In order for someone to be found eligible for NHS continuing healthcare funding it must be established that they have what is called a ‘primary health need’, which means that their primary need must be for healthcare, as opposed to social care. To determine if someone has a primary health need it must be demonstrated that an individual’s needs are at a nature, intensity, complexity or unpredictability. These are known as the four key indicators.
In combination, or alone, the four key indicators will demonstrate that someone has a primary health need, and thus may be eligible for NHS continuing healthcare funding.
Nature
The nature of someone’s needs describes the individual characteristics of that person’s needs, and the type of care which is required to meet those needs. This relates to the type of needs the individual has, and the type of care interventions required in order to manage them.
When determining whether the nature of someone’s needs indicate a primary health need, a health authority will consider a number of factors, such as:
what is the overall impact of the individual’s needs on their overall health and wellbeing;
what types of care interventions are required to meet their needs;
is there particular skill or knowledge which is required in order to address their needs;
is the patient’s condition deteriorating; and
what would happen if their needs were not met in a timely way.
The health authority will consider the resident’s needs as a whole. If the health authority considers an individual’s needs to be of a nature which a local authority are not under a duty to provide, then their needs are of a nature which would warrant eligibility for NHS continuing healthcare funding.
Intensity
The intensity of someone’s needs relates to the severity of an individual’s needs and whether they require an intense amount of care and support in order to meet those needs.
In determining whether there is a level of intensity to an individual’s needs which would indicate that they have a primary health need, the health authority will consider factors such as:
- how severe is the need or combination of needs;
- how often does the individual require care, and do they require care for prolonged periods of time;
- how many carers at the same time are required to meet their needs; and
- does the care relate to needs over several of their care domains.
If the health authority considers the intensity of an individual’s needs to be more than a local authority would be able to manage, or be under the duty to provide, then their needs will be considered to be intense.
Complexity
The complexity of an individual’s needs is determined by considering how complicated their needs are to manage, and whether these needs require an increased level of skill to monitor and treat. It relates broadly to the level of skill or knowledge which is required to address the need(s) of an individual.
In assessing the complexity of an individual’s needs, the health authority will consider a number of factors such as:
- how difficult is it to manage the individual’s needs;
- how much knowledge or special skill is required to manage the individual’s need or combination of needs; and
- do the needs of the individual interrelate across a number of their care domains, thus making them more complex to manage.
If the health authority considers an individual’s needs to require an increased amount of skill to manage, either due to the complexity of the needs or the interrelation between a number of their needs, then their needs will be considered above and beyond those which a local authority has the duty to provide for.
Unpredictability
The unpredictability of an individual’s needs relates specifically to the degree to which their needs fluctuate, therefore making them more unpredictable and difficult to manage.
When considering the unpredictability of an individual’s needs the health authority will consider a number of factors such as:
- is the individual or those who care for them able to predict their needs and how they may present;
- do their needs change often or at short notice requiring a prompt and skilled response;
- is their condition unstable, fluctuating or generally unpredictable;
- what would happen if their needs weren’t addressed as soon as they arose;
- how much monitoring or supervision do they require to manage their unpredictable needs; and
- do they require professional skill or knowledge at short notice to treat their needs.
An individual’s needs may be considered to be unpredictable if they present with a rapidly fluctuating or deteriorating condition which requires constant monitoring and timely intervention in order to manage.
Summary
The totality of an individual’s needs will be considered, and if an individual’s needs are considered to be of a nature, intensity, complexity or unpredictability, in combination or alone, which indicates that they have a primary health need (that is their needs are above and beyond that which a local authority has the duty to provide for), then that individual may be found eligible for NHS continuing healthcare funding.
How can we help?
Our in-depth knowledge of the NHS continuing healthcare process and the four key indicators of a primary health need can help you maximise the prospects of your relative being found eligible for full NHS continuing healthcare funding.
We are experts in analysing and criticising unfavourable decisions which are reached by health authorities. In many cases, a negative decision may be overturned through the correct application of the four key indicators.
If you choose to instruct Hugh James, you can rest assured that we will handle your claim professionally and skilfully to ensure fairest possible outcome.
