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3 December 2021 | Comment | Article by Lisa Morgan

NHS Continuing Healthcare Tips: Assessing eligibility

For anyone who is living with a long-term condition, which is progressive in nature, has the potential burden of escalating care costs, NHS Continuing Healthcare can be a lifeline. It is a package of care that is fully paid for by the NHS, for adults with long-term and complex health needs.

For over two decades, tens of thousands of people with a range of conditions, including dementia, stroke, Parkinson’s Disease, have had their applications rejected. From our fifteen years of experience, we know thousands of individuals and their families are missing out due flawed assessments and a lack of understanding. If they are aware of the process, families struggle to navigate the system and feel discouraged and daunted by a complex process.

This series is to raise awareness of the funding and assist families so they are empowered to make the right decisions for their relatives.

How is Continuing Healthcare assessed?

To determine whether an individual is eligible for a full continuing healthcare assessment, a health authority will usually complete a continuing healthcare checklist. The continuing healthcare checklist is a screening tool used to determine whether an individual’s continuing healthcare eligibility should be fully assessed.

If it is determined that an individual is entitled to a full continuing healthcare assessment following the completion of the checklist, the health authority should then go onto complete a Decision Support Tool (DST).

What is a DST?

The DST is a document that allows different sources of evidence to be brought together to enable a health authority to determine whether an individual has a primary health need. The DST is arranged into the following 12 care domains:

  • breathing
  • nutrition
  • continence
  • skin
  • mobility
  • communication
  • psychological and emotional needs
  • cognition
  • behaviour
  • drug therapies and medication
  • altered states of consciousness
  • other significant care needs

In completing the DST, the multidisciplinary team will award a level of need for each care domain ranging from no needs through to a priority level of need. It is important to note, however, that it is not possible for an individual to be awarded a priority or severe level of need in all care domains. It is only possible for a priority level of need to be awarded in the domains of breathing, behaviour, drug therapies and medication and altered states of consciousness and in the domains of communication, continence and psychological and emotional needs, the high level of need is the highest level of need that can be awarded.

How is the DST used to determine continuing healthcare eligibility?

If an individual is assessed as possessing one priority level of need or a total of two severe levels of need, a recommendation of eligibility for continuing healthcare would be expected.

However, if an individual is assessed as possessing one severe level of need combined with needs in a number of other domains or a number of needs with high and/or moderate levels of need then this may also indicate that they are eligible for continuing healthcare. Whether a recommendation of continuing healthcare is made in these circumstances will hinge upon the multidisciplinary team’s application of the 4 key characteristics; i.e. whether it is determined that the individual has needs of a nature, intensity, complexity or unpredictability demonstrative of a primary health need.

Who completes a DST?

The DST should be completed by a multidisciplinary team (MDT). An MDT is defined within the National Framework as a team consisting of at least two professionals from different healthcare professions or one professional from a healthcare professional and one person who is responsible for assessing persons who may have needs for care and support under part 1 of the Care Act 2014.

The National Framework stipulates that whilst an MDT can comprise two professionals from healthcare professions, the MDT should usually include both health and social care professionals, who are knowledgeable about the individual’s health and social care needs and who, where possible, have recently been involved in the assessment, treatment or care of the individual.

If a social care professional is not involved in the completion of a DST it is therefore worth querying with the health authority why this is the case and the attempts that have been made to obtain local authority input into the assessment process.

What evidence should be obtained in order to complete the DST?

The health authority should obtain all available and appropriate evidence to complete the DST, whether written or oral, from the GP, hospital, mental health professionals, the care home, etc. There should be an audit of attempts to gather any records said not to be available.

The individual’s/representative’s role in the completion of a DST

The individual or representative should be fully involved in the DST process and be given every opportunity to contribute to the MDT discussion. Where there is a dispute between the level of need suggested as appropriate in a care domain between the individual or representative and the MDT, it should be asked that this disagreement be recorded on the DST.

How to prepare for a DST meeting

Whether you are the individual to be assessed or their representative it is important that you familiarise yourself with the content of the DST. You should consider each of the domains and the descriptors for the levels of need in each of the domains. Have an indication as to the level of need you believe should be awarded to the individual within each of the domains and be prepared to explain to the MDT why you believe that level of need to be appropriate.

Our advice is to think about how the individual’s needs present on a bad day, as it’s important for assessors to know the full range of health needs and not just how they present on a good day.

It is important to play close attention to the level of need descriptors within each of the domains. It is will not be enough for you to submit at the DST meeting that individual should be awarded a high level of need in continence, for example, just because you think they had a lot of continence needs. Rather, you will need to evidence your submission for the high level of need in continence by evidencing that their continence care is problematic and needs timely and skilled intervention beyond routine care (for example frequent bladder wash-out/irrigation, frequent re-catheterisation, etc), in line with the high level of need descriptor within the domain of continence.

How Hugh James can assist at a DST meeting

Representatives from the Nursing Care Department at Hugh James do, and will, attend DST meetings to assist clients in contributing to the assessment process and completion of the DST. We are able to discuss the needs of the individual with you beforehand to suggest the levels of need that should be submitted as appropriate at the DST meeting and to subsequently attend the meeting virtually in order to submit those levels of need and arguments in respect of the 4 key characteristics and why the individual should be found eligible for continuing healthcare funding.

We know that families and friends of people who are going through the process are often doing so at an emotionally difficult time and the system itself can be onerous and emotionally difficult. Due to our experience and depth of knowledge, our clients inform us we remove this burden from you.

The decision following the completion of the DST

Once a DST has been completed, the MDT should include within the DST their recommendation on eligibility. This should then be forwarded onto the health authority for a final decision to be made. The health authority may ask an MDT to carry out further work on a DST if it is not completed fully or if there is a significant lack of consistency between the evidence recorded within the DST and the recommendation made.

However, the health authority should not refer a case back, or decide not to accept a recommendation, simply because the MDT has made a recommendation that differs from the one that those who are involved in the final decision would have made, based on the same evidence.

A copy of the completed DST should be forwarded to the individual or their representative, with the final decision made by the health authority along with the rationale for this. The decision should usually be made by the health authority within 28 calendar days.

If the decision on eligibility is negative, the individual or their representative should be informed of their right to appeal the decision and the timescales in which an appeal should be submitted. The time frame to appeal is usually 6 months and should be met or the individual will lose their chance to challenge a decision.

Get advice

If you would like advice in relation to any of the topics discussed in this blog, please get in touch with our Nursing Care Department.

Author bio

Lisa Morgan


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.

Disclaimer: The information on the Hugh James website is for general information only and reflects the position at the date of publication. It does not constitute legal advice and should not be treated as such. If you would like to ensure the commentary reflects current legislation, case law or best practice, please contact the blog author.


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