Our advocates have attended hundreds of Checklist, DST and Appeal meetings. We have picked out 5 of the most commonly used phrases by the healthcare professionals that conduct the assessments and we have provided you with the paragraphs contained in the DST document to rebut these misconceptions.
We recognise that often, the healthcare professional using these phrases may be inexperienced, not adequately trained or not up to date on current legislation and information however, we contend that the fairness and accurateness of the assessment should not be compromised as a result.
Here are our top five misconceptions about continuing healthcare:
1. “You aren’t allowed to have an advocate involved, it's only the family that can be here”
Paragraph 5 of the DST states the following:
“The assessment of needs that informs completion of the DST should be carried out with the informed and active participation of the individual wherever possible. The individual should be given the opportunity to be supported or represented by a carer, family member, friend or advocate if they so wish. The eligibility assessment process should draw on those who have direct knowledge of the individual and their needs.”
As advocates and representatives of the individual being assessed and their families view, we are often told that an advocate is unnecessary as the paperwork is all the Nurse Assessors needs. When this situation arises, or advocates highlight this paragraph which not only states that an advocate or representative should have “active participation” in any assessment, but also that the assessment is person-centred and as such, the assessment process should draw on those who have a direct knowledge of the individual.
Due to covid, many assessments are currently held virtually and as such, those assessing the individual have not met the individual they are assessing. Indeed, this creates a huge reliance on paperwork but as we already know, paperwork is not always up-to-date and correct. As such, the families input and the input of the carers is more essential than ever.
2. “Unfortunately, the social worker was unable to attend so we will go ahead with just me and the social worker can review and sign the DST.”
Paragraphs 16 and 17 state the following:
“In accordance with regulations, an MDT in this context means a team consisting of at least:
- two professionals who are from different healthcare professions, or
- one professional who is from a healthcare profession and one person who is responsible for assessing persons who may have needs for care and support under part 1 of the Care Act 2014.”
“Whilst as a minimum requirement an MDT can comprise two professionals from different healthcare professions, the MDT should usually include both health and social care professionals, who are knowledgeable about the individual’s health and social care needs and, where possible, have recently been involved in the assessment, treatment or care of the individual. ICBs may use a number of approaches (e.g. face-to-face, video/tele conferencing etc.) to arranging these MDT assessments in order to ensure active participation of all MDT members, the individual and their representative, and any others with knowledge about the individual’s health and social care needs as far as is possible. It is best practice for assessors to meet with the individual being assessed, ideally before the MDT meeting, and any arrangements should include consideration of the best options for the individual, following a person-centred approach. For example, it may be that a hybrid meeting (including a combination of people in the room and people “dialling in”) should be considered.”
In short, there must be at least two professionals involved in the assessment that come from different backgrounds. For example, you may have two nurses completing the assessment, but they cannot be from the same field and must specialise in different areas.
If you get to an assessment, and one of the professionals has not shown up, please inform the nurse assessor that you are not willing to go ahead without a legally compliant multi-disciplinary team and reschedule. I know that this can be exhausting as you have likely built yourself up for the meeting and obtained records, but if the assessment is not compliant but goes ahead with your permission, there may be repercussions in the long run.
3. “I, the nurse assessor, believe the individual has a Moderate level of need in this domain so will mark it down as a Moderate but I will note that the social worker believes it is a High.”
4. “We have already considered this in the other domain, therefore it cannot be considered in this domain too.”
Per paragraph 25 of the DST, the highest level under consideration should be the one recorded.
“The descriptors in the DST are examples of the types of need that may be present. They should be carefully considered but may not always accurately describe every individual’s circumstances. The MDT should first determine and record the extent and type of need in the space provided. If there is difficulty in placing the individual’s needs in one or other of the levels, the MDT should use professional judgement based on consideration of all the evidence to decide the most appropriate level. If, after considering all the relevant evidence, it proves difficult to decide or agree on the level, the MDT should choose the higher of the levels under consideration and record the evidence in relation to both the decision and any significant differences of opinion. The MDT should not record an individual as having needs between levels. It is important that differences of opinion on the appropriate level are based on the evidence available and not on generalised assumptions about the effects of a particular condition or assumptions about the individual’s needs.”
Ultimately, if the MDT disagree on the levels of need in a particular domain, the DST must be marked with the highest level of need that is under consideration. The document must highlight the arguments put forward for the views of each person involved in the meeting however, the back sheet and the DST itself must be marked with the highest level of need under consideration.
Per Paragraph 28, one need can arise in several domains and should be considered in each.
“It should be remembered that the DST is a record of needs and a single condition might give rise to separate needs in a number of domains. For example, an individual with cognitive impairment will have a weighting in the cognition domain and as a result may have associated needs in other domains, all of which should be recorded and weighted in their own right (refer to Practice Guidance note 30).”
It is regularly pointed out in the assessments that each need must be considered in only one domain however per paragraph 28, this is not true. By way of working example, if an individual is incontinent, this will affect their skin integrity and thus the incontinence should be considered in both the Skin and Continence domains. Further, if someone is unable to the recognise the risk of standing up without their frame despite a number of falls, this would need to be considered under both the Cognition and the Mobility domains.
Don’t forget that when the domains and needs cross over this is an indication that the needs are complex.
5. “The medication she is on stops the pain. We can't consider her pain if it's not there.”
Per paragraph 31:
“Needs should not be marginalised just because they are successfully managed. Well managed needs are still needs. Only where the successful management of a healthcare need has permanently reduced or removed an on-going need, such that the active management of this need is reduced or no longer required will this have a bearing on NHS Continuing Healthcare eligibility. This principle is incorporated into the domain descriptors of the DST. For example, in the behaviour domain the level of support and skill required to manage risks associated with challenging behaviour helps determine the domain weighting. In such cases the care plan (including psychological or similar interventions) should provide the evidence of the level of need, recognising that this care plan may be successfully avoiding or reducing incidents of challenging behaviour (refer to paragraphs 162-166 of the National Framework and Practice Guidance note 23). For example, where psychological or similar interventions are successfully addressing behavioural issues, consideration should be given as to the present-day need if that support were withdrawn or no longer available and this should be reflected in the Behaviour domain.”
Undoubtably this is the phrase that creates the most annoyance within our team. In meetings we are often required to remind the assessor that a well-managed need is still a need. By way of working example, if an individual is diabetic and it is managed effectively by diet, monitoring, and insulin, whilst the condition is not currently problematic, there is still a level of monitoring required, food management and extra skin integrity checks to ensure that the diabetes does not become problematic. Therefore, this must be considered in all the relevant domains and not just disregarded because the condition is “well-managed”.
This is supported by the National Framework which states that “The decision-making rationale should not marginalise a need just because it is successfully managed: well-managed needs are still needs.” It goes on to state that “Only where the successful management of a healthcare need has permanently reduced or removed an ongoing need, such that the active management of this need is reduced or no longer required, will this have a bearing on NHS Continuing Healthcare eligibility.” As such, unless the need has vanished in its entirety, and management is no longer required (inc. Medication), the need and management of such should be considered in the assessment process.