The cost of care and accommodation should be paid in full by the NHS where an individual has what are called ‘continuing health care’ needs (CHC). But qualifying for CHC is unpredictable and extremely difficult. The test involves subjective judgements and is contentious, and the process of identifying eligibility is complex. The process of CHC assessment is laid down in the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care. The National Framework sets out a clear process that MUST be followed by all Clinical Commissioning Groups (formerly Health Trusts) and Local Authorities when considering eligibility for CHC. It states very clearly that all Health and Social Care staff MUST be familiar with the National Framework, legislation and relevant case law before they undertake an assessment of eligibility for CHC (see link 1 below).

Unfortunately, the latest set of statistics indicate that nationally the assessment and eligibility processes are not always being applied in a consistent, fair and equitable manner. They highlight the possibility that Health and Social Care staff are not as familiar with the assessment processes as they should be. As a consequence, decisions on eligibility can be open to challenge and appeal.

The latest set of data shows that the national average of people receiving CHC funding is 58.3 per 50,000 of the population in any Clinical Commissioning Group (CCG). However, there are 211 CCGs in total. The five highest scoring Groups fund between 104.9 and 144 people per 50,000, while the lowest scoring Groups fund 11.4 to 19.5 people. Only 36 of the 211 CCGs score more than 70, but 83 score below 50. Obtaining CHC in London and Thames Valley seems to be a particular problem (see link 2 below).

The variation across the country indicates there is a ‘postcode lottery’ when it comes to obtaining CHC. It also suggests that in some areas the training and knowledge of Health and Social Care staff maybe lacking (see link 3 below).

Assessing and qualifying for CHC has been a source of contentious debate for many years, and there are many critics of the way decisions are made (see links 4 and 5 below for two articles).

Have a read of the NHS advice on CHC. You will see from the article and the National Framework guidance (not an easy read) that trying to obtain CHC funding can be difficult and is complex (see link 6 below).

As can be seen from the National Framework and the BBC and Telegraph articles the crucial FIRST STEP in the CHC assessment process is to identify whether an individual’s care needs are ‘social care’. If their needs are identified as being more than social care, then they MUST be classified as health needs and are eligible for CHC. This is known as needs being ‘beyond LA limits’. This a key legal principle and it is a requirement in every CHC assessment. The law is very clear: IF NEEDS ARE ASSESSED AS BEING MORE THAN SOCIAL CARE NEEDS, THEY

ARE HEALTH NEEDS AND THE INDIVIDUAL SHOULD BE AWARDED CHC (see link 7 below, para 21, 7 (a) and (b)).

Unfortunately, the question whether a person’s needs are more than social care needs (and so beyond LA limits) is not always considered by Health and Social Care staff when they make decisions on CHC funding. At Care Review Services we run one day workshops that clarify the legal divide between a health and social care need (see link 8 below).

There is an ongoing campaign about malpractice in the assessment of CHC that you may wish to sign (see link 9 below).

There is also an excellent, award winning website which provides very good advice on CHC and has regular updates (see link 10 below).