CCGs to cut NHS Continuing Healthcare assessments in hospital

Published 24/08/2017

Please note: This article was published prior to July 2022, and some information may be outdated.

Watch out for more pressure on families to get relatives out of hospital

If you have a relative in hospital and they need ongoing care, you may soon come under even greater pressure to get them out before the proper NHS Continuing Healthcare assessments in hospital have taken place.

NHS England has issued new guidance to CCGs regarding hospital discharge and Continuing Healthcare assessments. It means that CCGs may now do whatever they can to avoid assessing people while they’re still in hospital.

The new guidance comes in the form of a letter sent by NHS England to CCGs and it’s dated 17th August 2017.

We’ve pulled out a few points from the letter and added our comments and words of caution below. The focus of the letter is, on the surface, about making the NHS Continuing Healthcare assessment process more efficient. However, it may make things even more difficult for families.

Here’s what the letter says about NHS Continuing Healthcare assessments in hospital:

“1. CCGs must ensure that less than 15% of all full NHS CHC assessments take place in an acute hospital setting;”

and…

“These CCGs are required to submit a plan for improving this to less than 15% by March 2018…”

There are some crucial things to watch out for here:

You may come under enormous pressure to get your relative out of hospital. If you can stand firm and insist that the NHS Continuing Healthcare assessment process takes place while they are still in hospital, you will have more leverage to get it done quickly.

If/when your relative is discharged, they may be offered intermediate care (rehab) – if that’s appropriate for them. Your relative should not be charged for this. At the end of the period of rehab, and if your relative still has ongoing care needs, there should be an NHS Continuing Healthcare assessment. Again, your relative should not be charged a penny for any care until this process is complete – even if they have left rehab.

If intermediate care is not appropriate and, for example, your relative is going straight into a care home or having ongoing care at home, you do not have to pay a penny in care fees until the NHS Continuing Healthcare assessment process is complete. It doesn’t matter whether the assessment process takes place inside or outside hospital, the NHS has a legal duty to cover all the costs of care until it is complete. Guidelines do not negate the law.

The NHS England letter also states:

“2. CCGs must ensure that in more than 80% of cases with a positive NHS CHC Checklist, the NHS CHC eligibility decision is made by the CCG within 28 days from receipt of the Checklist (or other notification of potential eligibility). CCGs are expected to ensure that full assessments are only undertaken when required, for example, assessments are not required for people who are going on to NHS rehabilitation services or do not have long-term care needs;”

The last few words here contradict existing guidance and are, frankly, alarming: NHS Continuing Healthcare funding is for any stage of life. It doesn’t have to be ongoing; instead, it can be provided during those times when a person’s care needs meet the criteria, and then cease if/when the person no longer needs it.

So, saying that people who don’t have long term care needs shouldn’t be assessed at all would seem to mean that anyone recovering from illness or accident (and who is actually recovering) would never get the funding. This must surely be in conflict with the whole legal basis on which the NHS operates, i.e. to provide healthcare.

Be alert also for the following:

CCGs may be more reluctant to do Checklist assessments in the first place. Stand firm. Read about the typical mistakes made with NHS Continuing Healthcare Checklists.

The scores in Checklist assessments may be lower than they should be, essentially to avoid the need for the CCG to do full multidisciplinary team (MDT) assessments.

“NHS CHC assessments should only be undertaken when an individual has recovered after an acute period of care and when their long term care needs can be more clearly identified.”

This is essentially the same as before. However, remember that part of the purpose of the NHS Continuing Healthcare assessment process is to inform the kind of care that is required. If people are being shunted out of hospital without a clear ongoing care plan in place, this presents a huge risk to patients.

“CCGs must ensure that decisions can be made swiftly throughout the week, as soon as patients are ready for discharge. Verification of MDT recommendations should take no more than 2 working days.”

Whilst it’s good news that funding decisions will be made more quickly, be alert for the following potential scenarios:

NHS Continuing Healthcare full MDT assessments being arranged in haste without families being informed.

NHS Continuing Healthcare full MDT assessments being carried out so quickly that they do not reflect the true picture of need of the individual being assessed.

A lack of proper evidence at assessments, because the time it takes to pull it together may mean the CCG does not complete the process in the required time.

This may all sound cynical, but there is already a huge amount of impropriety in the way NHS Continuing Healthcare assessments take place (or don’t take place); these extra requirements placed on CCGs risk making this even worse.

Remember always 3 crucial things:

Guidelines are just guidelines; they are not the law.
Whether or not a person pays for care has nothing to do with their money, house or assets; it’s about their care needs only – and the decision about who does actually pay can ONLY be made once the NHS Continuing Healthcare assessment process is complete and a finding decision has been made, in writing, and with a full rationale.
The local authority has a vital role to play in the NHS Continuing Healthcare assessment process.

So be vigilant, stand your ground and don’t be afraid to dig your heels in and get the Checklist carried out while your relative is still in hospital.

Tagged Categories: Care homes and hospitals, CHC essentials, CHC funding, Checklists and assessments, Getting assessed, Hospitals and discharge, NHS Continuing Healthcare

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55 Comments

Kirstie December 22, 2017 at 2:16 pm

Thanks to the advice from this website I persevered and won. My Dad has been awarded NHS Continuing Healthcare. We are now in the process of finding Dad a suitable nursing home, he can then be discharged from hospital. I am completely ignoring the fact that the discharged bureau are pressuring the family to find Dad a nursing home NOW and labelling Dad as a 'bed blocker', they will actually go to any lengths to ensure a speedy discharge...
Many thanks to this site and the advice given along the way, a trustworthy source of information. Merry Christmas :)

Angela Sherman December 23, 2017 at 9:48 am

That's great news, Kirstie - well done for persevering. Thank you also for your very kind words about the website. That's really kind of you, and I'm glad it's a useful resource. Wishing you well.

Chris-G December 14, 2017 at 7:51 pm

Barry,
Let them do the Deprivation of Liberty Safeguard (DoLS). If done comprehensively it might give you ammunition to try to gain more hours of care. As for overlooking something....... Every need that is carried out to a totally bedbound and non cognizant patient is in my mind covered under DoLS. Now what needs to be questioned is why you have to work 21 hours a day to provide the rest of the care to someone who is effectively incarcerated. I very much doubt that such a situation is legal..... I can't imagine the outcry if nurse or doctors had to work or to be on standby 21 hours a day, 7 days a week.

Barry December 14, 2017 at 4:34 am

Many Thanks, so do you think it is a good idea to let them do a DoLS, is there anything you can think of for me to watch out for that they might overlook or forget to mention. They pay for two carers to come in everyday for three hours from a reputable company, the rest of the time I am her 21-hour carer. It’s just that she was diagnosed in 2008 and now they want to do a DoLS. When she was diagnosed she made me promise I wouldn’t put her in a home, I will keep that promise and look after her till the end, not for money not out of duty, but because I still love her, being registered as end of life and bed bound because everything has gone, what’s the point now of a DoLS .

barry December 13, 2017 at 4:41 am

We had a review with Continuing Healthcare (CHC) and at the end they agreed to continue for the next 12 months, but then they said we will do a Deprivation of Liberty Safeguard (DoLS). We are living in our own home, so I contacted the DoLS team and they said it is normally only for people in hospital or in a care home. So I asked would the Local Authority be able to do it and they said they would have to apply to the Court of Protection. So why would CHC need to do a DoLS? What would be their ulterior motive - as we have been together for 60years and I am her main 24 hour carer?

Kirstie November 30, 2017 at 4:45 pm

Hi,
We had the Multidisciplinary Team (MDT) a few weeks ago, what happens if the majority (namely the sister of the ward and the social worker) say my Dad's primary need is health, but the Continuing Healthcare coordinator says otherwise?
There was no decision made at the MDT, I am told that a decision will now be made outside of an MDT.

Chris-G December 1, 2017 at 12:29 pm

The Multidisciplinary Team (MDT) must agree a recommendation. If not, the highest should become the recommendations. The Decision Support Tool (DST) with the default recommendation must be used by CCG decision makers to make the decision. Only in exceptional circumstances can the MDT recommendation not be accepted.

Barry November 26, 2017 at 7:50 am

This is interesting
https://www.local.gov.uk/parliament/briefings-and-responses/nhs-continuing-healthcare-house-commons-monday-27-november-2017

Kirstie November 9, 2017 at 4:09 pm

My dad is in hospital after being admitted 8 weeks ago, he had a check list done before his admission. The LA have asked for three check lists since then. Our Multidisciplinary Team is next week. I have asked several times to see the checklist however the Social worker seems to be avoiding this request. Fortunately the nurse advocates for the patient. My dad had a significant CVA 7 years ago, he is subject to Deprivation of Liberty Safeguard (DoLS), he is doubly incontinent, PEG fed, communication limited, vascular dementia, type 1 diabetes, hypertension, frequent UTI and aspirated pneumonia, unable to mobilise, pressure sores, gall stones, TIAs, depression, social isolation, cataracts, macular degeneration,glaucoma, Hyperplasia prostate, Hypercholesterolemia,Chronic kidney disease stage 3

So complex .... yes!
Unpredictable ... yes
Intensity....??
Nature....??
I am not sure how the Local Authority could possibly think they can legally be responsible for the care of my dad, when its clear his primary care is nursing, even the medication prescribed is complex due to interacting with others, timings etc...
He was in a Nursing Home however there is a safeguard alert in place he was in receipt of Funded Nursing Care but am I right in staying that this amount of money could not possibly cover the amount of nursing care he needs.
Please could you advise me on intensity and nature, so that I can prepare my argument.
Thank you

Chris-G November 9, 2017 at 9:01 pm

Oh and regarding Deprivation of Liberty Safeguard (DoLS)..... Get a copy and have a look at it. It is normal for the social services to slightly overemphasise the needs that allow the decision to deprive someone of liberty. Get it amended if needs and reasons are missing.
To under emphasise needs in such a document might well lead to a challenge of their decision to effectively place someone under house arrest and that could see someone in authority undergoing a similar fate.
That all being the case, the NHS/Social Service will usually try to under emphasise the same things to avoid Continuing Healthcare (CHC) funding.
What they are basically writing is that there simply being a DoLS means nothing...... It is up to you to ensure (regardless of assessors trying to ignore it), that the damaging content of the DoLS is used against them or to inform them that the the DoLS becomes illegal because it is obviously (in their minds), an unnecessary action and document.
For others reading.... Ensure that DoLS records are made a comprehensive as possible. It does help to have an official document quoting complex, intense and unpredictable needs to allow the locking up of another human being on hand when the same people working with the NHS then try to back track to avoid acknowledging the same person's needs and forcing them to pay for the 'prison' as it were.....

Chris-G November 9, 2017 at 8:46 pm

The funded nursing care payment is a sop to make you go away. It is arguable that needing this funding indicates that Continuing Healthcare (CHC) funding including accommodation costs is really required.
Also... Don't let them get away with ignoring the Framework regarding the part about Deprivation of Liberty Safeguard (DoLS)....
Page 38.
'123. The Mental Capacity Act 2005 contains provisions that apply to a person who lacks capacity and who, in their best interests, needs to be deprived of their liberty in a care home or hospital, in order for them to receive the necessary care or treatment. The fact that a person who lacks capacity needs to be deprived of his or her liberty in these circumstances does not, in itself, preclude or require consideration of whether that person is eligible for NHS continuing healthcare. '

DoLS is supposed to be assessed even though assessors will try to misuse what is written. Consider for a moment that a social service dept cannot provide accommodation if it is ancillary to the nursing needs. Without somewhere to accommodate someone..... How can they have their liberty deprived?

As for 'Intensity' That is the amount of effort required to meet the needs..... How many people, how often, is it repeated because of failure, Do other domains (Challenging Behaviour) interact thereby making perhaps, mobility needs, more intense? To explain.... My mum was highly mobile. However she was also very aggressive for a long time...... Being scored low on mobility actually endangered patients and staff..... Challenging behaviour had to be scored 'severe'. As the Independent Review Panel (IRP) chair eventually understood.... 'Mrs X's care needs were not being met in a vacuum' And, 'her challenging behaviour became more of a risk because of her good mobility'.

As for 'The Nature'.... These people do not like to deal with diagnoses. And to a degree that has some validity. However the starting point for Nature is the illnesses themselves. The Framework:-

' ’Nature’ is about the characteristics of both the individual’s needs and the interventions required to meet those needs.

Questions that may help to consider this include:

• How does the individual or the practitioner describe the needs (rather than the medical condition leading to them)? What adjectives do they use? • What is the impact of the need on overall health and well-being? • What types of interventions are required to meet the need? • Is there particular knowledge/skill/training required to anticipate and address the need? Could anyone do it without specific training? • Is the individual’s condition deteriorating/improving? • What would happen if these needs were not met in a timely way?'

barry October 2, 2017 at 3:48 am

Hi I have a Continuing Healthcare (CHC) review coming up soon and my wife is at the end stages of Alzheimers and is registered as “end of life care”. What I was wanting to know - would I be better off not telling them and go through the normal assessment or would I be better off telling them that she is” end of life” registered, and I presume they would Fast Track but is that a guarantee that I would continue with funding? Many Thanks. Barry

Chris-G October 3, 2017 at 12:07 am

Surely barry, the hospital/nursing home/GP should have instigated Fast Track in this case. The fast track actually short cuts the assessment for a while. The CCG will undertake an assessment shortly after being forced as it were, by the Fast Track application. Please remember that needs must be emphasised and not the causes of your wife's decline. We had this very recently with my mum and we pushed the nursing home nurse to do this and then before sending it, we had her edit it a little to reflect need because she did not comprehend that was the essence of the Fast Track. Best Regards in this difficult time.

SL September 14, 2017 at 7:50 pm

In my area people are discharged from hospital into an NHS funded bed for 28 days to enable a Checklist and Continuing Healthcare assessment to take place.

Chris-G September 15, 2017 at 2:02 pm

Sounds like a plan........ Until of course one is already in a nursing home for which you have had your NHS Continuing Healthcare (CHC) funding removed. The hospitals seem to believe that all sick and recovering patients already within a nursing home that are sick enough to require repetitive hospital admissions, already receive CHC funding (because they are so sick???), and so they are simply sent home with even greater needs for funding than when they were previously funded or even as in my mother's recent case, without any Fast Track or followed up palliative care..... Even having clearly been discharged to her care home to die....... The care she eventually received was only given once, (three weeks after discharge), we had demanded the discharge notes and then had a meeting and then got the GP who had clearly not read the discharge notes to do her job. Just a pity that pain relief and antibiotics etc. was not given as prescribed by the consultant for three weeks prior to my mum's death.

Amanda Weeks September 7, 2017 at 1:15 pm

I have just received a response this morning from The Ombudsman where I complained that my mother was discharged from hospital with a package of 6 weeks intermediate care to a care home, which we were then charged for. The Ombudsman's response is that the Council states on its website that they will not pay for 'The Council’s policy on reablement says it will not accept referrals from people “needing long term support with no potential for improvement in their level of independence”.
So the decision is no wrong doing by the council. I did point out the clause in the 2014 Care Act but to no avail. So it seems the Council decide not the Care Act. I am in disbelief.

Peter Wiltshire August 28, 2017 at 8:09 am

If the National Director of Operations and Information of the NHS, Matthew Swindells issues an instruction or an advice to the Clinical Commissioning Groups that demands or advocates illegal activity (https://www.england.nhs.uk/wp-content/uploads/2017/08/letter-improve-nhs-continuing-healthcare-assessment-processes.pdf ) by denying people who need nursing care access to those who are familiar with their condition, i.e. the nursing staff who have been dealing with them in hospital, surely anyone can take out an action against him. I'm game for setting up a fighting fund. Anyone feel the same?

Cecilia Toole August 24, 2017 at 11:41 am

Thank you for this new information, it is invaluable.

Chris-G August 24, 2017 at 11:06 am

Furthermore, to last comment..... This is a CCG 'Rubber Stamper's' charter.
The hurry up is more important than health care and observation of and provision of care needs.
I am also mystified as to the role of government in this, having apparently taken managerial responsibility for the NHS from the Secretary Of State some time ago, when it was restated that his role was only to provide an environment in which the NHS could function....... It appeared at the time to be a vehicle to enable the Sec' to avoid blame by not being seen to actively manage the NHS. If so then why does this report mention his involvement?
Angela Sherman's point about Continuing Healthcare checklist and Multidisciplinary Team assessments and the documentation forming part of the care plan is entirely and centrally relevant. To circumvent or to avoid such processes is to risk the healthcare of patients just at the time that it is transferred to social workers.........
Imagine if you will what would happen if the Atomic Energy people circumvented rules and/or rubber stamped the recommendations regarding who would continue in custody of used nuclear fuel once they no longer have a use for it........... would the fuel remain safe and secure? Would they be allowed to mess about with the laws and rules in such cavalier manner..... I sincerely doubt it.

Andrew August 25, 2017 at 9:05 am

Chris

Neither Her Majesty's Secretary of State for Health nor Her Majesty's Government have had day to day managerial or operational responsibility for the National Health Service since the Health and Social Care Act 2012 came into force, mainly on 1 April 2013.

Since 1 April 2013, in England day to day decision making concerning the National Health Service rests with the Chief Executive of NHS England and to those within NHS England to whom the Chief Executive delegates responsibility.

And following the coming into force of the Care Act 2014 and secondary legislation The Care and Support (Discharge of Hospital Patients) Regulations 2014 (which secondary legislation has not been debated nor scrutinised by our MPs), are worded in such a manner that it seems NHS England is entitled to issue directives to CCGs like the one issued on 17 August 2017.

An online article on 21 August 2017 suggests English local councils have also been contacted by the Department of Health. In summary, the article alleges the Department of Health has told local councils if they do not assist CCGs in speeding up hospital discharges they (local councils) may have their social care budgets further cut!

Local council's initial response is that what they are being asked to do is "undeliverable."

http://www.independent.co.uk/news/uk/home-news/nhs-beds-blocking-targets-councils-social-care-funding-threat-a7900271.html

Secondary legislation without proper oversight is an extremely bad way of implementing policy. Perhaps now only Her Majesty's judges will be able to overturn this policy if it is affecting patients adversely. But who is going to be willing to take the Department of Health and/or NHS England to court?

Angela is absolutely right. Those fighting to ensure that a proper and comprehensive assessment of their loved one's needs for NHS Continuing Healthcare is conducted should follow Angela's advice above and fight for what they believe is right.

Chris-G August 24, 2017 at 10:52 am

A good article based upon yet more cynical cost and service cutting. Interesting to see that my CCG has completed only 48% of Continuing Healthcare assessments within the mandated 28 days.
Assuming that the Professor of Nursing is a Registered Nurse; what I wonder, would be the Nursing And Midwifery Council's response to a complaint that a Nurse has signed off this document, much of it apparently ignoring the National Framework Guidance and the in so doing, ignoring law.