Answers on a postcard…
Anyone who is seeking information on continuing healthcare funding will have come across the term, “primary health need”. This is the basis upon which a decision on eligibility for continuing healthcare is made.
In order to claim that the NHS should be responsible for the payment of an individual’s care fees, it has to be established if their primary need is in relation to their health. This is the point when the balance tips from an individual primarily having social needs, a mixture of social and health needs, to the majority of their needs being health related.
“Social needs” is the term applied to needs which generally can be provided in the community by a local authority.
If found eligible for continuing healthcare funding, the NHS will cover the full cost of an individual's care fees, regardless of their financial situation. However, if a person is deemed to have social needs, care is provided by the local authority. In this scenario, the individual is “means tested” to establish if they are in a financial position to cover the full cost of their care or pay a contribution towards it.
But what exactly is the difference between a health and social need?
Many needs which are considered to be social in nature often appear to be linked to the health of an individual. It can be extremely frustrating for families to be told that their loved one does not have a primary health need when it is apparent they are no longer able to care for themselves, are unable to prepare their own meals and/or require assistance from carers throughout each day.
However, it is the amount and type of care that a person needs over a 24 hour basis which indicates if an individual’s needs are predominantly health or social in nature.
In essence, if an individual needs assistance with aspects of their daily living and require care within a safe and secure environment, these can be considered to be social needs. This could include help with washing and dressing, assistance at mealtimes, help with mobilising, etc.
While it may be the case that an individual is unable to remain in their own home due to the risk of injury or personal neglect, this would not necessarily indicate that they have a primary health need. If the care provided mirrors that which can be provided by the local authority, the needs would be deemed to be predominantly social in nature.
The reason why an individual enters a care setting in the first instance or the diagnosis of a medical condition will not have any bearing on a decision for eligibility for continuing healthcare. It is the needs which arise as a result of an individual’s circumstances which would be the deciding factor.
It may also be the case that an individual requires an element of nursing care. Often a person will have a combination of health and social needs. If more timely and skilled interventions are needed, in addition to access to a registered nurse over a hour 24 hour period, a person may need to be transferred to a nursing home. Should this be the case, funded nursing care will be awarded. This is a weekly contribution paid by the NHS to the care home and covers the portion of nursing care required. Again, while it may be necessary for an element of nursing care to be provided, the primary need remains social overall.
Until health care becomes the overwhelming need of an individual, they will fail to meet the criteria for continuing healthcare.
To determine if a person has a primary health need, the primary health needs test is applied. This involves considering four key characteristics. Only one of these characteristics needs to be met in order for eligibility to be found. The characteristics are nature, intensity, complexity and unpredictability.
A brief summary of these key characteristics being;
- Nature: Looks at the type of condition or treatment required and its quality and quantity.
- Intensity: Assesses whether or not there are one or more needs which are so severe that they require regular interventions.
- Complexity: Whilst the idea of a Town and Village Green may conjure up images of a church fete and a maypole, the reality is often very different. Assesses whether or not there are symptoms that interact, making them difficult to manage or control.
- Unpredictability: Looks at any unexpected changes in condition that are difficult to manage.
If it can be proven that the needs of an individual, meet any one of the descriptors against these key characteristics, it can be argued that their needs are over and above the care that can provided by a local authority. The quantity and quality of care needed indicating that a higher level of skilled intervention is necessary.
As a result, the responsibility of that person’s care fees becomes that of the NHS, meeting the eligibility for NHS funded continuing healthcare.
While most individuals have a combination of health and social needs, it is not until it is apparent that the needs are over and above what can be provided by the local authority that the individual no longer has the responsibility of funding the cost of their care.