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31 January 2019 | Comment | Article by Lisa Morgan

Change has come for NHS Continuing Healthcare guidance

NHS Continuing Healthcare guidance as well as the assessment documentation has recently been updated by the Department of Health. This new guidance now applies to people in England from 1 October 2018.

The National Framework, the Decision Support Tool (DST) and the checklist assessment have all been updated. If you are not familiar with these documents, they are as follows:

  • The National Framework is guidance that sets out the principles and procedures required for the Continuing Healthcare process. It was initially introduced in 2007 to provide uniformity for health authorities throughout England and has been updated on a number of occasions.
  • The Checklist is a pre-DST assessment. The threshold for the checklist is set low with the purpose of screening out anyone who would clearly not be eligible for NHS Continuing Healthcare.
  • The DST is a document that is used by a multidisciplinary team to assess a patient’s needs. This document is then used to determine whether someone is eligible for NHS Continuing Healthcare.

The changes

National Framework

There have been a number of changes to the National Framework in order to reflect legislative changes, such as the Care Act 2014. The new National Framework also aims to clarify a number of areas of confusion.

The main changes to the new framework can be summarised as follows:

  • Assessments should mainly take place outside acute hospital settings, which should reduce unnecessary stays in hospital. In addition, Continuing Healthcare assessments should not delay hospital discharge.
  • The updated framework provides guidance for assessors as to whether they should undertake a checklist assessment or proceed straight to a full assessment. The aim of this is to reduce the completion of unnecessary assessments.
  • The purpose of the three and twelve month reviews has changed. Previously the focus was on reassessing eligibility for Continuing Healthcare, they are now to review the appropriateness of the care package in place.
  • There is a bigger emphasis on resolving disputes regarding eligibility in a more timely manner.
  • Previously there had been a misconception that needs could not be ‘double-scored’ i.e. that if someone had needs from the same condition that fell into more than one domain, these could only be recorded in one domain. The new framework clearly states that needs associated with a single condition can be reflected in more than one domain.
  • When a recommendation has been made by a multidisciplinary team, the Clinical Commissioning Group (CCG) should now respond to that recommendation within 48 hours or two working days, whereas previously there was no set time frame for a response. The overall assessment process (for current assessments) should not exceed 28 days from the date that the CCG receives the positive checklist. An individual cannot complete the checklist themselves- it must be completed by a health or social practitioner that they are known to or by the CCG. If the patient is found eligible and there has been a delay of more than 28 days, the CCG should refund the care back to day 29.
  • In line with the Care Act 2014, the updated National Framework has provided further guidance relating to whether a patient’s need is a primary health need. Paragraph 55 of the National Framework states the following: An individual has a primary health need if, having taken account of all their needs (following completion of the Decision Support Tool), it can be said that the main aspects or majority part of the care they require is focused on addressing and/or preventing health needs. Having a primary health need is not about the reason why an individual requires care or support, nor is it based on their diagnosis; it is about the level and type of their overall actual day-to-day care needs taken in their totality. However it may be argued that this definition does not in fact provide a definitive explanation of what a primary health need is.

The updated framework can be found here.

Checklist Assessment

There have been a number of changes to the checklist, however these changes do not drastically alter the checklist criteria. The changes to the checklist can be summarised as follows:

  • The order of the care domains has been changed, although this has no impact on patients or the process.
  • The checklist guidance also provides information for assessors in relation to the cases when a checklist assessment is not necessary (as mirrored in the National Framework). The cases when a checklist assessment is not necessary include:

– When the patient has not reached their optimum potential (therefore it is likely that the assessment will be delayed until the patient’s health has improved),

– Where it has been agreed by professionals that the individual should proceed directly to full assessment,

– When the patient has a rapidly deteriorating condition – in this case, the Fast Track tool would be more suitable,

– When Section 117 services (Mental Health Act 2007) are already being received,

– There has been no change in the patient’s needs from a previous assessment or review,

– And where it is “clear to practitioners working in health and care system that there is no need for NHS Continuing Healthcare at this point in time”. Therefore, the patient would clearly not be eligible for Continuing Healthcare.

Decision Support Tool (DST)

As with the framework and the checklist assessment, there have been a number of changes to the DST. These changes do not have a substantial effect on the DST or the eligibility criteria for Continuing Healthcare. The main purpose of the changes is to make the document more user friendly as well as to provide further guidance for users.

The main changes to the DST are as follows:

  • The order of the care domains has been changed and mirror the new order in the checklist assessment.
  • There have been some small changes to a number of domain descriptors. These changes are not significant and therefore the levels of need for each domain have not been altered.
  • There is further emphasis within the DST guidance on the information contained within the framework i.e. timescales and double scoring


The changes that have been made to the National Framework, checklist assessment and the DST do clarify some of the long-standing issues that have surrounded Continuing Healthcare. These changes will hopefully make the Continuing Healthcare process clearer for patients and their representatives who are using it. There still continues to be some confusion regarding a number of CHC areas and processes, which we expect to be clarified in future framework updates.

If you would like more information regarding NHS Continuing Healthcare, please visit the Nursing Care section of our website here, or get in touch with our Nursing Care solicitors

Author bio

Lisa Morgan is a Partner and Head of the Nursing Care department. She is regarded as an experienced and specialist solicitor leading in the niche area of continuing healthcare.

She has been instrumental in developing a niche legal department in Hugh James, which comprises of 40 fee earners who solely act for the elderly and families in recovering wrongly paid nursing fees.

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