It is tempting to breathe a huge sigh of relief when your relative finally proves eligible for NHS Continuing Healthcare. But then, all too soon, comes the NHS Continuing Healthcare review. This is normally within three months of the initial decision, and then again every 12 months. According to the National Framework for NHS Continuing Healthcare, the rationale is to ensure the care package is still appropriate to meet healthcare needs. “It is expected that in the majority of cases there will be no need to reassess for eligibility.”
However, far too many Clinical Commissioning Groups (CCGs) use the NHS Continuing Healthcare review as an opportunity to reassess eligibility. We hear almost daily of reviews that result in the removal of funding without any clear reason as to why the person is no longer eligible.
So what should you do if your relative is due for an NHS Continuing Healthcare review?
- Make sure you get adequate notice of the review meeting so that you are able to attend. Often we hear of families receiving a fait accompli that a review has taken place and their relative now needs to go through the eligibility assessment process again. But such a vital meeting should never happen behind closed doors. Representatives should have every opportunity to attend.
- Re-familiarise yourself with the Decision Support Tool (DST) from the original application. The likelihood is you are all too familiar with the lengthy DST and the domains it covers. The National Framework makes clear that your relative’s most recent DST should be the main point of reference at the review. The CCG must use it to evidence any claim that needs have reduced. If you haven’t got a copy, ask for one before the meeting so you can go through it.
- Be aware of what the National Framework says about when reassessment for eligibility should happen. ie “Where there is clear evidence of a change in needs to such an extent that it may impact on the individual’s eligibility for NHS Continuing Healthcare”. If the CCG is pushing for reassessment, make sure they state clearly the evidence of a significant change in needs.
- Be clear on the distinction between underlying needs, and how well those needs are managed. We cannot overstate how crucial this is when it comes to reviews. For example, say your relative has dementia, which causes severe behaviour issues such as resisting care. Maybe the care setting can only manage this successfully through covert medication. Does this mean the underlying need has gone away? No. Without covert medication, the behavioural needs would be just as high. And covert medication is a last resort, with its own onerous requirements for safeguarding, monitoring and review. The National Framework is clear. Only where the successful management of a need has permanently reduced or removed that need should it be relevant to the question of eligibility.
- Know that even if the CCG believes your relative’s needs have changed, this is not sufficient grounds to remove a care package and/or full funding. The National Framework states that it must arrange to carry out a whole new DST with a full multidisciplinary team to establish this with a clear rationale. Even if there is a change in eligibility, existing funding must remain in place until alternative arrangements are put into effect.
Remember, help is only a phone call away
Hopefully, forewarned will be forearmed. But we know that sometimes when it comes to NHS Continuing Healthcare, that isn’t enough. Trying to assert your relative’s rights and get a rational answer can feel like you’re on the wrong end of the battering ram. So if you’re feeling dazed and confused, why not get in touch? The first thing we will do is listen to your story with compassion. The second will be to assure you that you are not going crazy – it really is this hard! And the third will be to give you a considered and honest evaluation of your case. We may be able to send you away with enough ammunition to carry on the fight yourself. Or you might need us to bring out the big guns. Whichever, it will be your call. So why not call or email us today?