Continuing Health Care - Preparing to fight PCT's decision

Les_Booth

Many thanks for the prompt and lengthy replies - a lot to digest so will get back to you.
fwiw - the guy who did the screening said he wouldn't be recommending an assessment - admittedly prior to seeing B.I.L. - but did say he didn't think this view would change.

Interesting point about the October date referred to above - he actually got on to a social worker's list early September - but the SS assessment was not done until the 6th October - which date would be relevant ?

monkeyspanner

The revised National framework issue July 2009 seems to have tightened up the wording of the relevant clause if the initial checklist does not indicate the need for a full assessment.

Revised National framework

66. Whatever the outcome of the Checklist – whether or not a referral for a full assessment for NHS continuing healthcare eligibility is considered necessary – the decision (including the reasons why the decision was reached) should be communicated clearly and in writing to the individual and (where appropriate) their representative, as soon as is reasonably practicable. Where the outcome is not to proceed to full assessment of eligibility, the written decision should also contain details of the individual’s right to ask the PCT to reconsider the decision. The PCT should give such requests due consideration, taking account of all the information available, including additional information from the individual or carer. A clear and written response should be given to the individual and (where appropriate) their representative, as soon as is reasonably practicable. The response should also give details of the individual’s rights under the NHS complaints procedure.

Oct 2007 National framework

51. In many cases, whether in a hospital or community setting, a full consideration of NHS
Continuing Healthcare will be inappropriate. If the outcome of the screening assessment
is that a referral for a full consideration for NHS Continuing Healthcare is unnecessary,
this decision, together with the reasons for it, should be communicated clearly to the
individual, and their carers or representatives where appropriate. They may still request
a full assessment from the PCT, and the PCT should give this request due
consideration, taking into account all the information available including additional
information from the individual or carer. Care planning for those individuals with ongoing
needs, including the consideration of need for registered nursing care, will still be
necessary (see the section on care planning, below).

CHCscandal

It is abundantly clear that here and now, nearing the end of the first decade of the 21st century, 60 years after
the NHS and welfare state was created, , that the emphasis is on denial of the statutory basic duty of care responsibilities
to people who 'appear to have means' in order to possibly deny them the statutory obligations that they are entitled to within
the current legislation, statute and directions.

Since 1948 to now, good working people paying taxes not only to help the poor, disabled and the unfortunate, which was the basic
ethos of the welfare system, but also in preparation to reap the benefits of the 'system' when and if the need arose.

The defining factor/common denominator of the current denial to Fully funded continuing Health Care is simply one test 'means'.

Monkeyspanners link to the actual 2009 directions & RESPONSIBILITIES, slightly updated form the 2007 version,
which is a derivative of the 2004 directions along with the delayed discharges directions of 2004, clearly outline the legality
in statute of the responsibilities of the NHS and LA/SS.

This current document clearly states that any process started prior to 1/10/09 is subject to the previous system in place.

Les Booth, In my opinion, your process started prior to 1/10/09, therefore the system in place then is the guidance to be used.
BUT, we have been informed by our SHA that the DST is an information gathering tool/needs analysis and can be used
for ANY period in time even prior to 2007, as the appropriate 'tool' to gather in the information to show the totality
of the needs.

ONLY the operation of the revised 'framework' guidance is subject to the timeframes when the doc was issued, not the DST.

It is clearly stated that only 'newly identified' cases after 1/10/09 are subject to the 'revised' guidance, including REVIEW.

This is the new area where perverse incentives are in operation, many PCT's are applying the 1/10/09 guidance to reviews
of people either on CHC or in the 'system', why would they want to do this! because there is a crucial change in this guidance where
they can successfully deny CHC until all of the appeal system is completed, whereas previously any challenge to ineligibility
was on 'hold' until the appeals process was completed in full.

From 1/10/09, if ineligibility is the outcome, the guidance now advises that the decision remains until proved otherwise through the appeals procedure.
BUT, they were only implementing that after further instructions/information was given, this hasn't happened yet, it is not applicable yet, it is only applicable to
absolute new cases, not anyone in the system prior, but the PCT's are using this now, if they can get away with it.


Your case is the typical example of the outrageous denial system in place, perverse incentive is the best description,
that the new CHC ( funded NHS ) framework has produced following on from other perverse incentives from previous criteria in place via directions/statutes.
currently the checklist being the 'tool' that enables perverse incentives, previously the culprit from 2001, the perverse incentive for denial was the RNCC,
as outlined in many parliamentary debates and questions many many times.

The Checklist, as advised, is deliberately (supposedly) set low to 'capture' as many as possible to put forward for full assessment,
the process is still subject to the strict multi disciplinary assessment/team criteria involving the service user/patient and family in the
'person centred planning' process, in fact the purpose of this fact finding process is to facilitate the care plan eventually,
resulting from a full, concise & in-depth needs analysis.

As with the DST domain information gathering 'tool' the outcome becomes the care plan, where future 'inputs' / 'care' will be/should be delivered to the person on a continuously assessed process, to meet their every identified need, if that does not happen comprehensively then the person will have unmet needs.

Unmet needs is a form of neglect and maladministration by the authorities, NHS primarily but equally the LA/SS especially if they assess first using SAP or FAC and do not involve the correct health need assessments.

Both authorities are bound by 'duty of care' directions and guidelines, which are a statutory requirement designated to them by the secretary of state,
as outlined in the directions and responsibilities, these are key area's of process, procedure & protocol, especially since 2006.

Anyone telling you prior to an assessment that you are unlikely to succeed at checklist or CHC full assessment, has acted irresponsibly
and should be reprimanded, this must be reported to the authorities, the DoH, the Ombudsman, in fact, currently the Ombudsman is
investigating a significant number of complaints in this 'new' area of discretionary / interpretation of denial.

This type of comment, makes a mockery of the supposed safety system in place to protect vulnerable people.

The people the 'directions/assessments' are aimed at are merely 'having their care 'transferred' to others' either in a care home or home care,
otherwise a plain and simple discharge plan to home for district nurse input if necessary/ community nurse team input if necessary would immediately be arranged.

If you haven't already, it is necessary to point out to the person (s) currently leading the process, that you know the procedure they must follow,
that you must be involved, that all professional input must be involved as the statutory directions in place.
The outcome of any decision made, if the process has not been followed. is not not valid, the process will have to be addressed again.

It is crucial that anyone in the 'assessment arena' 'gets it right first time' at the MDA/MDT meeting re the CHC assessment,
as this is the ONLY opportunity that you have to influence the final decision.

At the end of an MDA/MDT meeting, if comprehensive covering all aspects in full and in depth, the result should be plainly obvious to all and recorded.
All the assessment domains are subject to INTERPRETATION, this is admitted in the revised framework, that is why they have expanded on some descriptors
and included now ASC as a * domain in the checklist, this domain is critical if anyone has dementia/Alzheimer's/epilepsy/fits etc as risk is the main factor.

At the end of any assessment MDA/MDT if you do not agree with the nurse assessors domain markings say so, do not agree to sign the final document.

Complex and Intense refers to the overall totality of the needs, not each individual need, people are forgetting , as the 'new system' roles on, that only ONE
element needs to be present to be eligible for 'FULL NHS CONTINUING HEALTH CARE' not all, the elements are:-

Complex OR
Intense OR
Unpredictable OR

Unstable, (which they have tried to drop but it is still applicable in the actual responsibilities)

OR

Coupled with the social services lawful limits which are classified by the phrases
Quality / Quantity and 'of a nature' defined in the 'Coughlan' Case 1999, all covered in the framework documentation as their legal obligation.

The overall 'rationale' comment at the end of the assessment MDA/MDT if carried out correctly and interpreted correctly, will clearly show, complex
and/or Intense and/or unpredictable and/or unstable.
Often the assessors will attempt to downgrade the domain due to the NEED being MANAGED successfully, this must be challenged strongly, it is not permitted
to downgrade a successfully managed need, they have to assess that need as if it were not being managed, because the need would still be there if not managed, or
if the management ceased, there fore this is the unstable/unpredictable element immediately.

Example, if epilepsy/fits/tia's/asthma/copd for instance is the 'condition' the health need is to 'control/manage/contain' the 'need/risk' is always there,
it has not been cured, eliminated, merely controlled successfully one day at a time, a risk/recovery plan MUST be in place, even if the 'condition' is
apparently temporarily 'stabilised' through drug regime for instance, the 'health need'
still exists, the ASC domain now has a clear definition extract from the revised domain 11. ASC:-

11. Altered States of Consciousness (ASC): [FONT=AGaramond,AGaramond][FONT=AGaramond,AGaramond]ASCs can include a range of conditions that affect consciousness including[/FONT][/FONT]
[FONT=AGaramond,AGaramond][FONT=AGaramond,AGaramond]Transient Ischemic Attacks (TIAs), Epilepsy and Vasovagal Syncope [/FONT]
[/FONT][FONT=AGaramond Bold,AGaramond Bold][FONT=AGaramond Bold,AGaramond Bold]1.Describe below the actual needs of the individual providing the evidence that informs the decision overleaf [/FONT]
[FONT=AGaramond Bold,AGaramond Bold]on which level is appropriate (referring to appropriate risk assessments), [/FONT]
[FONT=AGaramond Bold,AGaramond Bold]including the frequency and intensity of need, unpredictability, deterioration and any instability.[/FONT][/FONT]

Les_Booth

Sorry – I know that this will be a bit of a ramble but to give some background:
Pat – my B.I.L. 80 years of age, married to my sister Enid 81 years of age for 43 years. In his day – a real gentleman with never a rude word to say to anyone.
Enid – 30+ years in Psychiatric nursing including a number of years as a sister on a ward
Pat was suffering from rheumatoid arthritis in both wrists and also needed operations to replace both elbows. Unfortunately within a few years one of the elbows needed to be re-done. When he came out of this operation he was hallucinating and that was the start of his memory problems. As his condition worsened, Enid elected to look after him at home even when the incontinence set in “If I’ve done it all my working life I’m sure I can do it for Pat !”
Sadly with the worsening of his dementia he did resort to violence on one or two occasions – it was after one such episode when another sister called in to help and seeing that Enid had received a blow to the face – insisted on him being put in a home to give her some respite – she had been existing on 3-4 hours sleep for some time.
This respite was initially to be only for a week or two – but as time progressed Enid realised that he was far more settled in the home and reconciled herself to the fact that this would be a permanent arrangement.
Throughout this time we wrongly assumed Social Services were involved. Enid had tried to get hold of the duty worker on call when he was admitted but she was on holiday. Eventually I telephoned the duty worker who the informed me that we should have contacted Social Services to get the assessment done – and gave me their telephone number. I made this call on the 4th September and that is the date that Social Services are using.
Throughout his time in the home, Pat’s funding has been done by Enid (£675 per week less the RNCC element)
Pat’s problems:-
Vascular dementia – unable to hold a conversation – recognises Enid but not relatives
Rheumatoid arthritis in both wrists – unable to feed himself
Doubly incontinent.
Immobile – needs two assistant to get him into a wheelchair.
I am desperately trying to understand all of your posts and the info’ provided on the links – but am struggling. I am extremely grateful for your time and advice – no doubt I will be back J

CHCscandal

Les_Booth wrote: »

Sorry – I know that this will be a bit of a ramble but to give some background:
Pat – my B.I.L. 80 years of age, married to my sister Enid 81 years of age for 43 years. In his day – a real gentleman with never a rude word to say to anyone.
Enid – 30+ years in Psychiatric nursing including a number of years as a sister on a ward
Pat was suffering from rheumatoid arthritis in both wrists and also needed operations to replace both elbows. Unfortunately within a few years one of the elbows needed to be re-done. When he came out of this operation he was hallucinating and that was the start of his memory problems. As his condition worsened, Enid elected to look after him at home even when the incontinence set in “If I’ve done it all my working life I’m sure I can do it for Pat !”
Sadly with the worsening of his dementia he did resort to violence on one or two occasions – it was after one such episode when another sister called in to help and seeing that Enid had received a blow to the face – insisted on him being put in a home to give her some respite – she had been existing on 3-4 hours sleep for some time.
This respite was initially to be only for a week or two – but as time progressed Enid realised that he was far more settled in the home and reconciled herself to the fact that this would be a permanent arrangement.
Throughout this time we wrongly assumed Social Services were involved. Enid had tried to get hold of the duty worker on call when he was admitted but she was on holiday. Eventually I telephoned the duty worker who the informed me that we should have contacted Social Services to get the assessment done – and gave me their telephone number. I made this call on the 4th September and that is the date that Social Services are using.

Throughout his time in the home, Pat’s funding has been done by Enid (£675 per week less the RNCC element)

Pat’s problems:-
Vascular dementia – unable to hold a conversation – recognises Enid but not relatives
Rheumatoid arthritis in both wrists – unable to feed himself
Doubly incontinent.
Immobile – needs two assistant to get him into a wheelchair.
I am desperately trying to understand all of your posts and the info’ provided on the links – but am struggling. I am extremely grateful for your time and advice – no doubt I will be back J

Les, there seems to be some confusion here, if BiL was receiving RNCC then an assessment must have been carried out.
The RNCC element will not be paid unless assessed.

A FULLY FUNDED CONTINUING HEALTHCARE ASSESSMENT MUST BE CARRIED OUT AND ELIGIBILITY ELIMINATED BEFORE RNCC IS ASSESSED AND DECIDED

http://news.bbc.co.uk/1/hi/business/8270740.stm

If your sister has not been involved with any assessment, then the process has not been followed.

The SS, cannot assess for a health need, they are not qualified to do this, and have a legal limit as to what they can place, provide and charge for in the 1946 Nat Assistance Act, & confirmed in 'coughlan'.

Can you ascertain from the sister if an assessment has taken place with her involved and please contact the PCT to request a Full CHC assessment.

If BiL has been in hospital at all, this should have been carried out discharge.

Les_Booth

Perhaps my terminlogy is wrong - the invoice from the N.H. states Fees at £675 p.w. "Less funded nursing care at £106.30 p.w."
Does this clarify things ?

monkeyspanner

I think the point CHCScandal is making is that the nursing care element is a fall-back position if it is considered that continuing healthcare funding cannot be awarded. Thus by implication an assessment should have been performed at some time. It is possible that no-one was informed of this assessment or the decision, in which case proceedure has not been followed.

Les_Booth

Just had a phone call from the Social Services worker who is coming to do the financial assessment. I asked her if an assessment would have been done prior to this being paid - she said "No, this is automatically paid for anyone in a nursing home" !

CHCscandal

Les_Booth wrote: »

Just had a phone call from the Social Services worker who is coming to do the financial assessment. I asked her if an assessment would have been done prior to this being paid - she said "No, this is automatically paid for anyone in a nursing home" !

Les

Quite simply, the SW is totally and utterly wrong.

Also the SW should not be assessing anything re health Les, what is the Sw coming to 'ASSESS'?


The nursing contribution CANNOT be awarded without an assessment, and cannot be awarded without firstly having an assessment, or consideration (checklist) for fully funded continuing healthcare.

This can only be carried out by the NHS, the SW cannot assess for a health need, let alone primary health need, they are not qualified, by law they cannot place, provide and charge for nursing services
where the need for health is the reason for the care home placement not social care.

Healthcare is slowly being redefined as Social Care, in order to charge via a means test, but for now, the nursing contribution can only be awarded only after an assessment of need, which then becomes the care plan,
if this has not been carried out, then your BiL is likely to have unmet needs maybe in an inappropriate placement.

Link to 2009 directions and responsibilities:-

[URL="mhtml:{648DC2E2-4F05-4994-9C5D-0F22C5857FA6}mid://00004098/!x-usc:http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_106175.pdf"]http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_106175.pdf[/URL]

Continuing care assessments and hospital discharge:-

[URL="mhtml:{648DC2E2-4F05-4994-9C5D-0F22C5857FA6}mid://00004098/!x-usc:http://www.dh.gov.uk/en/SocialCare/Deliveringadultsocialcare/Continuingcare/DH_4074689"]http://www.dh.gov.uk/en/SocialCare/Deliveringadultsocialcare/Continuingcare/DH_4074689[/URL]

Link to page on DoH website where all history and info can be researched:-

[URL="mhtml:{648DC2E2-4F05-4994-9C5D-0F22C5857FA6}mid://00004098/!x-usc:http://www.dh.gov.uk/en/AdvanceSearchResult/index.htm?searchTerms=nhs+continuing+care+directions+and++responsibilities+2006"]http://www.dh.gov.uk/en/AdvanceSearchResult/index.htm?searchTerms=nhs+continuing+care+directions+and++responsibilities+2006[/URL]


Note on the descriptions on the DoH page ecnlosed below all CHC and Funded nursing care, both have to be assessed, no exceptions.


[URL="mhtml:{648DC2E2-4F05-4994-9C5D-0F22C5857FA6}mid://00004098/!x-usc:http://www.dh.gov.uk/en/SocialCare/Deliveringadultsocialcare/Continuingcare/DH_079288"]Continuing care Directions[/URL] Directions related to NHS continuing health care and NHS-funded nursing care.
30 September 2009
Continuing care section
3. [URL="mhtml:{648DC2E2-4F05-4994-9C5D-0F22C5857FA6}mid://00004098/!x-usc:http://www.dh.gov.uk/en/Publicationsandstatistics/Legislation/DH_078059"]The NHS Continuing Healthcare (Responsibilities) Directions 2007[/URL]

The National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care was issued as best practice guidance in June 2007.


These directions make compliance with that guidance mandatory, with effect from 1 October 2007.

Les_Booth

When I originally saw the social worker who did the social services assessment - she told me that she would be recommending a CHC screening for B.I.L. and that she would also arrange for a financial adviser to see me to assess B.I.L. assets in case CHC funding is not available. I was led to believe that this can go ahead even though we will be appealing the refusal to grant CHC funding. Basically, they're saying we need to put a peg in the ground should SS have to pick up the tab at a later date.