What to focus on in an NHS Continuing Healthcare appeal

Published 08/09/2013

Please note: This article was published prior to July 2022, and some information may be outdated.

When you’re short of time and energy it helps to focus on specific aspects of an appeal

Disputing the outcome of an Continuing Healthcare assessment can feel daunting, and so it helps to identify in advance what to focus on in an NHS Continuing Healthcare appeal.

When you start to pull apart assessment notes and care notes and put together an appeal, you quickly realise that the time and energy that needs to go into this can be substantial. Focusing predominantly on specific aspects of an appeal can help.

In a full NHS funding assessment for full time care (an NHS Continuing Healthcare assessment), the assessors will look at 12 different areas (domains) of health and give the person being assessed a particular score in each domain.

To be eligible for NHS funding, the person being assessed has to achieve a minimum combination of scores at the end. One such combination includes two ‘Severe’ scores; another such combination includes one ‘Priority’ score.

Here’s an example of how to decide what to focus on…

Typically, someone with advanced dementia will be given a ‘Severe’ score in the Cognition domain. The person may also have significant Behaviour challenges and ordinarily you would expect them to have a relatively high score in the Behaviour domain as well. However, increasingly assessors are declaring the person to have no Behaviour needs because they say it’s all to do with the person’s poor cognition.

This is despite the fact that the official Continuing Healthcare guidelines clearly state that health and care needs should be recorded in every relevant domain.

Assessors will also often say that someone with dementia cannot have any psychological needs or emotional needs, and yet this is of course completely wrong.

As in the above example, if you find yourself in that position where you have one Severe score and you believe at least one of the other domains should also attract a Severe score, when you come to appeal it’s a good idea to direct much of your time and energy into arguing the case for this additional domain. That’s how you are most likely to achieve the required scoring combination of two Severe scores.

With the other domains that perhaps have lower scores, you may decide not to spend so much time and energy focusing on these. Of course, where the assessment notes are wrong in these domains and contain misstatements of fact, or where the assessment has not been carried out properly and/or relevant evidence ignored, you’ll still want to make this point.

So remember to look at where you’re best directing your energy when you’re putting together an appeal, and look at the most likely way you could achieve an eligible combination of scores.

Tagged Categories: Appeals and reviews, CHC essentials, CHC funding, NHS Continuing Healthcare, Ready to appeal

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5 Comments

Al Smith February 20, 2017 at 2:09 pm

Hi - after much protestation on our behalf, the local Continuing Healthcare (CHC) finally agreed to a Stage 2 Decision Support Tool (DST) assessment for our father.
During the discussion, two of the domains resulted in a "Severe" categorisation, with others a combination of High, Moderate and Low, which we understood, as the DST guidance note, meant he would be eligible for full CHC funding - however - the 'recommendation' of the Multidisciplinary Team (MDT) was that he was eligible for 'Funded Nursing Care' only - does anyone else have examples of where the authorities chose to ignore the National Framework guidelines when making a recommendation in similar circumstances - we understand the 'nature, intensity, complexity, deterioration and unpredictability' argument - however - surely this was addressed by the MDT when it decided the 2 "Severe" domain categorisations having heard the evidence from the clinicians?

Angela October 3, 2013 at 6:15 pm

Anna - sounds like you may need to make a more formal complaint about how the needs are being interpreted. If the Speech Therapist is onside, he/she may be able to help.

Anna September 16, 2013 at 8:50 pm

We have just had a yearly NHS CC meeting, which although was run in a slightly more organised and professional way than previously, it was still a minefield of confusing semantics. In particular I wondered what advice anyone could ofer about 'communication' section of DST. Our relative is globally aphasic ( following a severe stroke 2 years ago) so no verbal communication at all . As far as we are concerned he cannot communicate his needs at all. Any non verbal 'responses' such as an occasional nodding or shaking of the head, have already been assessed by the Speech Therapist as highly likely to be mimickry and at best unreliable . However, as we described a facial expression in response to pain when limb contracting or is moved, the assessor said that this shows that he is communicating. We tried to say there was a difference between an automated response to physical pain and communicating needs but to no avail. Apparantly, some poor people are unable to show any response on their faces at all... in which case they score a high. Has anyone experienced this or can anyone point us in the direction of how communication is defined?
On another criteria - behaviour- he scores low because he does not lash out ( he cannot physically move his limbs) nor does he shout or say obscene things. He is described as passive. He is viewed as 'compliant' as he does not verbally refuse medication. However, he does sometimes keep his mouth closed ( although the nursing home inconsistently report this) which to us is an indication he is refusing . The nursing home say he ' is just tired and not deliberately refusing'. Regardless, the assessor said that if he is keeping his mouth shut then he is ( wait for it....) COMMUNICATING HIS NEEDS! On 'psychological', despite being on anti depressants he is not deemed to have a high score, because his behaviour or communication does not indicate sufficient anxiety. We tried to say that the anti depressants manage his mood but apparently this is not the case. I described how I sense he is depressed, has tears in his eyes. ( which of course is more evidence for him communicating his needs) .. I feel sure if he could speak he would be be pleading for this torture to stop. ... He is truly trapped ... What a terrible way to end an a life .. It is a living hell for him.. And a nightmare for us to have to watch. Meanwhile nhs cont care will doubtless not fund . We do our best to take care of him but ironically the better care we take the less likely it is he will ever get Cont Care. The one thing that might make life a bit more bearable would be some massaging/ physio etc but even that is denied him. In fact any bit of one to one would be lovely ... But when you don't speak, don't call out, don't misbehave and sit staring at a wall no one bothers........ Sometimes I think we treat our pets better than we do our precious older people.

Anyone got any pointers about the communication part of DST?

Tania September 30, 2013 at 9:46 am

Dear Anna

Unfortunately, I cannot agree more with your final comment. Watching someone you love go through this living hell is appalling. The red tape we have to cut through is never ending and I feel our system really lets our older generation down. Although I can offer you no solutions as we are still battling the NHS ourselves - it is a continuing learning curve and very frustrating. Best of luck

Angela September 18, 2013 at 8:05 am

Thanks very much for sharing your experience Anna. The obstacles you've been facing are, I'm sure, ones shared by many other families. The excuses given by NHS assessors for playing down health needs and refusing funding are becoming ever more ridiculous.