Having a Diagnosis of Dementia Does Not Guarantee You Will be Eligible

Eligibility for continuing healthcare is not dependent upon a diagnosis, and so a person who has been diagnosed with Alzheimer’s disease, Parkinson’s disease or another degenerative condition will not necessarily be assessed as having a primary health need. Eligibility is determined by assessing your day-to-day care needs and how those needs should be met.

Depending on the progression of the illness a person with dementia or any other disability or illness will present with a number of health and social care needs, some of which may well be intense, complex and/or unpredictable. If any one particular health need or a combination of those needs are assessed as being of an intensity, complexity or level of unpredictability that means their primary need is for health, then they will be eligible for continuing healthcare.

Nobody Can be Certain That You Will be Eligible Before an Assessment has Taken Place

We frequently hear of false promises being made to people about their chances of eligibility or otherwise by health and social care professionals such as GPs and consultants who do not properly understand the continuing healthcare criteria. Attitudes toward continuing healthcare in the medical community vary greatly – many see it as an unnecessary administrative burden and some GPs simply refuse to take part in it at all.

Unless the professional has spent time working within the dedicated field of NHS continuing healthcare it is unlikely they will fully understand it. Eligibility is based upon the presence of a primary health need which is established through an in-depth assessment process during which a multidisciplinary team assesses the totality of your needs. Until this process has taken place nobody can unilaterally decide that an individual will or will not be eligible, even your GP.

Decisions Must Never be Influenced by Budgets

According to the 1946 NHS Act, nursing care in England must be provided free at the point of delivery. This means that if your needs have been assessed as primarily health needs by law, then the NHS must pay the full cost of your health and social care and accommodation.

NHS continuing healthcare is not means tested and financial considerations must not be taken into account. Coordinating assessors should not ask you questions about your financial situation and if they do, you do not have to answer them because they do not need that information in order to assess your needs. Likewise a person’s continuing healthcare status should be established before means tested social care is considered.

The National Framework is absolutely clear about this issue and makes provisions to ensure that decisions regarding eligibility are free from budgetary and commissioner influences. Beacon’s caseworkers have dealt with cases in the past where commissioner influence on decision-making panels had clearly occurred. In each case our challenge to this procedural failure was upheld and the assessment process started again.

Since the implementation of the National Framework in 2007 we have tracked changes in the way in which the eligibility criteria have been interpreted. It is common for Clinical Commissioning Groups (previously PCTs) to review the way in which their assessment teams are interpreting and applying the criteria from time to time and to make changes in an effort to bring decisions in line with what they feel to be a more accurate interpretation of the guidance. However, one of the problems with the National Framework – like the 28 sets of criteria before it – is that the lack of clear definition of a primary health need, coupled with the multidisciplinary approach, leaves wide room for differing interpretations of the criteria.

This leaves the NHS open to accusations that whilst the criteria itself has not changed, the way in which it is applied has changed significantly in conjunction with the economic climate. Whilst we would not say that the economic climate impacts directly upon eligibility decisions, we certainly have plenty of evidence that points to significant differences in the way the criteria have been applied over a period of time within the same NHS trusts.

Your Continuing Healthcare Assessment: Things to Bear in Mind Part 2 soon to follow…