Are you eligible for a service?

Criteria in health and social care

Everyone has the right to medical care and necessary social care. However, many health and social care services have criteria to make sure you are eligible for certain kinds of support.

This page outlines the assessment and eligibility criteria for support in the following areas:

 

Continuing Healthcare (CHC) Policies:

Who is it for?
NHS continuing healthcare is free care for adults outside of hospital that is arranged and funded by the NHS.

Children and young people are not eligible, but may receive a “continuing care package” if they have needs arising from disability, accident or illness that can’t be met by existing services. You can find out more about this here.

How the assessment works
The CHC assessment takes place in two parts:

  • Continuing healthcare screening checklist (Download here)
    and if criteria is met for a full assessment;
  • Continuing Healthcare Decision Support Tool (DST) (Download here).

To be eligible for continuing healthcare, you must be assessed by Multidisciplinary Team (MDT) of healthcare professionals as having a “primary health need”, which is assessed by looking at all your care needs and relating them to:

  • what help is needed
  • how complex these needs are
  • how intense or severe these needs can be
  • how unpredictable they are, including any risks to the person’s health if the right care isn’t provided at the right time

Your eligibility depends on your assessed needs, and not on any particular diagnosis or condition. If your needs change then your eligibility for NHS continuing healthcare may change.

Assessment 1: Continuing healthcare screening checklist

Domains:
The checklist looks at the following domains:

  • Behaviour
  • Cognition
  • Psychological/Emotional
  • Communication
  • Mobility
  • Nutrition
  • Continence
  • Skin integrity
  • Breathing
  • Drug therapies and medication: Symptom control
  • Altered states of consciousness

Scoring:
Each of these domains are scored as A, B or C. Each category has statements about the severity of the condition, and the score is decided by the closest matching statement.

Example:

Eligibility
A full assessment for NHS continuing healthcare is required if there are:

  • Two or more domains selected in column A;
  • Five or more domains selected in column B, or one selected in A and four in B; or
  • One domain selected in column A in one of the boxes marked with an asterisk (i.e. those domains that carry a priority level in the Decision Support Tool), with any number of selections in the other two columns.

You should be fully involved in the assessment process and kept informed, and have your views about your needs and support taken into account. Carers and family members should also be consulted where appropriate.

Assessment 2: Continuing Healthcare Decision Support Tool (DST)

Domains
The checklist looks at the following domains:

  • Behaviour
  • Cognition
  • Psychological/Emotional
  • Communication
  • Mobility
  • Nutrition
  • Continence
  • Skin integrity
  • Breathing
  • Drug therapies and medication: Symptom control
  • Altered states of consciousness

Scoring
The assessment looks at each of the domains in further detail, and is scored as levels ranging between:

  • No Needs
  • Low
  • Moderate
  • High
  • Severe
  • Priority

Not all domains have a “priority” level.

Example:

Eligibility
In general, eligibility is defined as:

  • A level of priority needs in any one of the four domains that carry this level
  • A total of two or more incidences of identified severe needs across all care domains

Where there is either:

  • One domain recorded as severe, together with needs in a number of other domains
  • A number of domains with high and/or moderate needs

This may also indicate a primary health need and therefore consideration would be needed, and clear reasons recorded if the decision is that the person does not have a primary health need.

Successful eligibility may not be a definitive decision at the end of this assessment, and may be referred to a panel in the event of disagreements or cases which may be on the borderline of eligibility.

If you aren’t eligible for NHS continuing healthcare, you can be referred to your local authority who can discuss with you whether you may be eligible for support from them. If you still have some health needs then the NHS may still pay for part of the package of support. This is sometimes known as a “joint package” of care.

You can find out more about Continuing Healthcare on the NHS Choices website here.

 

Healthcare Policies:

Who is it for?
Everyone in Blackpool.

How the assessment works
Blackpool Clinical Comissioning Group (CCG) are responsible for setting the critera for many health procedures. You can see a full list of their policies and find out more information for requesting funding for certain procedures here.

* Also see Lancashire Principles for the Commissioning of Health and Healthcare

 

Social Care Policies:

Who is it for?
The Care Act (2014) gives everyone the right to have an assessment of their needs. Blackpool Council are responsible for conducting assessments and establishing if someone is eligible for further services. They use the Department for Health eligibility criteria.

Assessment
The assessment:

  • must be provided to all people who appear to need care and support, regardless of their finances or whether the local authority thinks their needs will be eligible
  • must be of the adult’s needs and how they impact on their wellbeing, and the outcomes they want to achieve
  • must be carried out with involvement from the adult and their carer or someone else they nominate. The adult may need an independent advocate provided by the local authority to help them with the assessment process

Eligibility
A person will have eligible needs if they meet all of the following:

  • they have care and support needs as a result of a physical or a mental condition
  • because of those needs, they cannot achieve two or more of the outcomes specified
  • as a result, there is a significant impact on their wellbeing

The outcomes are specified in the regulations, and include people’s day-to-day outcomes such as dressing maintaining personal relationships, and working or going to school.

Where the person has eligible needs, and wants the local authority’s help to meet them, then the authority will discuss the person’s care and support plan with them. In all cases, the local authority must give people advice and information about what support is available in the community to help them.

The local authority must provide the adult with a copy of their assessment and their eligibility determination.