Understanding the four key indicators
When looking at whether your relative is eligible for NHS Continuing Healthcare Funding (CHC) you first have to consider whether they have a ‘primary health need’. In short, they must have health needs over and above what Social Services would ordinarily be expected to provide.
Your relative’s needs will be assessed at a Multi-Disciplinary Team Meeting (MDT) and their health needs will be scored using the Decision Support Tool (DST).
However, the DST is just what it says – a ‘tool’ to help practitioners assess an individual’s healthcare needs across the various Care Domains (listed below) and reach a decision as to eligibility for CHC Funding:
The 12 Care Domains are: 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.
Whilst a high score in one or more of the Care Domains may indicate that your relative has a primary health need, you still have to look at the overall totality of their needs – and in particular, consider the four indicators (or ‘characteristics’) and how they impact on the level of care needed. This is the essential point that most people fail to grasp.
The four key indicators are: Nature, Intensity, Complexity and Unpredictability.
So, for example an individual diagnosed with Dementia is unlikely to be eligible for CHC Funding on that basis alone. It is not the diagnosis that is critical, but the nature of those healthcare needs, and whether they require intense nursing, are complex in their management or are unpredictable.
The four key indicators are set out in paragraph 60 the National Framework for NHS Continuing Healthcare and NHS funded Nursing Care (revised October 2018), and are summarised below:
Nature: describes the particular characteristics of an individual’s needs (which can include physical, mental health or psychological needs) and the overall effect of those needs on the individual, including the type (‘quality’) of interventions required to manage them.
Intensity: relates both to the extent (‘quantity’) and severity (‘degree’) of the needs and to the support required to meet them, including the need for sustained/ongoing care (‘continuity’).
Complexity: looks at how the needs present and interact with one or more other conditions to increase the skill required to monitor the symptoms, treat the condition(s) and/or manage the care.
Unpredictability: describes the degree to which needs fluctuate and thereby create challenges in managing them. It also relates to the level of risk to the person’s health if adequate and timely care is not provided. An individual with an unpredictable healthcare need is likely to have either a fluctuating, unstable or rapidly deteriorating condition.
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.”
Here’s an example of how you need to look carefully at the four key indicators when considering the interaction between all the Care Domains and assessing your relative’s eligibility for CHC Funding:
Example: Fictional Case study
NATURE
Mrs Jones (not her real name) has Diabetes and was diagnosed with Alzheimer’s disease. She is confused, disoriented and has poor short term memory. Mini-Mental State Examination shows a deterioration over many years.
COMPLEXITY
Mrs Jones is at risk of a seizure or hypoglycaemic attack. She was reported to have a vacant episode preceded by very pronounced jerky movements and tremors.
Mrs Jones needs staff to manage and monitor her continence needs which at times are problematic. Because of her memory loss she needs prompting to go to the toilet every 2 hours. She has a history of haemorrhoids and chronic constipation. However laxatives are usually ineffective and she needs District Nurse intervention with manual evacuation at times and phosphate enemas.
Due to Mrs Jones’s diabetes, she requires a managed diet to ensure that her blood glucose levels remain as constant as possible. She frequently suffers with diarrhoea, and on particularly bad days, must only take a small diet to avoid further aggravating her bowel.
Her Blood Sugar levels are high and are monitored by the District Nurse. She needs regular courses of antibiotics for infections. She was prescribed Metformin, but her appetite had deteriorated. She is very shaky and unsteady on her feet.
Mrs Jones is susceptible to weight loss because of her sporadic bowel, health and diabetic condition, and staff must ensure that her nutritional needs are met sufficiently. Staff are needed to observe her and record her dietary intake, and the District Nurse has intervened to educate staff about her diet.
Mrs Jones needs trained staff to administer and monitor her medication for its effectiveness. She has a complex regime which is frequently reviewed. Mrs Jones has a history of depression, and takes sertraline to alleviate some of the symptoms.
She suffers from tremors and shakes, and Diazepam has been tried to alleviate her anxiety and reduce her movements. However this proved to be ineffective and she was prescribed Lorazepam.
Sometimes Mrs Jones has swollen legs and these need to be kept elevated to dissipate built up fluids. As Mrs Jones is diabetic, special attention is due to her extremities as she is at risk of neuropathy and specialist advice may be necessary.
INTENSITY
Mrs Jones’ mobility is greatly affected by her tremors and dizziness which put her at risk of falling. She needs to be checked every 2 hours, and she needs staff to stay with her whilst she is getting washed and dressed.
Mrs Jones suffers with bronchitis and other chest infections and needs antibiotics. At one point. Staff have to monitor and observe Mrs Jones for any symptoms that may indicate a latent chest infection and alert her GP as appropriate.
Mrs Jones is diabetic and must adhere to a diabetic diet to maintain constant blood sugar levels and prevent hyperglycaemic seizures. Staff are responsible for providing Mrs Jones with suitable meals and monitoring her blood sugars for fluctuations.
Due to her dementia, she needs assistance as she can no longer sequence clothes, and forgets one task to the next when washing and dressing. She needs prompting to use the toilet, and now needs full assistance to locate the toilet. She needs staff supervision to ensure she doesn’t use inappropriate creams on her face, and these have had to be removed. In particular, with her recent basal cell carcinoma.
UNPREDICTABILITY
Mrs Jones is suffering from Alzheimer’s disease and is therefore prone to becoming confused and disorientated, putting her at risk of falls and emotional trauma. Staff have to ensure that her environment remains safe and hazard free to minimise risks.
She is unable to assess risks and hazards in her environment and has no insight into her condition and the impact it has on her activities of daily living and her health needs. Staff report that her memory has significantly deteriorated with decreased activities of daily living, and she is now doubly incontinent.
She was initially able to express her needs and communicate; however her communication has deteriorated and is no longer reliable. She is able to speak but is repetitive and anecdotal in her communication. She needs staff to anticipate her needs and to make decisions for her.
She has bleeding and painful piles and is very embarrassed about her continence status. On one occasion she locked herself in the toilet and would not let staff in, because she had faeces on the floor. She needs staff to bath her everyday to maintain good hygiene.
Mrs Jones has suffered a marked deterioration in her mental health. She becomes anxious and confused and needs staff to offer reassurance and support her with daily tasks and situations.
She can sometimes express a desire to die. Staff must monitor Mrs Jones to ensure that she does not try to harm herself, and that reassurance is given in a timely manner to prevent low mood progressing.
Mrs Jones is frequently noted to be dizzy and shaking, which can prove to be problematic as she is currently quite mobile and could fall easily. Staff support Mrs Jones with all her mobility needs and assist her as much as possible.
On particularly bad days, Mrs Jones is required to relocate to a downstairs room to prevent her falling down the stairs, as she could forget that she needs assistance to descend. Mrs Jones has fallen on several occasions. Her involuntary jerking movements which appear to be a fit or a hypoglycaemic attack are more pronounced when she is anxious.
Mrs Jones is not able to dry herself properly after bathing, and this leads to red and sore areas developing in vulnerable areas. She is at high risk of developing pressure sores. She requires Canesten cream to be applied to fungal infections and daily creaming of dry areas.
Summary:
The example shows how you need to take a holistic approach and look at the overall totality of Mrs Jones’ needs in conjunction with the four key indicators, when assessing her eligibility for NHS Continuing Healthcare Funding. It is arguable that her needs could only be managed effectively by skilled intervention over a sustained 24 hour period to prevent further deterioration.
Read these other related articles which are helpful:
‘Apply for NHS Continuing Healthcare Funding if your relative has a ‘primary health need’…
‘Primary health need’ made simple – what does it really mean?
‘Take a holistic approach to improve your chances of getting CHC Funding’
As well as reading our website and downloading e-book, ‘How to get the NHS to pay for care’, you can also subscribe to our Bulletin and sign up today on our website for further information.
This is an excellent piece, which I have found useful as I prepare to attend my late father’s IRP.
I have fought CHC/CCG for the past two and a half years. Three Arch Lever folders full of documents and letters.
To get to IRP we have gone through 2 failed checklists, appeal accepted. MDT/DST- failed and appealed (this is what the IRP will focus on). FNC was awarded instead, which is yet another farce! FTT (Which was refused!!!!!) we argued with CHC about flouting the NF on this and the eventually gave in and the FTT was commissioned, only to be withdrawn 3 months later at the review, which we appealed on numerous grounds. The whole process is led by CHC individuals who believe they have the authority to over ride decisions of a Doctor, as was the case when the final FTT was submitted by the nursing home GP and manager in the final 6 weeks of my father’s life. The CHC nurse assessor denied eligibility even at this stage, by ring the nursing home to ask for further evidence of needs, and went as far to say that my father’s needs were stable! He died!
The point I want to make about the Key Indicators is that it seems to me that CHC/CCG will use these to justify not completing the DST accurately.
In our case the DST was incomplete. The assessors argued about the level of need for pyschological and emotional domain and it was left unawarded. The Social Services Assessor was in between levels and even wrote this on the DST. This should not happen if you follow the NF. I know I have read somewhere about not choosing a level in between scores! The lead Assessor should have known this and not allowed this to happen and awarded the higher score. She didn’t.
The point I make is that the evidence considered by the Individual Challenges and Disputes Review (local resolution)
which was completed by those we had complained about and had handled the case from the outset – so not independent!) Said:
1. It was not necessary for them to agree on a level of need as the held differing views.
2. In respect of the outcome letter ******** you are correct that the disagreement on the level of need is not mentioned,
but there is no need to do this in the letter. The purposed of the letter is to inform you of the outcome of the assessment, using the four key indicators, why the decision was made not to award CHC.
WHAT? So the argument is why have a DST at all, if the Scores have no bearing on eligibility?
How can I argue my case if no level is awarded.
The conclusion they gave was to focus on the four key indicators to determine if my father had a PHN.
Nature: a paragraph to describe his health and well-being – with incorrect information and nothing to portray his paranoia and emotional distress as a suffering of Parkinson’s disease and Dementia.
A few lines on Intensisty, Complexity and Unpredictability and then the PHN test!!!!
His needs are could best be met in a Nursing Home environment (in other words he needs nursing!)
But his needs are mostly to do with daily living needs ie washing, dressing, elimination, feeding and moving!!!! Yes, that’s what’s documented. So he couldn’t do anything for himself, not even empty his bowels without intervention.
This is the last few lines: There is intensity, complexity and unpredictability, but these do not extend to all of his needs and in the main, he is not overly complex, intense or unpredictable. For these reasons the Review concludes that my father did not present with a Primary Health Need and is therefore not eligible for CHC funding!!!
I welcome the expertise and comments from the readers of this excellent forum.
Good luck to everyone going through this horrendous fight.
Chc is a legal decision not one of NHS policy. The dividing line between nhs care and social care was established in the Coughlan case. By default it is not the NHS that make the decision because the decision is based on the limits of care social services can provide . Care Act 2014 section 22. The law only gives a general guidance under the Act . This is why it is reasonable to compare your needs with that of Coughlan this is what the courts did. Are your needs the same or worse? Coughlan’s needs were judged to be well outside the services that social services could provide. The primary Heath test is not the test performed by the courts. There is no legal definition of a primary health need. In Coughlan the phn was mentioned once in that if there is a phn and the Secretary of State agreed and this is the reason an individual is placed by a local authority in a nursing home then the NHS is responsible for the full cost of the care package. The criteria nature intensity complexity and unpredictability are illegal in law. (Grogan case). They create an altogether illegally higher threshold for chc qualification. They focus on the intensity of the treatment rather than the needs and condition of the patient . In Coughlan and in the National Framework it’s about the needs of the individual not the treatment. Pamela Coughlan has a video online you can see her condition and she is still alive and campaigning for chc. Chc cannot be denied on an input related rational see Framework. The chc process is a procedure you must go through before you can access the Ombudsman. After which it is a judicial review. It’s one thing knowing the law and it’s another thing getting it applied. But if your needs are equal to or greater than Pam’s then there is no reason you shouldn’t win. What has effectively happened is that the NHS has reclassified health care as social care and introduced the Funded nursing care contribution to pay for the registered nursing care element of the care that social services are not allowed to provide and with the view that a patient cannot be expected to pay for and not fully appreciated their duty to provide CHC which covers all your care costs. The government will not admit that it has been acting illegally for 25 years they have the money to put things right. Think about this while chc assessors lie in the comfort warmth and safety of their own beds and enjoy a freedom that their fathers and grandfathers risked their life’s to fight for ,only to deny them their legal entitlement for health care in their twilight years. Is this fair?
Hi M. Unfortunately knowing the law and getting it applied are two different things. The NHS never answer and social services give you obtuse answers. This has been my experience over the past year. I am extremely stressed and frustrated also and my MP is backing me in fact we have written to Matt Hancock secretary of state as other cabinet ministers just gave obtuse answers to my questions. My initial strategy was to refuse to pay care home fees because I was certain my mother should qualify for CHC. But it penalises the home and a parent could get evicted from the home or transferred back to hospital to end up in some other less desirable home which would affect you parents well being . But the nhs also have a bigger responsibility to safeguard your parents well being as they are the Authority. I refused to pay for 3 months thinking the nhs would capitulate but they didn’t I owed the nursing home nearly £12000. I caved in because I didn’t want to risk or cause mum any due stress nor penalise the home otherwise what’s the worst the nhs could do to you, take you to court for neglecting your duties as attorney? When as attorney you have a legal duty to protect your parent’s financial interests and you are also fighting for their legal right to health care? In court is where we unfortunately need to go to enforce our rights. Nobody really wants to go there especially the NHS as they know they don’t have a leg to stand on. If they move your father to hospital the care is free again. If they want to put him in a new home and you still refuse to pay, It changes nothing.. Also under Article 8 of human rights you have a right to a family home life. The nursing home is your dad’s home. Again how do you enforce this, you go to the police and press charges for assault and abduction? It starts getting messy. The bottom line is you have to exhaust the appeals process before you can seek legal action and this is all that matters. The NHS will take it right to the line. The Ombudsman is free but he is not truly independent of government. If he is not sympathetic to your case he could probably introduce reviews that will delay a judgment only to start up a new review process. If you go straight to court after the IRP and skip the Ombudsman the NHS will make up its mind pretty soon. I am preparing for the IRP I am quoting all the legalities and framework and also trying to paint a picture of mum’s condition and present a moral and political argument also. Its 8 pages long. It will probably be thrown in the bin by the IRP immediately after reading the first paragraph. Quite frankly I don’t care as it is a legal matter and can only be solved in court if they don’t grant CHC as the only thing that interests the NHS is budgets. Patient centered my backside institutional care is like Primark knickers and socks, one size fits all at Armani Prices. A lot of solicitors that are experts in this area will help you put a case together for the appeals process but they won’t litigate.
Do you or 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?
I’m very confused about all of this.
In the full chc assessment today, my mother scored 1 severe, 2 high and 4 moderate, yet was refused.
This seemed like a very high score to me. One of the moderates I do contest, the nurse told me that the high description was wrong, but only applied to patients who couldn’t talk at all, however that was not what the description stated and my mother matched that written description perfectly.
Also they downgraded her lots of times, despite admitting that the higher description did for my mother in lots of ways.
Seems to me that it’s a pointless exercise, as the result is now that the care home have put their fees up to accommodate all of my mother’s health needs.
I question if there is a way to ‘enforce by law’ the NHS/LAs to provide the healthcare – CHC is effectively having to prove that the ‘delegated healthcare’ is of a certain level, but surely the most important thing is to ensure the healthcare is delegated properly, to a professional standard – for example can a person insist that the NHS/LAs community/specialist nurses & therapist provide the appropriate care plans and ensure that the community care providers (nhs/council health & social care providers) have the appropriately trained regulated resources to provide the healthcare – has the local NHS delegated their responsibility for community healthcare to local councils in every area?, is the council supposed to be providing the nursing care & therapy direction with their responsibility for assessing and planning care? CHC is a stupid process used to identify healthcare needs which makes no sense to me as surely by law (care act) the LA should be aware of what the eligible care needs are and be ensuring they are met – NHS Delegation of nursing care & any other healthcare should include ensuring the private social care providers are willing and able to accept the responsibility of providing the healthcare.
I our case there was confusion as to who was responsible for providing the nursing care, so no one did – result unmet needs & traumatic hospital emergency.
All this ‘arguing’ about who pays for healthcare that is being delivered by unqualified, unsupported social care workers to me is missing the point, causing distress, worsening health and wasting a lot of professionals time & money that could be spent on providing healthcare – if the local health services, including councils just worked together to follow the law which is designed to deliver personal health care budgets to fund nursing care regardless of if it is provided by nurses or delegated to healthcare assistants or social care workers.
I don’t think anyone expects the state to pay for regular housing/hotel costs unless due to poverty a person can’t afford it – this is social care …. Nursing care is not social care, regardless as to whether low, moderate, high, severe, or priority and in England it is the responsibility of the NHS to deliver even if locally they have delegated some of this responsibility to local authorities – that is why we now have personal health care budgets and nursing funded care assessments are supposed to be combined with continuing healthcare – NFC/FNC – councils are responsible for working with the NHS community healthcare providers for integration of all care including nursing care which all ‘patients’ are eligible for regardless as to financial status.
appreciate this is just my understanding of the Law & maybe wishful thinking!