Has your relative been “optimised?” NHS invent more delays to avoid CHC Funding…
We have spoken to a number of people over the past month who have been refused assessment for NHS Continuing Healthcare Funding (CHC) because their relative is not “optimised”. This seems to be the latest NHS buzzword, as it is not mentioned anywhere in the National Framework.
We told you about the ‘Grogan Gap’, a newly invented NHS phrase in our last article. It seems that the NHS Clinical Commissioning Groups have either had a training session on yet more ways to evade their obligations, or else are trying to compete with the Oxford Dictionary to find some new words to add to their ‘CHC’ vocabulary before the year end.
If your relative has a ‘primary health need’ they may be entitled to a package of FREE care funded entirely by the NHS, known as NHS Continuing Healthcare Funding (often abbreviated as ‘CHC’). CHC is not means-tested, is paid irrespective of wealth, and is not dependent on the setting where the care is provided (eg in your own home or a care home facility).
If your relative is about to go into a care facility (or is already in one), they are entitled to ask the NHS to undertake an assessment of their healthcare needs at any stage to see whether they are eligible for CHC Funding.
This is a two-stage process, starting with the initial Checklist screening tool.
The bar is set low at this stage to ensure that the majority of people applying for CHC Funding are not screened out of the process prematurely. For more information about the Checklist assessment process read our blogs:
Can the NHS refuse to carry out an initial Checklist?
Do I have to pay for care whilst waiting for the Checklist Assessment?
If your relative scores positively at this Checklist stage, they will then move on to the second stage – a Full Assessment. This is carried out at a more formal meeting conducted by a Multi-Disciplinary Team of assessors (MDT) who are appointed by the Clinical Commissioning Group (CCG). They will make a recommendation to the CCG as to whether the individual is eligible for CHC Funding.
The MDT is the critical part of the assessment process and the first real opportunity (excluding Fast Track assessments) to secure free funded care for your relative. Good preparation is vital! You need to be fully prepared for this meeting. Otherwise, your relative could end up paying thousands of pounds a month for their healthcare and accommodation, quite unnecessarily!
For more helpful information as to what to expect at the MDT look at these blogs:
Preparing for the Multi-Disciplinary Team Assessment
What Happens At The Multi-Disciplinary Team Meeting?
Don’t let the Decision Support Tool become a ‘tick box’ exercise
What Is The Role Of The MDT Coordinator?
Learning valuable lessons prior to your MDT Assessment and how to avoid pitfalls
What to expect when you attend a Continuing Care assessment
Attending the Multi-Disciplinary Team meeting – some useful guidance
The latest NHS delaying tactic – “optimisation”
We spoke to an Enquirer who had recently attended a Multi-Disciplinary Team assessment on behalf of his mother, only to be told that the meeting would not go ahead because she had never had a Dementia Assessment, and so was not “optimised”.
The family were told that she would now need to have this Dementia Assessment first, which might result in a new regime of medication (ie be “optimised”), which, if successful, could result in reduced healthcare needs. Hence, upon review, a further Checklist would need to be completed to see whether a Full Assessment is still appropriate.
So, despite an initial positive Checklist already having been completed, this added ‘optimisation’ stage, not only adds another artificial stage in the assessment process, but, moreover, can have dramatic financial implications for the individual in care.
What does this mean in practical terms?
This added tactical delay means that our Enquirer could be forced into paying another six months full care home fees, maybe longer, without their mother ever having been assessed for NHS Continuing Healthcare Funding by an MDT. In the meantime, the family may be forced to sell their mother’s home to pay for her care, or else dig into hard earned life-time savings or private funds, to prevent her being evicted from the care home.
The National Framework NHS Continuing Healthcare Funding and NHS-funded Nursing Care (revises October 2018) states that patients should not now be assessed in an acute hospital setting, which we accept is quite reasonable. However, if the patient is in a Nursing Home, then the indication is that they have been medically discharged from hospital (i.e. their condition is deemed clinically stable).
In this eventuality, we cannot foresee any reasonable grounds for the NHS to delay arranging the preliminary Checklist assessment or proceeding to an MDT.
There is also an added risk that ‘optimisation’ could ultimately lead to the CCG refusing to carry out a Full Assessment after all, on the basis that the individual’s healthcare needs might reduce in future, once optimised! This is, of course, entirely speculative, as their needs might equally deteriorate.
Hypocritical?
Turning back to our Enquirer whose mother is awaiting ‘optimisation’ prior to carrying out another Checklist. Supposing, the boot is now on the other foot, and the proposed Dementia Assessment takes place resulting in a different medication regime being implemented. Healthcare needs that were previously stable and well-managed, could now potentially become unstable. Does that change mean that the CCG should automatically agree to fund her care on the basis that her needs might change, regardless of her current identified needs? Somehow, we very much doubt that the NHS would agree to pay for these speculative care needs, which may or may not arise.
The cynical would say that the obvious purpose of inserting an artificial ‘optimisation’ stage into the assessment process (not mentioned anywhere in the National Framework) is simply to try and save funds.
Remember: CHC assessments to determine eligibility for NHS Continuing Healthcare Funding are all about identifying present needs – ‘here and now’ – and not about speculation as to what might (or might not) happen in the future. That is why ‘optimisation’ is flawed.
If the latest NHS tactic is to introduce ‘optimisation’, then at least the NHS should agree to pay for the individual’s care in the meantime whilst this intervention is taking place, as inevitably delays occur. It is simply unfair and unreasonable for individuals to be expected to pay for their own care whilst waiting for the NHS to get their house in order and embark on ‘optimisation’.
By analogy, an individual discharged from hospital but requiring additional rehabilitation (i.e. ‘optimisation’) would have their care funded by the NHS via an interim package of care – either in their own home, a care home or community hospital. Similarly, those individuals who have been identified as requiring Full assessment for CHC, but need optimising ie further medical intervention or treatment before this takes place, should expect their care to be fully funded in the meantime.
Read: What’s new in 2018 NHS National Framework for CHC? Are you getting an interim care package?
What next?
We do not agree with ‘optimisation’ and would prefer to see individuals assessed far more quickly for CHC. But, if the NHS insist on ‘optimisation’ to see if more can be done to improve an individual’s healthcare once outside an acute (hospital) setting (and avoid paying for long term care!), then the NHS should fund their care in the meantime. Simple! The NHS can’t have it all ways!
Summary
Watch out for ‘optimisation’ as this seems to be purely a delaying tactic by the NHS to defer, or even avoid a Full MDT assessment and having to pay for your relative’s care home fees.
Don’t accept this delay and succumb to ‘optimisation’ or else your relative may end up paying for their care unnecessarily!
Tip: Ask the CCG to point out where ‘optimisation’ is provided for in the National Framework.
For additional reading around the subject take a look at these blogs:
How To Fast Track The Continuing Healthcare Funding Process
Let’s Talk Fast Track! Vital NHS Funding Withdrawn After 3 Months – The Latest NHS Controversy…
Things You Need To Check Before Your Relative Is Discharged From Hospital
If your relative has been “optimised”, then share your experiences below and tell others: what the NHS said to you to justify ‘optimisation’, what further assessments they needed to do before the Checklist could be carried out (or redone), and how long it took from ‘optimisation’ until the Full MDT assessment, did the matter in fact get to an MDT at all?
I am so grateful you raised this. The CHC nurse assessors have used the “optimisation” stage in order to withdraw CHC funding. When I made a formal complaint that they were not using the CHC 2018 Framework one of the junior nurses decided to make a vindictive safeguarding referral about me and the care of my mother. The optimisation was around their desire for my mother to be over sedated with barbiturates which was not in her best interests(GP fully agreed) They will literally go to any means to withdraw funding. The safeguarding referral was immediately closed as it was unfounded. I am now seeking a resolution. The CHC assessors are incompetent bullies and I am surprised that such a victimising system is able to exist.
My mother in law suffers from dementia as well as many other health conditions. Last week we had the multidisciplinary meeting and she scored 3 severe’s; we were informed that she had a primary health need and this would be recommended to the UHB quality meeting. The Co ordinator has now informed us that the recommendations has neither been agreed or refused; they want to do a ‘discharge to assess’ and place her in a nursing home with the idea to reassess in 6 weeks; surely the fact that she scored 3 severe’s and was deemed to have a primary health need she should ‘automatically’ get NHS continuing health care? What can we do?
Thank you for the article about patients needing to be “optimised” before they can be considered stable enough to be assessed for CHC. Sadly this is not a new phenomenon and it was used to deny my father an assessment for CHC back in 2016.
I too could find no reference anywhere in the National Framework or any of the relevant case law. I complained but the CCG took no notice and continued to refuse a CHC assessment despite a Checklist indicating the need for one.
I was told that a new anti-psychotic drug could bring improvements and they could not assess him until he had been optimised in this way.
This was despite the fact that he had been out of hospital for several months, ie he was considered “medically fit” and despite the psychiatrist telling us not to expect the drug to bring about any significant or even noticeable improvements in my father’s dementia and that the only prognosis, with or without the drug, was continued deterioration. This doctor unforgivably refused to contact the CCG to confirm this, saying mystifyingly that he wasn’t allowed to email or telephone them.
When I explained what the psychiatrist had told us the CCG said flippantly that if there was no improvement the dose could be increased and then increased again and again up to the maximum allowed.
The CCG staff were not qualified doctors/pharmacists etc and had never even met my father and yet felt entitled to say this.
The beauty of the “optimised” argument for CCGs is that they, and they alone, can decide if and when a patient is optimised. A patient they have never met.
It is simply another way of ensuring someone doesn’t get found eligible and cost them money by making sure they are not assessed in the first place.
very sadly reprisal actions against complainants are very common in private care home sector and NHS
Reprisal evictions and or reprisal exclusions of relatives raising safeguarding concerns is also escalating and is both corrupt and unjust
all agencies closing ranks and cohersively colluding and condoning such irregular victimisation of complainants
why ? Because they really do have something to hide and Elder abuse and day light robbery – of ‘self funder!’- vulnerable elderly by corrupt care providers is shamefully ! an indictment on our society
As is reprisal exclusion of their main advocate next of kin who raise alarm bells or blow the whistle!!! as I myself did only to be systematically victimised and excluded from my precious deteriorating then dying parent For 2.6 years!!!!!!!!??
I spoke recently on the telephone, at the request of the Director of Adult Social Care in South Yorkshire, to the ICB Chief nurse and her deputy. At the start of the conversation they first asked me whether my father in law had been optimised. I had no idea what this meant and said that he had been relatively stable for several months. He has paranoid schizophrenia and psychosis. Obviously, I thought this might be some form of trap, but my answer was probably not the one they wanted to hear. They have not carried out any CHC assessment despite the fact that he was admitted to hospital and the transferred to a care home almost exactly a year ago and this is despite my asking for a checklist at the beginning of february. In the past 4 weeks there has been a flurry of activity on their part of which I am suspicious. I spoke 2 weeks ago to his psychiatrist who told me that his assessment that day was that he no longer needed to be monitored by the Mental Health team and that this could be done in future by the staff at the care home. (I am alive, though, to para, 58 of the National Framework). The doctor explained that my father in law’s inability to regain his former excellent memory and cognisance was due to old age. This is nonsense. Within a few weeks this time last year he went from living independently, driving and shopping to someone who did not even recognise his own daughter (my wife). He had been on medication for schizophrenia since 2014 and this stopped working in 2018 (with almost catastrophic consequences) and again last July, causing the meltdown. The “memory team” has this week assessed him as having mild dementia- a social care rather than a medical care matter. Paranoid I may be, but would warn everybody to be on their guard against manipulation of this sort. It is in my view, an attempt to dilute his needs down to social care rather than the medical needs to keep him safe and relatively well.
Hi I have just completed a DST assessment for my mother who suffers from dementia, chronic pain, totally bedbound, doubly incontinent and immobile, the DST tool was completed and she scored 2 severes, 1 high that I argued should be severe, and multiple moderate scores across the categories. At the conclusion of the second meeting the assessor said her recommendation was that Mum wasn’t eligible for CCH The meeting was concluded with me putting forward several concerns around how they had reached their ineligible conclusion, for e.g I was told she didn’t qualify for CCH as she is being cared for at home and a lot of other wrong reasons IMO, to long and many to go into detail about here. I had made it known that I wanted to document my concerns and for these to be noted with the DST that gets sent to the ICB for final decision. Then the Monday after I had had the DST meeting on Friday, I was then told that actually Mum wasn’t in fact medically optimised at the time of the meeting, and I had to have a drugs review as a true record of here needs could not be reflected in making a recommendation to the CHC body! But they had allready given me their recommendation all be it not positive, and were now changing the goalposts after the end of the meeting when the assessment has in fact being completed. Medication was one of the categories that she scored severe in and this is what this relates to. They have said the report will not go further and that I have to start completely again with a CCH short list, ie they have binned this assessment and I have to start again right from the beginning, when it’s taken me since end March 23 to now to get this far. Also I’ve been given no guidelines as to what this means, how long does she have to be ‘optimised ‘ , what are the rules before I go back to them etc etc. It’s a complete farce and their is nothing in the National Guidelines to reflect this. The GP wasn’t even invited to the meeting. I was actually told separately by the Social Worker the moderator should have made sure Mum was medically optimised before we had the DST hence their reasoning. Yet they made the meeting with no mention in advance that I had to tick that box. Has anyone ever had this AFTER the assessment has been done and before it goes to the ICB Board. How can it be the MDT teams ultimate decision to make anyway, I thought the ICB does this, they just gather the info and report on it, and we had done that to it’s conclusion! I want to go back and say they should submit the report as it’s done now, you surely can’t move goalposts like that after the fact surely, can anyone advise what I should do as I haven’t gone back with a response as I am so shocked.