What is an NHS CHC assessment for a Previously Unassessed Period of Care (PUPoC)?

Posted on: December 12th, 2023 by Amy

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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 review of these ‘previously unassessed periods of care’ (PUPoC) 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 you can raise this with your local Integrated Care Board (ICB). Click here to find your local ICB.

An assessment for a Previously Unassessed Period of Care (PUPoC) may be undertaken for those currently paying for their care, or for individuals who have passed away, but it may only date back to care provided after 1 April 2012 (unless in ‘exceptional circumstances’). This is because in November 2007 the opportunity to request a review where the majority of care had taken place prior to 1 April 2004 was closed. A further ‘close down’ was announced on 15 March 2012, relating to requests between 1 April 2004 and 31 March 2012.

Many CHC firms will tell you to apply for a PUPoC assessment whatever the costs as you have a good chance of being successful. In our experience you should approach these assurances with caution as out of those who apply, only a very small percentage of individuals are successful in their application for PUPoC funding. No firm, regardless of credentials or experience, can guarantee a favourable outcome to an application.

Click here to read our article with tips and advice on applying for a PUPoC assessment.

Below we outline the procedure for requesting an NHS CHC assessment for a Previously Unassessed Period of Care (PUPoC).

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

 

The PUPoC assessment process

The below steps outline the process of the NHS CHC assessment for PUPoC.

It should be noted that if the individual lacks capacity to make the application for themselves, it may be made by a relative, friend or carer acting as a representative.

This representative should be:

  • A person holding Lasting or Enduring Power of Attorney
  • A deputy / receiver appointed by the Public Guardianship Office of the Court of Protection

Where the representative does not hold Power of Attorney and is not a court-appointed deputy, their application may still be accepted as part of a ‘best interests’ decision.

If the individual is deceased, sufficient proof must be demonstrated that the representative is an executor or administrator to the estate.

Sufficient proof may be deemed the provision of a copy of:

  • The deceased’s will
  • Grant of Probate
  • Letters of administration

 

The process:

  • A request for a PUPoC assessment should be made by the individual or their representative by contacting the local ICB, who then send an application form and consent form. These should be completed and returned to the ICB with any information / evidence the individual would like to submit, ideally within 28 days
  • The ICB will decide whether the request is appropriate (i.e. is it the correct ICB to deal with the request, has a previous NHS CHC assessment or PUPoC request been completed?). You will be informed in writing if the request is not found to be appropriate and reasons given for this. If it is not the correct commissioning body, it is the responsibility of the ICB to refer your request to the correct commissioning body
  • Once the ICB has confirmed that it is the responsible commissioner and that the PUPoC request is appropriate, the request will be acknowledged as soon as possible. This acknowledgement will take the form of a letter along with an application form with consent, which should be completed and returned to the ICB before the ICB determines if it is the responsible commissioner
  • An appropriately trained assessor will then compile a Needs Portrayal Document (NPD). This is a document which collates all the relevant information from the different sources of evidence to build up a comprehensive picture of the individual’s needs across the whole period under review. This evidence may include care home records relevant to the claim period, GP records, hospital records, social care assessments, notes from other NHS services such as Community Mental Health or Speech and Language Therapists, and documentation collated by the individual or representative. This evidence will be compiled in chronological order and broken down into the different care domains. If the assessment period is a long one, more than one NPD may be produced according to if there has been a significant change in needs, or according to calendar years
  • A first draft of the NPD will be shared with the individual or their representative. The applicant should respond along with any additional evidence within 28 days, where possible, in order to allow timely completion of assessment
  • The PUPoC request may then undergo screening using the NHS CHC Checklist. The Checklist is a screening tool which helps the ICB determine whether a full assessment of the past period of care is required. The threshold of the Checklist is set intentionally low to ensure that all those who may be eligible for NHS CHC are able to proceed to a full assessment. If the claim spans a number of years, the Checklist should be applied periodically where there is significant change in needs, or annually. This retrospective Checklist will indicate whether the request may proceed to the next stage. If the Checklist indicates that no full assessment is needed for the entire or part of the claim period, the applicant will be informed in writing and reasons given. If a full assessment of the entire claim or part of the claim period is required, the NHS CHC full assessment process will be undertaken. Please note that a retrospective Checklist does not have to be completed in every instance – it may be deemed that the application should proceed straight to the Decision Support Tool (DST) stage
  • Where it has been determined that the whole period or part of the period should be assessed for CHC the completed NPD will now be used to complete a full CHC assessment, including a Decision Support Tool (DST), to determine if the patient was eligible for CHC funding

  • A Multidisciplinary Team (MDT) of professionals will complete the DST and consider the case. In accordance with regulations the MDT will be a team consisting of at least:
    • two professionals who are from different healthcare professions, or

    • one professional who is from a healthcare profession and one person who is responsible for assessing persons who may have needs for care and support under part 1 of the Care Act 2014

  • It is very difficult to determine how long this assessment will take as it will depend on the availability of evidence, the length of the claim and the availability of the health and social care professionals
  • Once the MDT has made its recommendation and this has been verified by the ICB, the applicant will receive a written letter detailing the outcome of the PUPoC assessment. A copy of the NPD and the DST will be included with the decision letter
  • If the individual has been found eligible for all or part of the period under consideration, a restitution payment will be made. At this point the individual should provide evidence of any relevant payments, such as bank statements. ICBs should employ a transparent rationale and ensure they fully consider the individual circumstances of each case when calculating this payment
  • NHS Refreshed Redress Guidance maintains the principle that:

‘Where maladministration has resulted in financial injustice, the principle of redress should generally be to return individuals to the position they would have been in but for the maladministration which occurred.’

This means that successful applications should also receive interest redress, and the Guidance recommends that interest is generally now payable at RPI rates (with effect from 1 April 2015)

  • If the individual was found to be not eligible for NHS CHC funding for all or part of the period being considered, details of how to formally dispute the outcome of the CHC retrospective assessment will be provided

 

Timescales

ICBs each have their own individual timeframes for responding to PUPoC requests. These timeframes should be ‘reasonable and proportionate’ and take into account relevant factors, for example the length of the period of care, access to health and care records and local workforce arrangements. These timings should be clearly communicated, with regular and timely updates.

All cases covering an assessment period of less than 12 months should be completed within 6 months, and there is the full expectation that every request regardless of length will be completed within 12 months, except in exceptional circumstances.

 

Formally disputing the decision of an unsuccessful application – appeals and complaints

If you disagree with the outcome of a CHC PUPoC assessment application, you have a right to challenge it, and national guidance states you have six months from receipt of the decision letter within which to do so.

You also have the right to make a complaint if you received a CHC Checklist but were not told about it at the time, or if a previous consideration of CHC eligibility was not carried out in line with the National Framework and you were not given the opportunity to dispute the decision.

Similarly, if you feel that your PUPoC assessment is not being dealt with according to the specified timescales, and you have not received adequate communication to regularly inform you of the progress of your assessment, you have the right to make a complaint.

Click here to read our guidance on appealing a CHC decision.

 

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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