Review and Reassessment of those eligible for NHS Continuing Healthcare funding: Understanding the process

Posted on: May 7th, 2024 by Amy

Photo courtesy of Elliot Manches via the Centre for Ageing Better age-positive image library.

If you have been assessed as eligible for NHS Continuing Healthcare (CHC) funding either after undergoing a Full Assessment or via the Fast Track route, you should be reviewed within 3 months of the eligibility decision and at least every 12 months thereafter.

The main focus of the Review is to ascertain whether the care plan or arrangements remain appropriate to meet your needs.

However, where there is clear evidence of a change in needs to such an extent that it may impact on the individual’s eligibility for NHS Continuing Healthcare, a full Reassessment of eligibility for NHS Continuing Healthcare should be arranged.

Below we look in more detail at the definitions of Review and Assessment; the Review and Reassessment processes; and how to challenge poor practice if you come into contact with it.

Please see the National Framework for NHS Continuing Healthcare and NHS-Funded Nursing Care for further information.

Definitions

There is a distinct difference between a Review and an Assessment, however the terminology is often used incorrectly and interchangeably.

To clarify:

  • A CHC Review is usually carried out by one health or social care professional, often a ‘Nurse Assessor’ from the Integrated Care Board (ICB), to determine whether the package of care you are receiving remains appropriate to meet your  needs. At the Review it is expected that the most recently completed DST will be used as a point of reference to identify any change in needs. Eligibility cannot be determined at a Review.
  • A CHC Assessment is carried out by a Multidisciplinary team (MDT) made up of at least two professionals – either one from health and one from social care, or two health professionals from different disciplines. The Assessment looks at your needs and uses the Decision Support Tool (DST) to establish whether you have a Primary Health Need and are therefore eligible for NHS Continuing Healthcare.

Process

Everyone who is assessed as eligible for NHS Continuing Healthcare funding should be reviewed within 3 months of the eligibility decision, and at least every 12 months thereafter. Some individuals will require more frequent review in line with clinical judgement and changing needs. A guiding principle is that the frequency, format and attendance at reviews should be proportionate to the situation in question.

The main focus of the Review is to ascertain whether the care plan or arrangements remain appropriate to meet your needs.

Review of an individual’s needs who is eligible via the Full Assessment route:

For those who have been assessed as eligible for NHS Continuing Healthcare funding after undergoing a Full Assessment, the Review process should be carried out as follows:

  • The most recently completed Decision Support Tool (DST) should be available and should be used to identify any potential change in needs.
  • The National Framework does not go into great detail as to how a review should be carried out. However, as with all aspects of CHC, reviews should be person-centred and transparent to you and your representatives, and you should be given the opportunity to participate in the review.
  • Where there is clear evidence of a change in needs to such an extent that it may impact on your eligibility for NHS Continuing Healthcare, then a full Reassessment of eligibility for CHC should be arranged.
  • Where reassessment of eligibility for CHC is required, a new DST must be completed by a properly-constituted Multidisciplinary team (MDT) and comparison should be made with the information provided in the previous DST. Your needs should continue to be met during this reassessment of eligibility.
  • In many cases, Reassessment will not be necessary. Therefore if you are told that a Full Assessment is required, we recommend asking for clear rationale as to why and for a copy of the review document identifying clear evidence of the material change in needs. If the ICB cannot provide this clear evidence, the Reassessment of eligibility for CHC should not go ahead.
  • Where a Reassessment is not required the care plan and arrangements should be adjusted as required to continue meeting your assessed needs.

Please see paragraphs 201 – 205 of the National Framework for further information.

Review of an individual’s needs who is eligible via the Fast Track route:

Reviews of those who have been assessed as eligible for NHS Continuing Healthcare funding via the Fast Track route work slightly differently.

The main focus of a Fast Track review is to determine whether the care plan or arrangements remain appropriate to meet your needs. Reviews are to be expected at the same frequency as for those individuals who became eligible by the full assessment route. However, it is important to note that it is not appropriate to fully reassess the Fast-Tracked individual if:

  • You are expected to die in the very near future; or
  • It is apparent that you are rapidly deteriorating and may be entering a terminal phase, and the original eligibility decision was appropriate.

A guiding principle is that frequency, format and attendance at reviews should be proportionate to the situation in question.

If you are therefore told that a Reassessment is required, we would suggest asking for clear rationale as to why this is the case, and for a copy of the review document identifying the reason an Assessment is required. If the ICB cannot justify the appropriateness of an assessment in line with national policy, it should not go ahead.

Please see paragraphs 264 – 268 of the National Framework for further information.

Change in eligibility at Reassessment

If it has been determined that you are no longer eligible for CHC at your Reassessment, it is essential that alternative funding arrangements are agreed and put into effect before any withdrawal of existing funding in order to ensure continuity of care.

Any proposed change should be put in writing to the individual by the organisation that is proposing to make such a change.

Care must be taken during a Reassessment (and Review) not to misinterpret a situation where your care needs are being well-managed as being a reduction in their actual day-to-day care needs. This may be particularly relevant if you have a progressive illness or condition, although it is recognised that with some progressive conditions care needs can reduce over time. If you believe that well-managed care needs have been misinterpreted you have the right to challenge this.

Challenging an inappropriate Reassessment

If you believe a Reassessment has been arranged inappropriately, i.e. where there is no clear evidence of a change in need that may have a bearing on your eligibility for CHC, you have the right to challenge this.

The first step is to informally raise your concerns with the CHC team arranging the Reassessment and ask them to reconsider. If they are unable or unwilling to address your concerns, you can consider raising a formal complaint. Each ICB has a complaints webpage providing the complaints contact details and information about how to complain.

If the ICB insists on carrying out the reassessment in the interim, it is still important to engage fully to ensure that the views and input of you / your representative are taken into account.

Removal of funding without a Reassessment having taken place

Regardless of the route via which you were approved for CHC, funding can only be removed if:

  • A full Multidisciplinary Reassessment has been carried out using a Decision Support Tool; and
  • That Reassessment identified that you no longer have a primary health need.

If your funding has been removed without a full Reassessment, we would suggest raising a formal complaint, and consider requesting a review of the eligibility decision (appeal).

How we can help

Click here to download our Free Navigational Toolkit which includes expert guidance and advice on all aspects of CHC including referrals, assessments and reviews. If you are still feeling unsure, you can contact our Free Information & Advice Service for advice and to book a free consultation of up to 90 minutes with a specialist adviser.

If you find you need more help, our caseworkers can provide services to support you. To enquire please call us on 0345 548 0300 and select option 2, or email enquiries@beaconchc.co.uk.

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.

Sign up to our newsletter

Name
Trustpilot