Negative checklist
18. A CHC checklist looks at the person’s care in 11 care domains, scoring them from A (the highest level of need) to C (the lowest). A checklist is positive if the person scores certain combinations of As and Bs. Initially, the CHC checklist was carried out for Mrs B on 12 April 2023 was positive, and scored 2 A’s, 6 B’s and 3 C’s.
19. The National Framework says a positive checklist means an individual should have a full assessment of eligibility for CHC. The ICB then arranges for a multidisciplinary team (MDT) to complete a decision support tool (DST). This looks at the person’s needs in much more detail. The MDT will then make a recommendation to the ICB about whether the person has a primary health need and is therefore eligible for CHC.
20. The checklist was then reviewed by the ICB. Mrs B’s weightings were downgraded to 4 B’s and 7 C’s. This result was communicated to Compass CHC on 20 April 2023. Within this letter, the ICB explained there was a six month time frame from the date of the letter if the complainant disagrees with the decision, to raise this.
21. Compass says that the ICB did not follow the National Framework after receiving Mrs B’s positive checklist because it did not do a full CHC assessment.
22. The ICB explained that Mrs B’s current needs were not at a level that suggests that NHS CHC needs to be considered. As a result, further consideration for CHC was not required at that time.
23. On 17 May 2023, Compass wrote to the ICB and disagreed with the negative checklists. It then went on to explain, in detail, why it disagreed with the weightings for each individual domain by providing examples of the relevant records. It said that the decision to not proceed to a DST was in the complainant’s right under the National Framework and asked the ICB to either reconsider the decision or proceed straight to a DST.
24. On 30 June 2023, Compass, on behalf of Ms A, raised a formal complaint. They contended that the ICB had failed to apply sufficient weight to the evidence provided in the checklist meeting.
25. The ICB explained that it is the statutory body responsible for making decisions on eligibility for NHS Continuing Healthcare, and whilst it appreciates that in Compass’s view Mrs B demonstrates a primary health need, unfortunately, this is not based on clear clinical evidence and the key indicators.
26. The ICB explained to both Compass and us that the assessors raised concerns with the lead nurse due to feeling uncomfortable during the checklist meeting and pressurised regarding the domain scoring. Also, they felt like their experience and knowledge were being undermined.
27. The ICB said that all referrals for quality assurance and to ensure a consistent application of the National Framework. This process allows a panel of CHC trained staff, under the direction of the lead nurse, to challenge the levels identified by the Compass representative at the meeting based on the collated clinical evidence. The nurse assessors did not support the levels identified by Compass’s representative and finalised the checklist with levels they agreed based on the evidence that they observed, along with written and verbal information obtained from the care home.
28. Finally, on 10 October 2023, Compass requested a further checklist to be carried out. On 12 October 2023, the ICB responded by saying that as a result of the request, the ICB contacted the care home and spoke to the manager of the unit where Mrs B resides. It asked about her current needs to establish if there had been any changes, and it was advised that there had been no material changes in need.
29. The threshold for a CHC checklist resulting in positive result is set deliberately low to ensure nobody is missed who may be eligible for CHC. Paragraph 116 of the National Framework says there are two outcomes after a checklist has been completed. A negative checklist means the person does not need a full assessment of eligibility, and they are not eligible for CHC. A positive checklist means an individual now needs a full assessment of eligibility for CHC. It does not necessarily mean the individual is eligible for CHC.
30. The National Framework does not set out what an ICB should do if it gets a positive checklist but after the checklist is reviewed, it feels the domain scoring should be changed. However, we do not think an ICB should just continue a pathway it suspects is wrong. Our ‘Principles of Good Administration’ say if a public body decides to depart from recognised standards, it should record why.
31. The National Framework says, a copy of the completed checklist, together with a covering letter giving the appropriate details for challenging the decision, will be sufficient to constitute a written decision in many circumstances. This is provided the completed checklist or other documentation includes sufficient detail for the individual to understand the reasons why the decision was made. ICBs should consider making the decision available in alternative formats where this is appropriate to the individual’s need.
32. From viewing the available evidence, we can see that this information was given to Compass on more than one occasion. It also provided a great deal of information as to why the ICB reconsidered the checklist when it was received, and the reasons why it was not being progressed to a DST.
33. As there is no specific guidance on positive checklists being changed to negative, there are some basic principles we would expect the ICB to follow, based on the intent of the National Framework. Firstly, we expect to see the ICB had gone back to the person/s who did the checklist to discuss the scoring and obtained their agreement on the scores. We can see from the available evidence that this discussion was had verbally and as part of the quality assurance checks, as confirmed by the ICB. This has also previously been explained to Compass.
34. Following this, we would expect the ICB to have told Ms A/Compass what it had done, why, and provided a copy of the amended and now negative checklist and given the opportunity to complain about it, as per the National Framework. We can see that this information was issued to Compass on 20 April 2023.
35. The National Framework says that if an individual has been screened out following completion of the checklist, they may ask the ICB to reconsider the checklist outcome. The ICB should give this request due consideration, taking account of all the information available, and/or including additional information from the individual or carer, though there is no obligation for the ICB to undertake a further Checklist.
36. The ICB considered Compass’s requests to reconsider the checklist on multiple occasions. It responded explaining its consideration, and that no new evidence had been provided. As such, it would not be reconsidering the checklist.
37. We do not think the ICB made a mistake here. Whilst the National Framework does not set out specific guidance on what to do when a positive checklist is reviewed by the ICB, the ICB has not deferred from the National Framework. It has done what we would expect to see which is to make Compass aware of the checklist outcome and the reasons as to why it is negative, explain how to complain about this decision and provide a response, which it has done.
Further checklist request
38. On 10 October 2023, Compass requested that the ICB carries out another checklist to assess Mrs B’s needs.
39. As the National Framework states, there will be many situations where it is not necessary to complete a checklist. These include where:
• It is clear to practitioners working in the health and care system that there is no need for NHS Continuing Healthcare at this point in time. Where appropriate/relevant this decision and its reasons should be recorded. If there is doubt between practitioners a checklist should be undertaken.
• It has previously been decided that the individual is not eligible for NHS Continuing Healthcare and it is clear that there has been no change in needs.
40. From viewing the relevant correspondence, the ICB responded to Compass explaining that it had written to them twice detailing the outcome of the checklist and the reasons why Mrs B did not require consideration for NHS CHC at that time.
41. It said it contacted Mrs B’s care home and spoke to the manager of the unit where Mrs B resides to establish if there had been any changes in need. The ICB was told that there were no material changes in need, and that Mrs B continues to mobilise around the home with the assistance of her frame. She ate and drank well and used the toilet with minimal assistance. She could get upset and agitated but that is reflected on the previous checklist.
42. Lastly, she had been treated for a urinary tract infection but remains under review by her GP.
43. As above, one of those reasons for not carrying out a checklist is that the person was previously not eligible for CHC and their needs have not changed, but the decision a person’s needs have not changed should be made before a checklist is done. The National Framework does not say a checklist should be used to determine if a person’s needs have changed.
44. We feel that the ICB has acted in line with the National Guidance here. Mrs B was previously assessed, and a DST was deemed not necessary. It then checked with the care home that her needs had not changed when a new checklist was requested, and this was relayed back to Compass.
45. Our findings should not detract from the upset that Ms A’s complaint has caused her. We understand the CHC process can be lengthily. We would like to thank her for allowing us to consider her concerns.