Applying for an NHS CHC assessment for a Previously Unassessed Period of Care (PUPoC) – tips and advice

Posted on: December 12th, 2023 by Amy

Image courtesy of In-Press Photography via the Centre for Ageing Better age-positive image library

If you think you should have been considered for NHS Continuing Healthcare (CHC) funding but were not, it may be possible to request a retrospective assessment of these ‘previously unassessed periods of care’ (PUPoCs) and receive a reimbursement of these costs. An assessment may be made for care that the individual has funded either in full or in part and may be undertaken for those currently paying for their care, or for individuals who have passed away. Click here to read our article explaining the definition and process of a PUPoC assessment.

Many legal firms will tell you ‘Don’t take ‘no’ for an answer – if you believe you are right, fight on!’.

However in reality, the last time this exercise was undertaken, Integrated Care Boards (ICBs, then CCGs) received over 60,000 applications for CHC retrospective assessments. Of these applications 85% were deemed ineligible, and less than 10% were approved as fully eligible for NHS Continuing Healthcare funding.

Applying for NHS Continuing Healthcare funding can be a long and arduous process, at what is often already a difficult and painful time. Therefore please read through the below information carefully before you decide whether to make an application.

[You can scroll down to ‘How we can help’ to find out how we can support you with your PUPoC application]

 

Tips and advice

–  Just because a person self-funded their care home or home care package, this does not mean that they can automatically claim back care fees, or that they are automatically eligible. To qualify for NHS CHC, an individual must have a ‘primary health need’, which is assessed using the National Framework for NHS Continuing Healthcare. Before embarking on a PUPoC application, it is important to have a good understanding of what a ‘primary health need’ is, otherwise months or even years could be spent pursuing an application that has no likely chance of success.

–  The language of NHS Continuing Healthcare is complex and confusing. Become familiar with the Decision Support Tool (DST) document and the domains and definitions so that you can describe the relevant healthcare needs in appropriate language. Make sure that you read the NHS CHC National Framework Guidance which explains the definitions of nature, intensity, complexity and unpredictability. Click here to read our article breaking down and explaining common CHC language and acronyms.

–  PUPoC applications rely heavily on the quality of the care records and written evidence about care needs. In cases where the individual has passed away, these records may have been written by health and social care professionals who no longer work in this field, and indeed the care provider may no longer exist – care homes shut down, GP surgeries move or merge, and care and health records go missing. Unfortunately many PUPoC cases that could have had a reasonable prospect of success are found ineligible through lack of evidence. If you have records from your relative’s care home or hospital stay, keep them safe. If you are not in possession of records of this nature, be sure to request them as soon as possible.

–  NHS funding for PUPoC will not be awarded for someone who had only social care needs, no matter how long they needed care for, and no matter how much they spent on their care.

–  After an application has been received it may not be possible for the ICB to go ahead with the PUPoC review. This could be the case if the period of care has been previously assessed and found ineligible for funding, or if the ICB cannot access sufficient patient records to assess your needs (for one of the reasons mentioned above). Your ICB should always explain to you the reason for not going ahead with a PUPoC assessment.

–  During a PUPoC assessment, as with a standard NHS CHC application, the individual / representative should be asked for their input. This may take the form of a Family Statement of Needs – a written account about the individual’s care needs and why the family believes they should have been receiving NHS Continuing Healthcare funding. It is vital to make this as detailed and comprehensive as possible. It may be useful to go through each care domain (Behaviour, Cognition, etc.) and build a case for the score you believe your relative should have been given, highlighting every aspect of intensity, complexity and unpredictability in their care needs.

–  When you receive the Needs Portrayal Document from the reviewer, go through it meticulously. Challenge anything that is incorrect, misleading (including the language used) or missing.

– Ensure to check that all the evidence / records you are aware of relating to the period in question have been included in the NPD and if not, submit that evidence with your comments on the NPD. Remember that you can’t request evidence be removed if it legitimately relates to the period in question, but you can provide your reasons for disputing evidence you disagree with.

–  If you ask a consultant, doctor, therapist or other healthcare professional to write something in support of your case, make sure they understand exactly what this will be used for – you need something that highlights the individual’s specific care needs during the period in question.

 

How we can help

We are currently refining our paid services in light of this new guidance. If you require support in the form of advocacy or to understand if you have a PUPoC case, you can submit a contact form online, ensuring to choose ‘PUPoC assistance’ as the reason for your request. Please try to contact us as far as possible in advance of any important dates and let us know if there are any significant dates we should be aware of. We will get back to your request for assistance as soon as possible.

If you are in need of free support and guidance regarding PUPoC you can click here to access our repository of free online resources for PUPoC, and click here to download our Free Navigational Toolkit which includes expert guidance and advice on all aspects of CHC, including definitions, processes and timescales. Details of how to contact our Free Information & Advice service can be found here.

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