Recently the Welsh Government announced that any individuals that wished to request a review of eligibility for continuing healthcare from 31 October 2015 to 31 October 2016 needed to act by 31 October 2017.
As this date has now passed, we seek to explain the current position in Wales.
What period will eligibility for NHS continuing healthcare funding be considered?
NHS continuing healthcare is a package of care funded by the NHS for individuals with a primary health need, regardless of the individual’s ability to pay for their care.
With the responsibility for health being devolved to the Welsh Government, the continuing healthcare system in Wales is very different to the system across the border in England.
In England, a review of eligibility can be requested for a previously unassessed period of care, from 1 April 2012. If an individual is assessed for continuing healthcare, however, there is a six-month time limit to request a review of that assessment.
In Wales, the current position is that you can now request a review of eligibility for continuing health care. However, the NHS will consider a period of no longer than 12 months from the date of the application for a review.
For example, if an individual went into a nursing home on 1 January 2015 and on 1 January 2018 the NHS is asked to review that individual’s eligibility for continuing healthcare, they are only required to review the period from 1 January 2017 to 31 December 2017. The period 1 January 2015 to 31 December 2016 will not be considered. It is therefore extremely important for families to request a review of eligibility for continuing healthcare promptly if they feel an individual may qualify to prevent potential loss of claim.
What can you expect once an assessment has been requested?
The process for assessment is governed by the ‘Continuing NHS Healthcare – The National Framework for Implementation in Wales’ dated June 2014.
The responsibility for undertaking assessments in Wales falls to the local health board where the individual receiving care resides. Therefore the first step is to contact the local health board and request a continuing healthcare assessment. The guidance states that a review should be completed within a year of a claim being validated.
A claim is validated by completing a consent form and providing this, along with relevant legal authority and evidence of the care fees paid, to the local health board. This needs to be provided within five months of registering the claim.
The National Framework states that a screening tool can be used to determine whether an individual’s needs are of a sufficient level to warrant a full consideration of eligibility. This trigger tool should be the same tool as used in England and should be completed by at least two practitioners, including a local authority representative.
If the screening tool is met or it is decided there is no need for a screening tool a full consideration of eligibility is then made. The assessment tool used to assist in determining eligibility is called the Decision Support Tool. This is also used in England. This tool must only be used following a comprehensive assessment of an individual’s needs.
The assessment should be completed by a multidisciplinary team and should consider the overall needs and the interaction of those needs. Once the assessment has been undertaken the recommendation on eligibility must be undertaken in a formal multidisciplinary meeting, to which the individual or their representative should be invited. The decision on eligibility is then communicated to the individual, who also should be provided with a copy of the rationale for the decision.
If eligibility is agreed, a care package should be put into place within 8 weeks of the decision. If eligibility is not agreed the individual has the right to request a review of the decision.
The dispute should be attempted to be resolved locally by the health board. If it cannot be the case should be referred to an independent review panel who will consider the decision.
