and emotional needs, Cognition, Behaviour, Drugs/Medication/Symptom control, Altered state of consciousness & Other). You have to take a holistic approach and consider the totality of the individual’s needs when applying the Four Key indicators/characteristics (Nature, Intensity, Complexity and Unpredictability) to see whether there is an overall primary healthcare need that justifies fully funded NHS Continuing Healthcare. Read our blog: Understanding the four key indicators
According to the NHS National Framework, “Each of these characteristics may, alone or in combination, demonstrate a primary health need, because of the quality and/or quantity of care that is required to meet the individual’s needs.”
If your relative does not meet the eligibility criteria for fully funded NHS care, then they should automatically be considered for NHS-Funded Care instead to meet the nursing element of their care needs in a care home. Read: Have you considered NHS-Funded Nursing Care (FNC)?
Fictional Case study; Mary’s claim
Background – a brief summary of Mary’s daily care needs:
Mary has suffered two strokes and is in cognitive decline with vascular dementia; is immobile and requires use of a hoist for transfers; needs full time assistance of two carers; help with her mobility; frequent repositioning to maintain skin integrity and prevent pressure sores; cannot use her left arm due to weakness and has to use a spouted beaker when drinking to prevent spillage and burns from hot drinks; has difficulty swallowing – her food has to be pureed and her drinks thickened for consistency; is doubly incontinent and relies on staff to meet her needs in a timely manner in order to maintain her dignity and protect her skin from damage; has behavioural difficulties; limited awareness of her surroundings; is unable to reliably communicate her needs; and is totally reliant on her carers to anticipate her needs.
Here’s a selection of phrases that CCG assessors may use to argue the NHS case to refuse CHC Funding
Nature
Mary has routine care to maintain her safety and to ensure that her needs are met.
The care plans are reviewed routinely and the care records indicate that staff can manage her needs on a consistent and predictable basis.
Her nursing care and other needs are not of a nature entirely beyond which the Local Authority could lawfully provide.
Although Mary is immobile, unable to assist with her care, requires her skin monitoring for pressure sores, medication administering, nutritional needs monitoring and oversight of a Registered Nurse 24 hours a day, those needs were routinely met and should have been funded by NHS-Funded Nursing Care instead.
Primary health need is not about the reason why someone requires care or support, nor is it based on diagnosis, it is about the overall picture of care needs taken in their totality i.e. about the impact of the illness and disability.
The nature and quality of Mary’s health and care needs do not demonstrate a level of eligibility of NHS Continuing Healthcare, and do not produce a primary health need.
The quality of interventions required, are not in themselves, over and above that which a Local Authority could legally provide with the assistance of outside organisations e.g. GP/District Nurses etc.
Furthermore, any element of nursing care required to look after Mary in the care home has been incidental and ancillary to the provision of accommodation, which the Local Authority Social Services are duty-bound to provide in line with the Care Act 2014, anyway.
There is no evidence of any unmet needs, and all the care provided to Mary is predominantly of a routine and pre-planned basis and linked to her activities of daily living.
Her care is delivered routinely by care staff with access and oversight of a Registered District Nurse, as required. NHS Funded Care is more appropriate.
Complexity
Although Mary developed cognitive and physical impairment, which impacted upon her behaviour, communication, continence, mobility, nutritional and psychological domains, she declined food, fluids and medication, resulting in a large amount of weight loss, was immobile and required assistance to re-position her every two hours both day and night, there is nothing based on the available evidence to suggest that her care needs would warrant them being described as complex – whether taken in isolation or totality. Interactions between the various care domains do not make Mary’s needs for care delivery complex.
There is no evidence to support a level of complex needs – either individually, or in their interaction, or totality. Care providers are able to use their skill and judgment to monitor and intervene in Mary’s needs, which are not complex, and are within the remit of social services’ responsibility to provide. Her needs can be met through routine pre-planned care.
Intensity
Whilst Mary undoubtedly has needs in many of the Care Domains, the totality of those needs do not combine to create a quantity or intensity of need or care which will lead to a primary health need. She does not require sustained care intervention or continued care and monitoring.
Intensity is about the quantity or length of care interventions. Care is being delivered in a timely manner by two carers in line with say moving and handling guidelines. The records do not show a sustained or intense level of need, or that the care delivery was taking a lengthy period.
Unpredictability
Is about the degree to which needs fluctuate and thereby create challenges in managing them.
Mary’s needs do not fluctuate, are settled, stable and care is provided on a routine basis within the remit of pre-planned care plans. Care is delivered by two members of the care team together with the oversight and access to a Registered District Nurse. Her needs could readily be anticipated, even though she is unable to inform her carers of her needs.
The care provided was maintained and does not fluctuate at short notice.
Whilst timely care, monitoring and supervision is required around the Care Domains, her need for monitoring and supervision is not unpredictable and remains of a nature and extent which a local authority could lawfully provide.
CCG’s conclusion
The CCG’s assessor might conclude by saying something like:
Having considered the nature, complexity, intensity and unpredictability of the totality of Mary’s healthcare needs, and the interaction between those needs, together with all supporting evidence, the CCG’s conclusion of the assessment, indicates that Mary does not have a primary health need and would therefore not meet the criteria of NHS Continuing Healthcare Funding. Despite evidence of a health need in various Care Domains, which interact and impact upon each other, Mary’s care is routine, managed and monitored successfully in accordance with the care plans, and does not justify an award for NHS Continuing Healthcare Funding, as those needs could be met by the Local Authority. Alternatively, any nursing needs element could be met by the NHS-Funded Nursing Care Package.
Summary:
This scenario might be a typical example of a CCG’s position. You can now understand, how, even in cases where it may seem obvious that NHS Continuing Healthcare Funding ought to be awarded, that some CCG assessors can subjectively interpret the Care Domains, 4 Key Indicators and totality of needs, to present an entirely different picture, and effectively undermine an individual’s chances of securing CHC Funding.
When you consider that so many people are in care, it is often quite staggering to learn that so few people actually qualify for CHC Funding. Our message is – don’t give up. Fight on! Perseverance is the key, and if you feel that you have a strong case, you must Appeal.
Don’t forget, you can always seek specialist advice whether it is general advice, help with assessments or appeals, or even advocacy support.
Sounds familiar? Tell others below if you’ve had a similar experience to Mary’s case and how you successfully argued the 4 Key indicators/characteristics…
For further reading consider:
Take a holistic approach to improve your chances of getting CHC Funding
Thanks CTBD, another excellent article which is reflective of the paperwork we have received back from CHC/CCG.
Infact, if I didn’t know any better CTBD could have written the decisions made about our relative!
We are due to attend an IRP, but like so many contributors on this forum, don’t have much faith in the panel being Independent.
I have the letter informing us of the panel, which will consist of a person from our local commissioning group, who was directly involved in the decisions made at the local resolution stage of appeal. I have objected to the presence of this person on the basis that the meeting can not be truly independent when this person has a vested interest in ensuring the decisions they took are upheld, thus exonerating them from any blame/maladministration.
The coordinator has said that the panel is Independent and that this representative has to be there to give evidence about the decisions made. I disagree. To be Independent a representative should be nominated from the local CCG/CHC that has not been involved in the case. So I have now adopted my own acronym our meeting as a IYP – Yep you guessed it……Investigate Yourself Panel!
Has anyone else faced similar circumstances?
Thank you CTBD for the excellent articles and contributions from readers, which have been very useful in helping me to prepare for the IYP!!!
Thank you for this, is there any example of how you could counteract these statements? I have to say when we got Dad’s assessment, there wasn’t anywhere near the level of detail given as in the examples above, that’s why I am challenging it on these 4 indicators, as his scoring wasn’t ‘high enough’. I went through the Framework and attempted to frame my answers/arguments based on evidence I gathered and the ‘best practice guidelines’ questions in the appendix of the Framework. At the LRP, the independent assessor said I had ‘made good points’ and thanked me for them. I’m still awaiting the outcome of the LRP so will see how they respond!
Hi All
This is very interesting reading. Wasn’t sure where to put my question but this might be the best place
Does anyone know about the correct procedure regarding ‘the scoring’ after a CHC review meeting?
Our relative did get the funding again but we have just requested the report ( a year later) to find that one of the scores has been lowered from ‘severe” to high’. In the meeting we all felt that it had been agreed it would remain at severe. It wasn’t challenged by the assessor at the time and they seemed to agree. the meeting wasn’t minuted. Do they have the ability to change the scores after the meeting?
Can anyone please help with these questions?
Many Thanks
Tom
This example is almost identical to what we have experienced with our mother (without the strokes). How would we appeal this? And would we be likely to succeed?
Hi All I just got my Partner’s Care Fees refunded from day of CHC Funding Assessment on 7thSeptember 2016 .He has Advanced Dementia, Bedbound, unable to use right hand,Peg fed, has a catheter and unable to speak only looks at you when you call his name, He has grade 4 Pressure sore since 11th July 2016. He was assessed as Social Care. I appealed but I still did not get the CHC Funding .I took the case to NHS England IRP and they were very helpful and I managed to get the CHC Funding for him. It took 3 years but I never gave up. Most of the Assessors are not qualified and have no discretion or common Sense.If I had been turned down by IRP I would have gone to Ombudsman as I knew my partner should have Primary Health Care not Social Care. I was mentally and physically exhausted but I am pleased I never gave up.I was glad I wrote down every thing since he had the stroke in 2015 minute by minute from hospitaluntil today to show that I know more about my loved one’s health than the officials.
Hi SAL
Thank you so much for the advice. I complained to the IRP coordinator about the CHC member having direct involvement in the decisions made about our relative and I was told exactly the same as you have just outlined. They are not on the panel to make a judgement but I still have issues around the transparency of a supposed Independent review, when clearly the CHC member will want to uphold the decisions taken and exonerate not only themselves but the CCG they work for!! All highly irregular.
SAL can you elaborate a little more about your experience at IRP. How long were you allowed to speak? Were there any time constraints? It all feels like we will be disadvantaged from the outset if as you say IRP chairs are contacting CCG before the review to give them details of the agenda! I have made the focus of our appeal the Key Indicators to demonstrate that our relative had a PHN, but it might be the case that the focus will be on the scores awarded??
In your experience, what seemed to be the area of focus?
I’m guessing from your post that your were turned down at IRP and are now on to the Ombudsman?
Good Luck! No doubt I will be next in line! One thing is for sure, the Ombudsman are going to be busy!
Thank you CTBD, keep up the good work and PLEASE more on this area of concern.
Nature, Complexity, Intensity and Unpredictability. The NHS’s Four Horsemen of the Apocalypse!
The DST domain scores, whilst arguable to a certain extent, do at least have an element of black and white about them.
The fearsome four are (by design) highly subjective and can be manipulated by nurse assessors/CCG’s to ‘justify’ refusal of CHC funding, purporting to be on healthcare grounds as opposed to financial gate keeping.
As it is with the Law, where a defendant without legal representation will inevitably face a poor outcome, the same is true with CHC funding. I would strongly recommend (through experience) employing an experienced advocate who can speak the same language.
Good morning,
I write in reference to the above concerning the quantity, intensity etc. I am going to the IRP at present, nowhere in the entire universe it seems is there an actual clarification of intensity and quantity and complexity etc, it would appear that it is an individuals judgment that follows an outline of rules. Where are the notations, or examples? Just how many times when my father hit staff or residents was it too many? Was it 1 or 10? When my father was lying on the floor naked screaming for his mother, hallucinating how many times does that need to happen before it’s complex? When my fathers heart rate drops continually throughout the day as he has brachicardia how often does that need to happen? When he’s hitting staff with a walker, kicking and biting them, how many times does that need to happen? When a care home admits to you they haven’t recorded his notes properly, when does it all count? I find it utterly incomprehensible that there is no clear definition- a guideline is NOT a definition. Surely there should be a required number? Say over 6 incidents of medium aggression – and a definition of medium aggression, or 2 instances of severe aggression – and a definition of severe aggression provided, many domains such as Nutrition, Continence and Skin are quite clearly defined, however Behaviour, Cognition and Psychological & emotional are open to PERSONAL INTERPRETATION!
I feel honestly it’s a completely corrupt system, the CHC don’t want to fund because of budgets, the social services don’t want to fund because of budgets, and the care homes get more money from self founders than CHC pays, so who’s interests are best served in this format? A clear definition with defined amounts of quantity and complexity etc,, would help probably 70% of people on here, rather than effectively challenging an opinion.
Hi, We are having the assessment for my mum who has late stage dementia along with several complications but is living at home with several visits a day from a care company. My questions is should one of us be at the Multi Disciplinary Team Meeting afterwards? Is that required or just advisable? Thanks
It’s rather late in the day to comment about this article but I have just come across it and it is eye watering. It would be almost funny if it were not tragic. I have been refused CHC on behalf of my father in law and am going to an LRP..
When I read this spoof (i’ll call it that) assessment from a fictional MDT and then I read what my actual MDT put in their comments about the 4 characteristics, it’s almost uncanny. They have used exactly the same phrases to describe the 4 characteristics and in one case, an entire paragraph is word for word identical. My father in law seems to have been assessed almost entirely on his stable and predictable needs. Only they are not. He has schizophrenia for which he has been hospitalised 3 times due to failing to eat any food whilst at home for many weeks, exhibiting behaviour so violent and unpredictable that his care home could not cope and sent him back to hospital and also going on to the M! motorway at night on foot in order to stop the traffic following what voices in his head were telling him to do. he was sectioned for this. All the medical authorities say that this disease is so unpredictable that a relapse could occur at any time and sometimes without warning. He has had 3 so far. But the NHS think that his needs are stable and predictable on a day to day basis. Laughable. I spent 7 hours with the MDT going through the 12 domains and then before we got to the Primary health Need section and therefore the 4 characteristics, the lead assessor abruptly terminated my involvement, so that I had no say at all in that section and was unable to put forward any argument as to the nature of the illness and its risks and underlying needs. the limits of local authority care and also argument about the legal test in Coughlan which of course is reproduced in the Framework and by the Care Act.
Fortunately, I am a lawyer and so I am in the process of taking the MDT apart bit by bit on their assessment with reference to the evidence. Of course this will not make a blind bit of difference at the LRP. but thank you CTBD. Immensely helpful.