CQC We and I Statements
Theme 3 – How the local authority ensures safety in the system: Safe systems, pathways and transitions
We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between services.
When I move between services, settings or areas, there is a plan for what happens next and who will do what, and all the practical arrangements are in place.
I feel safe and supported to understand and manage any risks.
- NHS Continuing Healthcare (CHC) is arranged and funded by the NHS and provided to adults who have been assessed as having a ‘primary health need’.
- Deciding whether an adult has a primary health need and is eligible for NHS CHC involves a multidisciplinary team (MDT) assessing all the adult’s relevant needs using the Decision Support Tool (DST). A checklist tool is also available, and this can be used initially to identify adults who may need a full assessment of eligibility for NHS CHC.
- Local Integrated Care Boards (ICBs) will review the assessment of eligibility completed by the MDT. Only in exceptional circumstances, and for clearly stated reasons, can the MDT’s recommendation not be followed.
- Where an adult receives NHS CHC, a review should be undertaken within three months of the decision being made by the ICB. After this, further reviews should be undertaken on at least an annual basis by the ICB.
Department of Health and Social Care documents:
- 1. Introduction
- 2. Key Concepts in NHS Continuing Healthcare
- 3. Information for Adult Social Care Staff
- 4. Consent
- 5. Mental Capacity
- 6. Checklist Tool
- 7. Decision Support Tool
- 8. Multidisciplinary working
- 9. Decision-Making by the ICB
- 10. Care Planning and Delivery
- 11. NHS CHC three and 12 month reviews
- 12. Equipment
- 13. Disputes
- 14. Further Reading
- Appendix 1: Flow Diagram which sets out the process for NHS Continuing Healthcare
NHS Continuing Healthcare (CHC) means a package of ongoing care that is arranged and funded solely by the National Health Service (NHS) where the individual has been assessed and found to have a ‘primary health need’ as set out in the National Framework. Such care is provided to an individual aged 18 or over, to meet health and associated social care needs that have arisen as a result of disability, accident or illness. The actual services provided as part of the package should be seen in the wider context of best practice and service development for each client group.
Eligibility for NHS Continuing Healthcare is not determined by the setting in which the package of support can be offered or by the type of service delivery.
For adults living at home, it will cover their personal care and healthcare costs.
Support for carers may also be available – see NHS Continuing Care: Information for Adults and Carers.
There is a difference between NHS CHC and NHS-funded Nursing Care; NHS-funded Nursing Care is the funding provided by the NHS to those who are eligible and living in care homes with nursing, to support the provision of nursing care by a registered nurse.
The National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care was revised in July 2022. It includes Practice Guidance to support staff delivering NHS CHC.
This chapter is a summary of key information in the Framework.
2. Key Concepts in NHS Continuing Healthcare
2.1 Primary health need
Primary health need is a concept developed by the Secretary of State for Health to assist in deciding when an individual’s primary need is for healthcare (which it is appropriate for the NHS to provide under the 2006 Act) rather than social care (which the local authority may provide under the Care Act 2014).
To assist in deciding which – if any – health services it is appropriate for the NHS to provide to someone, the term ‘primary health need’ is used. Where an adult has been assessed to have a primary health need, they are eligible for NHS CHC and the NHS will be responsible for providing for all of their assessed health and associated social care needs, including accommodation – if that is part of their overall need.
Deciding whether an adult has a primary health need involves an assessment by a multidisciplinary team (MDT) which looks at all of their relevant needs using the Decision Support Tool (DST), see Section 3.6 Decision Support Tool.
An adult is said to have a primary health need if, having completed the DST, it can be said that most of the care they require is focused on addressing and / or preventing health needs. Having a primary health need is not about why someone needs care or support, nor is it based on their diagnosis; it is about the level and type of their overall actual day-to-day care needs taken as a whole.
Whilst there is not a legal definition of a health need (in the context of NHS Continuing Healthcare), in general terms it can be said that such a need is related to the treatment, control, management or prevention of a disease, illness, injury or disability, and the care or aftercare of a person with these needs (whether or not the tasks involved have to be carried out by a health professional).
Similarly, there is not a legal definition of the term ‘social care need’ in the context of NHS Continuing Healthcare. However, the Care Act 2014 introduced National Eligibility Criteria for care and support to determine when an individual or their carer has eligible needs which the local authority must address, subject to means testing where appropriate. These criteria set out that an individual has eligible needs under the Care Act 2014 where these needs arise from (or relate to) a physical or mental impairment or illness which results in them being unable to achieve two or more of the following outcomes which is, or is likely to have, a significant impact on their wellbeing:
- managing and maintaining nutrition;
- maintaining personal hygiene;
- managing toilet needs;
- being appropriately clothed;
- being able to make use of the home safely;
- maintaining a habitable home environment;
- developing and maintaining family or other personal relationships;
- accessing and engaging in work, training, education or volunteering
- making use of necessary facilities or services in the local community, including public transport and recreational facilities or services; and
- carrying out any caring responsibilities the adult has for a child.
In the context of NHS Continuing Healthcare, therefore, a ‘social care need’ can be taken to relate to the Care Act 2014 eligibility criteria outlined above.
Each adult’s case has to be considered on its own facts, in line with the principles outlined in the National Framework (see Core Values and Principles, National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care).
There should be no gap in the provision of care. People should not find themselves in a situation where neither the NHS nor the relevant local authority will fund care, either separately or together.
The requirement for a primary health need means that ineligibility for NHS CHC is only possible where, taken as a whole, the nursing or other health services the person requires:
- are no more than incidental or ancillary to the provision of accommodation which local authority social services are under a duty to provide (depending on the adult’s circumstances); and
- are not of a type beyond which a local authority could be expected to provide.
In applying the primary health need test, Integrated Care Boards (ICBs) should take into account that section 22 of the Care Act 2014, applies the ‘incidental and ancillary’ test in all situations, including where care is being provided in the adult’s own home. As there should be no gap in the provision of care, ICBs should consider this test when determining eligibility. Eligibility is the same for all individuals, whether their needs are being met in their own home or in care home accommodation.
Please note: ICBs replaced Clinical Commissioning Groups on 1 July 2022.
2.2 Characteristics of need
Certain characteristics of need – and their impact on the care required to manage them – may help determine whether the ‘quality’ or ‘quantity’ of care required is more than the limits of a local authority’s responsibilities, as set out in the Care Act 2014:
- nature: this describes the particular characteristics of an adult’s needs (which can include physical, mental health or psychological needs) and the type of those needs. This also describes the overall effect of those needs on the adult, including the type (‘quality’) of interventions required to manage them;
- intensity: this relates both to the extent (‘quantity’) and severity (‘degree’) of the needs and to the support required to meet them, including the need for sustained / ongoing care (‘continuity’);
- complexity: this is concerned with how the adult’s needs present and interact to increase the skill required to monitor the symptoms, treat the condition/s) and / or manage their care. This may arise with a single condition, or multiple conditions or the interaction between two or more conditions. It may also include situations where an adult’s response to their own condition has an impact on their overall needs, for example where a physical health need results in the adult developing a mental health need.
- unpredictability: this describes the degree to which an adult’s needs fluctuate, which can create challenges in managing them. It also relates to the level of risk to the adult’s health if adequate and timely care is not provided. An adult with an unpredictable healthcare need is likely to have either a fluctuating, unstable or rapidly deteriorating condition.
Each of these characteristics may, alone or together, show the adult has a primary health need, because of the quality and / or quantity of care that is required to meet their needs. All of their overall needs and the effects of the interaction of their needs should be carefully considered when completing the DST.
Practice Guidance note 3 in the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care contains examples of questions which the multidisciplinary team can use to develop an understanding of how each characteristic relates to the needs of the adult being assessed.
Eligibility for NHS CHC is a decision taken by the local ICB, based on an assessment of the adult’s needs, which is undertake by the MDT using the Decision Support Tool. The diagnosis of a particular disease or condition is not in itself a deciding factor of eligibility for NHS CHC. As noted above, NHS CHC may be provided in any setting (including for example a care home, hospice or the adult’s own home). Eligibility is, therefore, not decided or influenced either by the setting where the care is provided or by the characteristics of the adult who delivers the care.
When deciding whether someone is eligible for CHC, a need should not be dismissed just because it is successfully managed: well-managed needs are still needs. Only where the successful management of a healthcare need has permanently reduced or removed an ongoing need will this have an impact on the adult’s eligibility for NHS CHC.
Financial issues should not be considered as part of the decision on an adult’s eligibility for NHS CHC.
In summary, the reasons given for a decision on an adult’s eligibility should not be based on the:
- adult’s diagnosis;
- setting of care;
- ability of the care provider to manage care;
- whether or not NHS-employed staff provide care;
- need for ‘specialist staff ’ in care delivery;
- the fact that a need is well-managed;
- the existence of other NHS-funded care; or
- any other input-related (rather than needs-related) rationale.
Eligibility for NHS CHC is not indefinite, as needs could change. This should be made clear to the individual and / or their representatives.
Not all those with a disability or long term health condition will be eligible.
A decision about whether an adult is eligible should usually be made within 28 days of completion of the assessment.
2.4 Options for people who are not eligible
If the adult is not eligible for NHS CHC funding, the local authority maybe responsible for assessing their care and support needs and providing services if they are eligible.
If the adult is not eligible for NHS CHC but is assessed as having healthcare or nursing needs, they may still receive some care from the NHS. For an adult who lives in their own home, this may be provided as part of a joint package of care and support, where some services come from the NHS and some from adult social care services (see the chapters on Integration, Cooperation and Partnerships, Eligibility and Charging and Financial Assessment).
If the adult moves into a nursing home, the NHS may contribute towards their nursing care costs.
Once eligible for NHS CHC, care will be funded by the NHS, but this is subject to review; should care needs change, the funding arrangements may also change.
3. Information for Adult Social Care Staff
The National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care sets out the principles and processes which should be applied in order to assess an adult’s eligibility for NHS continuing healthcare and NHS funded nursing care.
Some individuals’ nursing or healthcare needs are such that the local authority is not permitted to meet their ongoing care and support needs, and instead they become fully the responsibility of the NHS. These are individuals who have been assessed as having a ‘primary health need’ through the processes set out in this National Framework and who are eligible for NHS Continuing Healthcare.
The limits of local authority provision and the concept of ‘primary health need’ arise from the interaction between duties and limitations placed on local authorities under the Care Act 2014 and the duties placed on ICBs and NHS England under the NHS Act.
A local authority must, when requested to do so by the Integrated Care Boards (ICB), co-operate with the ICB in arranging for a person or persons to participate in a multidisciplinary team. Local authorities should:
- respond within a reasonable timeframe when consulted by an ICB prior to an eligibility decision being made (refer to paragraph 22);
- respond within a reasonable timeframe to requests for information when the ICB has received a referral for NHS Continuing Healthcare.
Section 22 of the Care Act 2014 places a limit on the care and support that can lawfully be provided to individuals by local authorities. That limit is set out in section 22(1) and is as follows:
‘A local authority may not meet needs under sections 18 to 20 by providing or arranging for the provision of a service or facility that is required to be provided under the National Health Service Act 2006 unless –
(a) doing so would be merely incidental or ancillary to doing something else to meet needs under those sections, and
(b) the service or facility in question would be of a nature that the local authority could be expected to provide’.
The limit on social care pre-existed the Care Act 2014 and was considered and clarified in 1999 by the Court of Appeal in the Coughlan judgment (refer to Annex B). This judgment considered the responsibilities of health authorities and local authorities for social service provision, in particular the limits on the provision of nursing care (in a broad sense, i.e. not just registered nursing care) by local authorities. The principles from this judgment therefore inform section 22 of the Care Act 2014.
Section 22(3) of the Care Act 2014 provides a further limit of the care and support that can be provided by a local authority. This section prohibits local authorities from providing, or arranging for the provision of, nursing care by a registered nurse
Joint working between NHS and adult social care, and any other partner organisation/s who are involved, is essential to ensure the adult’s needs are met in the right way and that their care is effectively coordinated. The National Framework sets out the local authority responsibilities in relation to NHS continuing healthcare.
In order to understand and be able to implement CHC procedures, staff should:
- familiarise themselves with the National Framework for NHS Continuing Healthcare documentation;
- understand the definition of ‘primary health need’;
- be familiar with the Decision Support Tool;
- be able to apply the four key characteristics of need (see Section 2.2, Characteristics of need);
as well as the primary health need test to the adult’s assessed needs (see National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care p.60).
If adult social care staff consider that an adult may be eligible for NHS CHC, they must follow their local processes in order to refer the adult to the ICB.
Where at all possible, the same staff member should be involved with the adult and their carers throughout the continuing healthcare assessment process.
See also: Full Consent Form for Participating in the NHS Continuing Healthcare Process and for Information Sharing with Family / Friends / Advocates and Data Protection: Legislation and Guidance chapter.
There are a number of principles which underpin this process. Most importantly is that assessments and reviews should always focus on the adult’s individual needs and follow a person-centred approach. The adult should be fully informed and empowered to participate actively in the assessment process and any subsequent reviews, and their views should always be considered. There are also a number of legal requirements when it comes to obtaining an adult’s consent for parts of the NHS CHC process.
Before completing the Checklist and the Decision Support Tool (DST) (see below), consent must be obtained and recorded. Consent is sought for:
- completion of the DST;
- sharing of the adult’s personal information between different organisations involved in their care, and the continuing healthcare assessment and decision making process.
5. Mental Capacity
If there is a concern that the adult may not have mental capacity to give consent to taking part in the continuing healthcare process, this should be decided in line with the Mental Capacity Act 2005 (MCA) and Code of Practice (see Mental Capacity chapter). A third party can give consent for an assessment of eligibility for NHS CHC on behalf of an adult who lacks capacity, if they can demonstrate they have a valid Lasting Power of Attorney for Welfare or that they have been appointed a Welfare Deputy by the Court of Protection.
If the adult lacks the relevant capacity to either give or refuse consent to a physical intervention / examination, care and treatment as part of continuing healthcare, a ‘best interests’ decision should first be made and recorded (see Best Interests chapter).
ICBs and local authorities should ensure that all staff involved in NHS CHC assessments are appropriately trained in MCA principles and responsibilities.
6. Checklist Tool
The Checklist is the NHS CHC screening tool which can be used in a variety of settings to help practitioners identify individuals who may need a full assessment of eligibility for NHS CHC.
The regulations state that if an initial screening process is used to identify where someone may have a need for CHC, the Checklist is the only screening tool that can be used for this purpose. The purpose of the Checklist is to encourage proportionate assessments of eligibility so that resources are directed towards those people who are most likely to be eligible for NHS CHC, and to ensure that a rationale is provided for all decisions regarding eligibility.
The Checklist can be completed by a variety of health and social care practitioners, who have been trained to use it. This could include local authority staff such as social workers, care managers or social care assistants.
Completion of the Checklist should be quite quick and straightforward. It is not necessary to provide detailed evidence along with the completed Checklist.
There are two potential outcomes following completion of the Checklist:
- a negative Checklist, meaning the adult does not require a full assessment of eligibility, and they are not eligible for NHS CHC; or
- a positive Checklist meaning an adult now requires a full assessment of eligibility for NHS CHC. However, that does not necessarily mean they will be eligible for NHS CHC.
7. Decision Support Tool
Once an adult has been referred for a full assessment of eligibility for NHS CHC – after the Checklist has been completed or if it was not used in an individual case –a multidisciplinary team (MDT) must assess whether the adult has a primary health need using the Decision Support Tool (DST).
The DST is used to inform the decision as to whether an adult is eligible for NHS CHC. It is not an assessment in itself; the information gathered will need to be supplemented with professional analysis and conclusion. It is designed to assist data collection, analysis and presentation of information of the adult’s healthcare needs, including evidence from assessments and reports completed by other members of the MDT.
8. Multidisciplinary working
The core purpose of the MDT is to make a recommendation on eligibility for NHS CHC drawing on the multidisciplinary assessment of needs and following the processes set out in the National Framework.
An MDT in this context means 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 adult who is responsible for assessing people who may have needs for care and support under the Care Act 2014.
The MDT should usually include both health and social care professionals, who are knowledgeable about the adult’s health and social care needs and, where possible, have recently been involved in their assessment, treatment or care.
As far as is reasonably practicable, the ICB must consult with the local authority before making any decision about the adult’s eligibility for NHS CHC. Different approaches can be used (for example face-to-face, video / tele conferencing) for arranging an MDT assessment, to ensure active participation of all MDT members, the adult and their representative, and any others with knowledge about the person’s health and social care needs as far as is possible.
It is best practice for assessors to meet with the person being assessed, ideally before the MDT meeting. All arrangements should take a person-centred approach.
If an adult with mental capacity refuses to participate in the assessment process, the MDT may consider relevant health and care records or existing assessments to decide the best way to meet their needs and whether they are eligible for NHS CHC. The consequences of undertaking the NHS Continuing Healthcare assessment or review as a paper-based exercise should be carefully explained to the adult, including that this may affect the quality of the assessment, if information is not up to date for example.
Both the MDT recommendation and the decision should be recorded in the adult’s case records. The NHS CHC process should usually be completed within 28 calendar days. This timescale is measured from the date the ICB receives the completed Checklist, indicating the need for full consideration of eligibility (or receives a referral for full consideration in some other acceptable format), to the date that the eligibility decision is made. However, wherever practicable, the process should be completed in a shorter time than this.
9. Decision-Making by the ICB
See Decision-making on eligibility for NHS Continuing Healthcare by the ICB, National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care
ICBs are responsible for eligibility decision making, based on the recommendation made by the MDT. Only in exceptional circumstances, and for clearly stated reasons, should the MDT’s recommendation not be followed.
ICBs should ensure consistency and quality of decision making.
The ICB may ask an MDT to carry out further work on a DST if it is not completed fully or if there is a significant lack of consistency between the evidence recorded in the DST and the recommendation made.
10. Care Planning and Delivery
See Care planning and delivery, National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care
Where an adult is eligible for NHS Continuing Healthcare, the ICB is responsible for care planning, commissioning services, and for case management. It is also responsible for their case management, including monitoring the care they receive and arranging regular reviews.
The adult should be encouraged to have an active role in their care, be provided with information or signposting to enable informed choices and supported to make their own decisions.
ICBs may wish to commission NHS-funded care from a wide range of providers, in order to secure high-quality services that meet the adult’s assessed needs and offer value for money.
11. NHS CHC three and 12 month reviews
See NHS Continuing Healthcare Reviews (at three and 12 months), National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care
Where an adult has started receiving NHS CHC, a review should be undertaken within three months of the decision being made. After this, further reviews should be undertaken on at least an annual basis, although some adults will require more frequent reviews in line with clinical judgement and changing needs.
These reviews should mostly focus on whether the care plan or arrangements remain appropriate to meet the adult’s needs. It is expected that in most cases there will be no need to reassess for eligibility.
Where an adult is eligible for NHS CHC and chooses to live in their own home, the ICB is financially responsible for meeting all their assessed health and associated social care needs. This could include:
- equipment provision;
- routine and incontinence laundry;
- daily domestic tasks such as food preparation, shopping, washing up, bed-making; and
- support to access community facilities (including additional support needs for the adult while their carer has a break (see Carers Breaks chapter).
However, the NHS is not responsible for paying for rent, food and normal utility bills such as gas, electricity and water.
There are two types of disputes that may arise in relation to NHS CHC:
- challenges by the adult or their carer / advocate, including requests for reviews (also known as appeals). Staff may be involved in the appeal process, including undertaking an assessment / review of the adult’s needs and attending MDT / DST meetings;
- disputes between NHS and local authorities. In such cases staff should provide a clear rationale for disputing the outcome.
See Individual Requests for a Review of an Eligibility Decision and Inter-agency disputes, National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care) for information about processes for resolving these situations including ordinary residence issues (see Ordinary Residence chapter).