We have looked at what is classed as a primary health need during the continuing healthcare funding process.
The term ‘primary health care need’ is not defined in law and does not appear, nor is outlined, in legislation. The National Framework does however clarify that someone should be considered to have a primary health care need when the nursing or health treatment and services they require are:
- more than incidental or ancillary to the provision of accommodation which Social Services would be required to meet if the individual were under the means testing threshold or;
- ‘of a nature beyond which Social Services could be expected to provide’.[1]
The National Framework for continuing healthcare funding confirms that ‘where an individual has a primary health need and is therefore eligible for NHS continuing healthcare, the NHS is responsible for providing all of that individual’s assessed needs – including accommodation if that is part of the overall need’. One individual’s interpretation of a primary health care need may differ to another. At Compass CHC, we therefore seek to shed some light on what a primary health care need is.
Perhaps unhelpfully, the definition of a primary care need is open to subjective interpretation. The law seeks to further clarify this point by stating that the local authority can only meet nursing and healthcare needs when the requirements are below this level. When the individual nursing and healthcare needs are beyond the lawful power of the local authority, the patient has what is classed as a primary health need.
This point goes a long way to establish why it is crucial that Social Services are represented in the multidisciplinary team meeting for the individual’s Decision Support Tool assessment. Clearly if a Social Worker or representative for the local authority is not present how can it be stated or considered that a patient’s needs are within the lawful power of the local authority to meet if no one from the local authority is able to give their opinion that this is the case?
The determination, therefore, that an individual has a primary health need is paramount to securing continuing healthcare funding to meet the costs of care for an individual in full. Continuing healthcare funding is not in any way, shape or form means tested and as confirmed by the National Framework, meets the cost of care in full, including accommodation and associated costs.
It is important to remember that a primary health need is not diagnosis led. For example, having a particular condition does not automatically entitle an individual to be considered to have primary health care needs; rather it is about what the individual’s overall day-to-day care needs are when considered as a whole.
Therefore, it can be the case that somebody without any formal diagnosis of a particular condition is considered to have the required complex, intense or unpredictable nature of needs that would constitute primary health care needs and an entitlement to the funding, whereas somebody with a diagnosed condition such as Alzheimer’s disease or dementia does not meet the criteria.
The Four Characteristics Tested to Establish a Primary Healthcare Need
The key test, therefore, is the four characteristics of need; namely nature, intensity, complexity and unpredictability. Any one or a combination of these characteristics being present will determine whether an individual has a primary health care need or not.
1. Nature
This characteristic looks at the individual’s needs, and the care interventions required to meet those needs. The National Framework for continuing healthcare funding provides a number of questions that can be useful in determining whether an individual’s needs constitute the required nature characteristic to be considered primary health needs. Examples include;
- What is the impact of the need on overall health and wellbeing?
- What are the types of interventions that are required to meet the need?
- Is the individual’s condition deteriorating or improving?
- What would happen if those needs were not met in a timely way?
2. Intensity
The characteristic of intensity looks at the quantity, severity and continuity of needs. The areas for consideration in this domain include;
- How severe is this need?
- How often is each intervention required?
- How long is each intervention required?
- How many carers are required at any one time to meet the needs?
Therefore, there is an argument that there is an intensity of need where there are numerous interventions required over and above what might ordinarily be expected and where these care interventions are requiring the involvement of a greater level of staff and for a longer period than, again, might ordinarily be considered to be the norm.
3. Complexity
This characteristic looks at the level of skill and knowledge required to meet the individual’s needs as well as the interaction between two or more domains.
Points to consider include, as highlighted by the National Framework;
- How difficult is it to manage the needs?
- Are the needs interrelated?
- How much skill is required to address the needs?
- How problematic is it to alleviate the needs and symptoms?
Points to consider, therefore, by way of a working example, would be is there an interaction between a number of domains? Somebody who has marked cognitive impairment will therefore not be able to assess even basic risks.
Where they are at risk of aspiration due to dysphagia, there is an argument for an increased risk in this area and increased complexity of the management of their nutritional needs if they are unable to follow instructions and assess the risks of not following instructions that could lead to them choking. Equally, somebody who is unable to assess risk and who presents with extreme, challenging, aggressive behaviour is not aware of the consequences of their actions and the risks that they pose to themselves and others.
4. Unpredictability
This characteristic considers the degree at which needs fluctuate and create challenges in managing the needs.
Points to consider as highlighted by the National Framework include;
- Does the level of need often change?
- Is the condition unstable?
- What happens if the need isn’t addressed when it arises?
- What level of monitoring or review is required?
A domain in which unpredictability often arises can relate to behaviour. Somebody who presents with unpredictable behaviour can be more difficult to manage if and where there are no triggers to their behaviour occurring. They can require a far greater degree of supervision and interaction from staff if they pose a risk to themselves or others without warning.
In summary, the concept of a primary health need is crucial to the determination as to whether somebody has an entitlement to continuing healthcare funding. This article has sought to draw reference to the National Framework for continuing healthcare funding and highlight and explain the meaning as to what can constitute a primary health need.
What is clear is that there is no automatic entitlement to be considered to have primary health needs and there is a degree of complexity and subjective opinion involved when interpreting the evidence as to whether these criteria are met. If you have any queries regarding continuing healthcare funding you should not hesitate to contact the Compass CHC team where we shall be happy to address any queries that you may have.
[1] National Framework for NHS Continuing Healthcare, pg 51 para 3.3
Author: Tim Davies LLB
