Written by Tom Clements, Trainee Solicitor, Nursing Care team
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.
The first step to invoke the NHS Continuing Healthcare funding is a checklist.
What is a checklist?
A checklist is a screening tool used by the NHS to determine if an individual qualifies for a full assessment for NHS Continuing Healthcare.
The threshold to pass a checklist assessment is set intentionally low to ensure that all individuals that may qualify for NHS Continuing Healthcare are identified and assessed appropriately. If you pass the checklist, you will be eligible for a full assessment by way of a Decision Support Tool (DST). However, we often see the checklist criteria misapplied, resulting in individuals wrongly being denied full assessments for NHS Continuing Healthcare.
The primary purpose of the checklist is to identify individuals with care needs well outside of the eligibility criteria for NHS Continuing Healthcare and to ‘screen’ those individuals out of the process at an early stage. Conversely, the checklist is designed to identify those with more extensive health needs, thus progressing to a full assessment.
Successfully passing a checklist assessment does not mean that you are eligible for NHS Continuing Healthcare. It is simply the first stage in the assessment process. If you believe that you or a relative/friend may be eligible for a full assessment for NHS Continuing Healthcare, you should request the completion of a checklist assessment from your local Clinical Commissioning Group (CCG).
How does it work?
The individual’s needs are assessed in 11 different areas (care domains):
- psychological and emotional needs
- drug therapies and medication
- altered states of consciousness
Each care domain is given a score of either A, B or C, depending on the individual’s particular needs. The checklist assessment contains detailed criteria under each care domain, specifying what particular needs equate to either an A, B or C.
‘A’ is reserved for more significant needs, whereas ‘C’ is awarded where the individual has less significant needs in that particular care domain.
A full assessment for NHS Continuing Healthcare (by way of a DST) is required if the checklist identifies:
- two or more domains scoring A
- five or more domains scoring B, or one A and four B
- one A in any of the following care domains: breathing, behaviour, medication or altered states of consciousness
David can breathe normally, takes an adequate diet independently, is continent, able to communicate, does not experience any cognitive impairment, presents no challenging behaviour, and has not experienced any strokes or seizures. However, David is completely immobile and unable to cooperate with transfers, is at risk of skin breakdown necessitating regular re-positioning, suffers with depression that is increasingly impacting on his well-being, and requires the administration of medication by a trained professional due to the nature of the medication.
Having applied the checklist criteria, David would score:
- X7 C
- X3 B
- X1 A
David is therefore not eligible for a full assessment by way of a DST, as his needs are not sufficient to pass the checklist assessment.
Maria can breathe normally, has no skin issues, is independently mobile, has no psychological or emotional needs, no challenging behaviour, and has experienced no strokes or seizures. However, it takes care staff 40 minutes to feed Maria, she is doubly incontinent, completely unable to communicate, she suffers with severe dementia, and is non-compliant with taking medication.
Having applied the checklist criteria, Maria would score:
- X6 C
- X3 B
- X2 A
Therefore, Maria’s needs are sufficient to pass the checklist assessment. Maria is eligible for a full assessment by way of a DST.
How to challenge a checklist assessment
If you are unhappy with the outcome of a checklist assessment, you are able to request a reconsideration. Each NHS Clinical Commissioning Group has an individual procedure for challenging checklist assessments. Typically, however, this will involve:
- issuing a complaint to the CCG, detailing the grounds for disputing the checklist; and/or
- issuing a complaint to the Parliamentary and Health Service Ombudsman.
The Ombudsman will not consider a complaint until the CCG has provided a final response to any complaint made. However, the deadline to submit a complaint to the CCG and/or Ombudsman is one year from the date of completion of the checklist. However, the complaint(s) should be submitted as soon as possible.
You are unable to dispute the outcome of the checklist simply because you disagree with it. You must provide grounds for disputing the outcome.
Tips for challenging a checklist
- Rely on the evidence – If possible, request copies of the medical and care notes. Compare the notes to the content of the checklist. If any particular evidence is omitted or overlooked, detail this in the complaint. If required, attach copies of the relevant notes/records to the complaint to substantiate the points made. If you are unable to obtain or share copies of the care and medical notes, prepare a written summary of the individual’s needs from your first-hand perspective.
- Always check the scores – We often see individuals denied a full assessment despite the checklist scores meeting the relevant criteria. Often, a full assessment will be refused if the assessor concludes that it is highly unlikely that the eligibility criteria will be met if the case proceeds to a full review. If the scores within the checklist indicate the need for a full review (see above), remind the CCG that they are obliged to complete a DST, as stipulated within the National Framework for NHS Continuing Healthcare.
- Carefully review the scoring criteria – We often see the checklist criteria misapplied. For instance, in David’s case (refer to case study 1, as outlined above), had he scored an ‘A’ in the medication domain, he would have qualified for a full assessment. Thus, the misapplication of the checklist criteria in one single care domain can make all the difference. Often, negative checklist assessments can be overturned simply by disputing the score in one or two care domains. Always carefully read the criteria under each care domain. Pay careful attention to the distinction between the use of the words ‘and’ / ‘or’ within the checklist criteria, as you may not be required to meet every aspect of the descriptor to attain a higher level.
- Ensure that funding is awarded 28-days post checklist – If you successfully pass a checklist assessment, the NHS is required to complete a full DST assessment. If the outcome of the DST is positive, then you are eligible for NHS Continuing Healthcare. However, eligibility will often be awarded from the date of completion of the DST. The National Framework stipulates that if the DST is positive, eligibility should be backdated to 28-days after completion of the checklist (as this is the timeframe in which the DST should ordinarily be completed). For example, if you pass a checklist assessment on 1 January 2022 and found eligible via a subsequent DST completed on 1 March 2022, then eligibility should be backdated to 28 January 2022 (28-days post checklist). If the CCG does not apply this rule, refer them to the National Framework.
In theory, checklist assessments are a useful tool for determining which individuals should be subject to a full assessment for NHS Continuing Healthcare. Unfortunately, however, we often see the checklist criteria misapplied, resulting in individuals incorrectly being denied assessments for NHS Continuing Healthcare.