The Continuing Care Assessment
If you think you may be eligible for free NHS care, preparing thoroughly for your Continuing Care Assessment is crucial.This article should be read in conjunction with the article entitled Who Pays For Care. In that I wrote about how care funding is structured and how to navigate the funding maze. For this follow up article I focus on the Continuing Care Assessment.
Preparing for your Continuing Care Assessment
For the purposes of illustration I spoke to Joan Melville, Continuing Care Manager at Plymouth PCT and she supplied me with information on their Health Needs Assessment. These assessment areas (outlined below) should be the same or similar to the ones used by your Local Authority.
1. Communication, including sensory deficit
2. Emotional well being & spirituality
3. Mental Health
4. Behavioural issues & risks
5. Expressing sexuality
6. Mobility, including a risk assessment score
7. Personal hygiene
8. Continence
9. Tissue Viability, including a pressure risk score
10. Nutrition, including a nutrition risk score
11. Breathing
12. Pain & or symptom control
13. Sleep pattern
14. Work and leisure
15. Other
For someone with a high level spinal cord injury, wishing to demonstrate that they have a primary health care need, the areas of focus are likely to be emotional well being, mobility, continence (bowel & bladder management), tissue viability, breathing (whether fully or partially ventilated), pain and/or symptom control and sleep pattern. In addition autonomic dysreflexia and spasms should be highlighted as significant issues and/or health related risks.
At the time of writing, there is still no sign of the final Department of Health National Eligibility Criteria (see DoH website for the latest information) and so the conclusions reached within each assessment area will often depend on the judgement of your assessor. However, once the national criteria are published there should be much greater transparency and this should in turn help with your preparation.
The Legal Position
In 1999 the Court of Appeal considered the case of Pamela Coughlan, who was bringing a case to prevent her local Health Authority from closing the NHS residential home where she lived. The Court decided that where the primary need is a health need this requires NHS funding for the entirety of the persons care. Ms Coughlan is tetraplegic. On the back of this decision it would appear that someone who is tetraplegic should be able to make a case for NHS funded care. But it is not as simple as that.
The Government, worried by the cost of having to fund a large number of expensive care packages, instructed PCTs to review their eligibility criteria. However in 2006 the case of Maureen Grogan came before the High Court, who decided that the eligibility criteria used by Bexley NHS Care Trust were unlawful.
As a result of that case there has been some further guidance from the Department of Health. In particular the emphasis is on an assessment of whether an individuals primary need is a health need and this is the overarching test, which should feature prominently in the eligibility criteria.
However it is not sufficient to simply show that if you have nursing needs then your primary need is for health care. In order to establish the right to fully funded NHS care you need to be able to show that you have complex and intense nursing needs that cannot be met by the Local Authority.
Definitive eligibility criteria are still awaited, and until they are available different PCTs will interpret this in different ways. There is no guarantee that someone who is tetraplegic will be able to establish a right to fully funded NHS care, but in order to maximize your chance you need to stress the health aspects of all your needs.
Joint Funding
In circumstances where your assessment does not result in full NHS funding but you have complex needs, it is entirely possible that joint funding between the NHS and Social Services may be agreed. Not ideal, but at least the NHS portion will not be means tested!