Continuing NHS Healthcare information booklet for individuals, families and carers - Eligibility

You are eligible for CHC if you are over aged 18 or over and are assessed as having a primary health need. Your eligibility for CHC is based only on what your overall day-to-day care needs are and not based on any particular diagnosis or condition.

To determine if your care needs are primarily health related, you will have an assessment. This will look at 4 things:

1. Nature

This is about what your needs are, what effect they have on you, and what care and support you need to manage them.

2. Intensity

This is about how many needs you have, and how frequently you need support as well as the level of support  and regularity of that support e.g. 2 carers may be needed.

3. Complexity

This is about all your needs, how they interact with each other and how difficult they are to support or manage. This is also about the training or skills needed by health and social care staff, carers, family members, etc. to be able to provide your care.  The issue here is what your total health and care needs are, and not on who might deliver your care needs.

4. Unpredictability

This is about how much your symptoms change and how difficult that makes them to manage. It is also about the risk this poses to your health if the right care isn’t given quickly enough.

Each of these characteristics may alone or in combination, demonstrate a primary health need.

You have the right to a thorough assessment of all your needs.  These assessments will help to identify if you have a primary health care need.

Local Authority (LA) Adult Social Services teams are responsible for assessing people’s need for social care services. Social Services must tell the LHB if they are assessing someone who has needs that may fall under the remit of the NHS, including people they think might need an assessment of eligibility for CHC.  

A CHC assessment of eligibility could be triggered because:

• you have recently been admitted to hospital and it is clear that you will have on-going care and support needs once you have been discharged
• your current care needs are being reviewed and your needs have changed
• your physical or mental health has got worse and the current care and support you receive, at home or in a care home, is no longer enough
• you are transitioning from Children’s services into Adult services
• you have a condition that is getting rapidly worse and your need for care and support is increasing for example because you may be approaching the end of your life or there may have been a catastrophic event

If CHC has not been discussed with you, but you think you might be eligible for it, you should talk to the hospital staff involved with your care, social services or your GP.  You could also request that a CHC checklist tool is completed.

To help health and social care staff identify if you should move on to having a full CHC assessment, they can use something called the Checklist Tool. They do not have to use this, but it is there to help them to make the right decisions and to help make sure everyone who needs a full CHC assessment has the opportunity to get one.

Health and social care staff must get your permission before they complete your CHC Decision Support Tool checklist.

If you are in a situation where the use of the Checklist Tool has not been thought necessary and it has been decided that you will not be referred for a full CHC assessment, you could ask the local health board to reconsider the decision. You could also make a complaint if you believe that your needs have not been fully considered.

You should be given reasonable notice of the intention to undertake your checklist and you should normally be given the opportunity to be present on its completion, together with any family/carer or advocate you may have.  The completion of the Checklist tool should be in the language or communication method of your choice.  

The Checklist is based on the same 12 ‘domains’ or ‘areas of need’ as the Decision Support Tool (DST). Read further information on how eligibility is assessed. 

The 12 domains are:

• Breathing
• Nutrition
• Continence
• Skin Integrity
• Mobility
• Communication
• Psychological & Emotional Needs
• Cognition
• Behaviour
• Drug Therapies and Medication
• Altered States of Consciousness
• Other Significant Care Needs

It is important to note that this initial checklist does not decide if you are eligible for CHC funding. It identifies whether you should progress to a full CHC assessment using the DST.

The outcomes of the checklist assessment would be one of the following:

• Yes - the level of your needs suggest you may be eligible for CHC. Therefore a full assessment should take place 
• No - your level of needs to have a full assessment for CHC are not met. Instead, a decision needs to be made on whether other LA or NHS services could meet your needs

The outcome of the Checklist tool should be explained clearly to you, your family, carer or advocate and also be given to you in writing as soon as possible following the checklist assessment. The correspondence sent to you should be in the language of your choice and should include the reasons why the Checklist outcome was reached and normally include a copy of your completed checklist for your information.

You should not be left without appropriate health and social care support while you wait for the outcome of your CHC assessment.

If the outcome of your Checklist means you will not progress to a full CHC assessment, you may ask the LHB to reconsider this outcome.  The LHB should consider your request, taking account of all the information available, and/or including additional information from you.

The LHB does not have to undertake a further Checklist. It should provide you with a written response which includes details of your rights under the NHS Complaints Procedure.  If you remain unhappy about this decision, contact NHS Wales complaints and concerns: Putting Things Right.