NHS Continuing Healthcare Checklist
NAME……………………………… D.O.B…………………NHS NUMBER…………………
NHS Continuing Healthcare Checklist
November 2012 (Revised)
August 2016 version
(APPENDIX) Consent and Accessible Information V10
PART A – Complete if individual has mental capacity
PART B – Complete if individual does not have mental capacity
All sections to be completed by the responsible professional
Personal Details of individual being assessedSurname / family name: / First names:
Date of birth: / NHS number:
Personal Details of Responsible Professional
Name of professional: / Job Title:
Email address: / Telephone number:
Organisation name: / Consent form completion date:
This form relates to consent to completion of the NHS Continuing Healthcare Checklist (screening tool), the completion of a full assessment for NHS Continuing Healthcare, and the sharing of personal health and social care information in order to:
a)determine eligibility for NHS Continuing Healthcare (CHC)
b)assist in care and support planning (whether or not eligible for CHC)
1. / Does the individual have any communication difficulties that may impact upon their ability to consent?If yes please provide details of how these have been addressed below. / Yes / No
(Please delete as appropriate)
N.B. Under the Mental Capacity Act a person must be assumed to have capacity unless it is established that they lack capacity and a person is not to be treated as unable to make a decision unless all practicable steps to help him or her to do so have been taken without success.
Assessment of individual’s Mental CapacityMental capacity should be assessed at the time the decision needs to be made.
2. / In your judgement does the individual have the mental capacity to give consent, bearing in mind that mental capacity is always decision specific and time specific?
If yes please complete Part A
If no please complete Part B / Yes / No
(Please delete as appropriate)
3. / Is this patient subject to Section 117 (MHA 1983) / Yes / No
(Please delete as appropriate)
Part A – Consent for individuals that have mental capacity
Statement from responsible professionalA1. / I have explained the process and purpose of the CHC assessment / (Please indicate positively)
A2. / I have advised the individual how their health and social care information may be used and that it will be shared for this assessment process with a number of different health and social care professionals / (Please indicate positively)
A3. / I have explained that if the Checklist indicates that a full CHC assessment is required, this does not mean they will necessarily be found eligible for CHC. / (Please indicate positively)
A4. / Has the individual been given a copy of the NHS Continuing Healthcare and NHS-funded Nursing Care Public Information Leaflet? / Yes / No
(Please delete as appropriate)
A5. / Has the patient given consent but is physically unable to sign the form on the next page?
If yes please provide reasons below. / Yes / No
(Please delete as appropriate)
Responsible professional name (PRINT): / Responsible professional signature:
Responsible professional Designation: / Date:
Statement from Individual
Please read this carefully (or ask someone to read it to you) and tick/confirm those statements below that you agree with. You have the right to change your mind or withdraw your consent at any time.
A6. / Statement of Consent
(Please select one of the following statements by deleting as appropriate or circling option of choice) / I consent to the NHS Continuing Healthcare (CHC) assessment as explained to me, including the sharing of information about me between professionals involved.
(This may include Adult Social Services, GP, Clinical Commissioning Groups, Continuing Healthcare Teams, Financial and Quality Teams, this list is not exhaustive)
OR
I do not consent to the CHC assessment process and understand that this means I cannot be considered for CHC eligibility and this may affect the ability of the NHS and Local Authority to provide appropriate services to meet my needs.
(Please delete as appropriate)
A7. / Statement of Consent regarding representatives
(Please select one of the following statements by deleting as appropriate or circling option of choice) / I consent to any relevant family/friend(s)/advocates being involved in my assessment as considered appropriate by the professionals involved and understand that my personal health and social care information may be shared with them for the purposes of this assessment.
OR
I limit my consent to the following specific family/friend(s)/advocate being involved in my assessment and understand that my personal health and social care information may be shared with them for the purposes of this assessment.
Please list family/friend(s)/advocate in the space provided below
OR
I do not consent to any family/friend(s)/advocate being involved in my assessment nor to my personal health and social care information being shared with them.
(Please delete as appropriate)
Name / Relationship / Contact telephone number & address
Individual’s name (PRINT):
Individual’s signature: / Date:
N.B. If the individual has given consent but is physically unable to sign the form please confirm and give reason in section A5 above.
Part B – Record of Mental Capacity Assessment and Best
Interest Decision
This section should only be completed for Individuals that lack the mental capacity to consent
AssessmentBased on the above information, my judgement is that, ………………………. (Name of Individual being assessed) has the mental capacity / does not have the mental capacity (delete as appropriate)to make a decision regarding consent to the NHS Continuing Healthcare assessment process and the sharing of information in order for this assessment to take place.
Name of Assessor: / Assessor signature:
Assessor Job Title: / Date of assessment:
Before deciding that the individual lacks mental capacity to consent you should consider:
a)whether the Individual might regain or acquire capacity to consent in the future and, if so,
b)whether the NHS Continuing Healthcare (CHC) assessment process can be delayed until they are able to give consent
The 2nd principle of the Mental Capacity Act states that:
‘A person is not to be treated as unable to make a decision unless all practicable steps to help him or her to do so have been taken without success’
Describe what steps have been taken to enable the person to make the decision themselves (e.g. use of interpreter or communication aids, ensuring they have all the relevant information in an accessible form, considering times of day when their ability to understand is better, treating a medical condition which may be affecting their mental capacity, involving someone who knows them etc.):Mental Capacity Assessment
On the date given above and in relation to the decision whether or not to give consent to a CHC assessment and sharing information:
B1. / Is the Individual able to understand the information relevant to the decision?
(i.e. were you satisfied that the person could understand the nature of the decision, why the decision needed to be made at the time and whether they could understand the likely effects of deciding one way or another or making no decision at all?)
Please give reasons below: / Yes / No
(Please delete as appropriate)
B2. / Is the Individual able to retain the information long enough to use it to make the decision?
(i.e. long enough to complete the decision-making process, including making and communicating their decision. Consideration should be given to the use of notebooks, photographs, videos, voice recorders, posters etc. to help the Individual record and retain the information)
Please give reasons below: / Yes / No
(Please delete as appropriate)
B3. / Is the Individual able to use or weigh up this information as part of the decision making process?
(e.g. to consider the consequences, benefits and risks, of making the decision one way or another or making no decision at all? Understand the pros and cons)
Please give reasons below: / Yes / No
(Please delete as appropriate)
B4. / Is the Individual able to communicate their decision? (Verbally, using sign language or by any other means?)
Please explain below how the decision was communicated or give reasons if answer is ‘No’ / Yes / No
(Please delete as appropriate)
In order to establish that someone does not have the mental capacity to make a particular decision the assessor must have a reasonable belief (i.e. on the balance of probabilities) that they lack mental capacity. If the answer is ‘Yes’ to all the above questions, the person must be assessed to have the mental capacity to make the decision themselves.
An answer of ‘No’ to any one of the above four questions indicates that the person lacks mental capacity to make the decision in question, if the reason for this is because they have an impairment or a disturbance in the functioning of their mind or brain.
B5. / Does the Individual have an impairment of, or a disturbance in the functioning of, their mind or brain?Please state below the nature of the impairment (e.g. dementia, acquired brain injury, learning disability, acute confusional state, short-term memory loss, concussion, symptoms of drug/alcohol use) and the basis of this information (e.g. recent clinical assessments, established diagnosis etc.) / Yes / No
(Please delete as appropriate)
Permissions
If the individual lacks mental capacity to consent have either of the following been appointed?
If so please ensure an original or certified copy of this document is provided to the CHC Team.
Document / Yes / No / Contact Details
Someone with a Registered Lasting Power of Attorney for Health and Welfare (LPA)
Court appointed Deputy (Health and Welfare)
Either of the above has the authority to give or decline consent on behalf of the individual and therefore must be consulted and their decision respected and recorded.
Best Interest DecisionIf the individual lacks mental capacity and there is no-one with an LPA or a Deputy with the relevant authority (i.e. to make health and welfare decisions), a best interest decision must be made.
The Mental Capacity Act requires the best interest decision maker to consult with family/friends before making a best interest decision. However, as noted in the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care, the expectation is that it will be in an individual’s best interest to have an assessment for CHC and for information about their health and welfare to be shared for this purpose.
Please give details below regarding any consultation you have made with family / friends and the outcome of this.
Is it in the Individual’s best interest to be assessed for NHS CHC and for information about their health and welfare to be shared for this purpose?
Please provide reasons for this decision below. / Yes / No
(Please delete as appropriate)
Name of Assessor: / Assessor signature:
Assessor Job Title: / Date:
Accessible Information
Does the patient/representative have a disability, impairment or Learning Disability that requires an alternative communication format? / Yes / No
(Please delete as appropriate)
If yes please advise who requires the alternative communication format:
If yes please select the reason for an alternative communication format
d/Deaf / Hearing impairment / loss
Blind / Sight impairment / loss
Deafblind / Disability
Other (Please provide details)
If yes please select the preferred alternative communication format
Large Print / Easy Read
Braille / British Sign Language
Audio Format / Email / Electronic Format
Other (Please provide details)
Does the patient/representative have a problem with understanding or speaking English? / Yes / No
(Please delete as appropriate)
If yes please advise who requires the alternative communication format:
If yes please advise CHC what their preferred language is:
Patient’s Name: / Signature:
Patient’s Date of Birth: / Date:
NHS Continuing Healthcare Checklist
November 2012 (Revised)
Notes
1.Clinical commissioning groups (CCGs) and the NHS Commissioning Board (the Board) will assume responsibilities for NHS Continuing Healthcare (NHS CHC) from 1 April 2013.
2.The Board will assume commissioning responsibilities for some specified groups of people (for example, prisoners and military personnel). It therefore follows that the Board will have statutory responsibility for commissioning NHS CHC, where necessary, for those groups for whom it has commissioning responsibility. This will include case co-ordination, arranging completion of the decision support tool, decision-making, arranging appropriate care packages, providing or ensuring the provision of case management support and monitoring and reviewing the needs of individuals. It will also include reviewing decisions with regards to eligibility where an individual wishes to challenge that decision.
3.Where an application is made for a review of a decision made by the Board, it must ensure that in organising a review of that decision, it makes appropriate arrangements to do so, so as to avoid any conflict of interest.
4.Throughout the Checklist where a CCG is referred to, the responsibilities will also apply to the Board (in these limited circumstances).
5.This Checklist is a tool to help practitioners identify people who need a full assessment for NHS continuing healthcare. Please note that referral for assessment for NHS continuing healthcare is not an indication of the outcome of the eligibility decision. This fact should also be communicated to the individual and, where appropriate, their representative.
6.The Checklist is based on the Decision Support Tool for NHS Continuing Healthcare. The notes to the Decision Support Tool and the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care guidance will aidunderstanding of this tool. Practitioners who use this tool should have received suitable training.
7.The aim is to allow a variety of people, in a variety of settings, to refer individuals for a full assessment for NHS continuing healthcare. For example, the tool could form part of the discharge pathway from hospital; a GP or nurse could use it in an individual’s home; and social services workers could use it when carrying out a community care assessment. This list is not exhaustive, and in some cases it may be appropriate for more than one person to be involved. It is for each organisation to decide for itself which are the most appropriate staff to participate in the completion of a Checklist. However, it must be borne in mind that the intention is for the Checklist to be completed as part of the wider process of assessing or reviewing an individual’s needs. Therefore, it is expected that all staff in roles where they are likely to be involved in assessing or reviewing needs should have completion of Checklists identified as part of their role and receive appropriate training.
8.Individuals may request an assessment for NHS continuing healthcare. In these circumstances, the organisation receiving the request should make the appropriate arrangements for a Checklist to be completed.
9.All staff who apply the Checklist will need to be familiar with the principles of the National Framework for Continuing Healthcare and NHS-funded Nursing Care and with the Decision Support Tool for NHS Continuing Healthcare.
How to use this tool
10.Before applying the Checklist, it is necessary to ensure that the individual and (where appropriate) their representative understand that completing the Checklist is not an indication of the likelihood that the individual will necessarily be determined as being eligible for NHS continuing healthcare.
11.The individual should be informed that the Checklist is to be completed and should have the process for completion explained to them. The individual and (where appropriate) their representative should be supported to play a full role in the process and should be given an opportunity to contribute their views about their needs. Decisions and rationales should be transparent from the outset.
12.As with any examination or treatment, the individual’s informed consent should be obtained before the process of completing the Checklist commences. Further advice on consentissues can be found at:
13.It should be made explicit to the individual whether their consent is being sought for a specific aspect of the eligibility process (e.g. completion of the Checklist) or for the full process. It should also be noted that individuals may withdraw their consent at any time in the process.
14.If there is a concern that the individual may not have capacity to give their consent, this should be determined in accordance with the Mental Capacity Act 2005 and the associated code of practice. Anyone who completes a Checklist should be particularly aware of the five principles of the Act:
- A presumption of capacity: A person must be assumed to have capacity unless it is established that they lack capacity.
- Individuals being supported to make their own decisions: A person is not to be treated as unable to make a decision unless all practicable steps to help him or her to do so have been taken without success.
- Unwise decisions: A person is not to be treated as unable to make a decision merely because he makes an unwise decision.
- Best interests: An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his or her best interests.
- Least restrictive option: Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action.
15.It must also be borne in mind that consideration of capacity is specific to both the decision to be made and the time when it is made – i.e. the fact that a person may be considered to lack capacity to make a particular decision should not be used as a reason to consider that they cannot make any decisions. Equally, the fact that a person was considered to lack capacity to make a specific decision on a given date should not be a reason for assuming that they lack capacity to make a similar decision on another date.
16.If the person lacks the mental capacity to either give or refuse consent to the use of the Checklist, a ‘best interests’ decision, taking the individual’s previously expressed views into account, should be taken (and recorded) as to whether or not to proceed. Those making the decision should bear in mind the expectation that everyone who might meet the Checklist threshold should have this opportunity. A third party cannot give or refuse consent for an assessment of eligibility for NHS continuing healthcare on behalf of a person who lacks capacity, unless they have a valid and applicable Lasting Power of Attorney (Welfare) or they have been appointed a Welfare Deputy by the Court of Protection. Before making a best interest decision as to whether or not to proceed with the completion of the Checklist the assessor should be mindful of their duty to consult with appropriate third parties. This is particularly important if the decision is not to complete a Checklist.