Continuing Healthcare – Clinical Evidence

What length of Clinical Evidence Should a Multi-Disciplinary Team (MDT) Consider?

When a Multi-Disciplinary Team assessment is undertaken for NHS Continuing Healthcare Funding, the Integrated Care Board will look at the clinical records from the care provider.

There is a difference around the country as to the amount of clinical evidence Integrated Care Boards will consider when assessing for CHC Funding. Different ICBs have differing approaches to the time period they will review. There is no guidance in the National Framework to govern this. So, each Integrated Care Board can make its own policy.

The generally accepted rule of best practice is that reviewing three months’ clinical records is sufficient to give a good picture of an individual’s needs.

However, due to Covid restrictions and the pressure on the NHS to clear backlogs, some ICBs were only considering one month’s clinical records in an effort to get assessments processed more quickly. However, our concern is that when assessing eligibility for Continuing Healthcare Funding, some ICBs may not yet have reverted back to the customary three month period, and we worry how that might impact outcomes.

In our view, one month is just not enough to reliably capture an individual’s care needs.

Is it a problem if Multi-Disciplinary Teams use only one month’s clinical evidence in their assessments?

Care home records are often poorly written and lacking in detail. So, looking at a longer period can often really help to get a more accurate picture of the current care needs. Looking at only one month’s information is not helpful in identifying quality and quantity of the needs; for example, the frequency of challenging behaviours.

The Decision Support Tool, or DST, is a screening tool used by Multi-Disciplinary Team assessors to record healthcare needs across all 11 main Care Domains in one document (namely: Breathing, Nutrition, Continence, Skin, Mobility, Communication, Psychological/Emotional Needs, Cognition, Behaviour, Drugs/Medication and Altered States of Consciousness).

The Decision Support Tool ascribes different levels of need based on the frequency and severity of the care requirements in each Care Domain. Therefore, having such a short enquiry period of only one month can skew the level of need – usually in favour of the ICB – resulting in a negative outcome and a finding of ineligibility for CHC Funding.

These skewed results can often be seen in the Domains of Altered States of Consciousness and Skin. For example, if a pressure sore is not responding to treatment, this can rarely be properly measured in just one month, as more serious sores can take longer than this to heal; and then they can partially heal but break down again. Additionally, if a wound is long-standing, this would not necessarily be apparent from reviewing one month’s records. Similarly, a person suffering from unpredictable seizures may experience periods of relative inactivity, only for seizures to reoccur again in future. Looking at only one month’s records would not demonstrate this pattern and would distort the Multi-Disciplinary Team’s impression of the needs.

In addition, the assessment for Continuing Healthcare Funding is measured against four Key Characteristics: Nature, Intensity, Complexity and Unpredictability. An individual can qualify for CHC Funding under any one of the four Key Characteristics. To measure Unpredictability, we would normally expect the ICB to consider more than one month’s clinical records in order to build a picture of the ongoing care needs and assess how they are fluctuating.

Decision Support Tools completed using only one month’s clinical records could have great potential to disadvantage families and their relative’s application for CHC Funding. Sadly, the likely outcome is that many people who are entitled to CHC Funding could be turned down incorrectly and end up paying for their own care; perhaps by depleting their savings or even selling their home, quite unnecessarily.

What to do if you have had a DST completed using a one-month period of clinical information

Firstly, consider whether you think increasing the time-period beyond one month might give you a better outcome.

If so, write to the Integrated Care Board immediately and complain about the short period and ask them to reassess your relative’s healthcare needs using the usual three months’ evidence.

If the ICB refuses, then request an appeal of that decision. You must do this within 6 months of the decision being communicated to you.

As part of your appeal submission, you may want to consider obtaining the additional two months’ evidence yourself and submitting it to the Integrated Care Board’s appeal team, highlighting important information you believe has been overlooked.

The ICB will then conduct a Local Review, taking into consideration your concerns. However, it may be that the ICB reaffirms that one month is its policy, and that’s as far back as it’s prepared to go.

If the matter is not rectified at Local Review, you can always appeal to NHS England who will refer the matter to an Independent Review Panel. Whether the IRP accepts the Integrated Care Board’s decision to consider only one month’s evidence will depend on the region and the Panel Chair. In our experience, IRPs will increasingly refuse to consider any evidence not already reviewed by the ICB, even if this is patently insufficient to inform a robust decision.

We are extremely concerned by these developments and recommend you challenge an inadequate review period on every occasion it arises. However, without clear guidance from NHS England, Integrated Care Boards will continue to reduce the enquiry period for current assessments, to their own advantage and the patient’s detriment.

If the Independent Review Panel refuses to consider a longer enquiry period, and you feel this has led to a finding of ineligibility, you will need to complain to the Health Service Ombudsman.

It can be a long way round to achieve the result you desire, but at least it will mean that you are likely to get the additional two months’ clinical records looked at – and that could make the difference between being awarded Continuing Healthcare Funding or not. In financial terms, it could mean the difference between having all your relative’s care fees and their accommodation paid for in full by the Integrated Care Board, or having to self-fund.

If you do not submit the additional evidence you wish to be considered to the Integrated Care Board at Local Resolution stage, it is highly unlikely it will later be accepted by the Independent Review Panel. This is because the Panel can only consider the information available to the Integrated Care Board when making its decision. You cannot submit “new” evidence to the Panel, which is not already contained within the ICB’s casefile.

So remember…If you do not supply the ICB with the evidence you wish to be considered before requesting an Independent Review then, unfortunately, it may be too late.