Practice Guidance Notes: What is a primary healthcare need?

PG 2  What is the difference between a healthcare  need and a social care need?

2.1     Whilst  there  is not a legal  definition  of  a  healthcare  need  (in the  context  of  NHS continuing healthcare), in general terms it can be said that such a need is one related to the treatment, control or prevention of a disease, illness, injury or disability, and the care or aftercare of a person with these needs (whether or not the tasks involved have to be carried out by a health professional).

2.2     In general terms (not a legal definition) it can be said that a social care need is one that is focused on providing assistance with activities of daily living, maintaining independence, social interaction, enabling the individual to play a fuller part in society, protecting them in vulnerable situations, helping them to manage complex relationships and  (in   some   circumstances)   accessing   a   care   home   or   other   supported accommodation.

2.3     Social care needs are directly related to the type of welfare services that LAs have a duty or power to provide. These include, but are not limited to: social work services; advice; support; practical assistance in the home; assistance with equipment and home adaptations; visiting and sitting services; provision of meals; facilities for occupational, social,  cultural  and  recreational  activities  outside  the  home;  assistance  to  take advantage of educational facilities; and assistance in finding accommodation (e.g. a care home), etc. CCGs should be mindful that where a person is eligible for NHS continuing healthcare the NHS is responsible for meeting their assessed health and social care needs.

PG 3  What is a primary  health need?

3.1     ‘Primary health need’ is a concept developed by the Secretary of State to assist in deciding when the NHS is responsible for meeting an individual’s assessed health and social care needs as part of his overall duties under the NHS Act 2006 to provide ‘services or facilities for the prevention of illness, the care of persons suffering from illness and the after-care of persons who have suffered from illness’ [NHS Act 2006, section 3(1) (e)].

3.2     This Framework (paragraph 33) states 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.’

3.3     The term ‘primary health need’ does not appear, nor is defined, in primary legislation, although it is referred to in the Standing Rules26 where it sets out that a person should be considered to have a primary health need when the nursing or other health services they require, when considered in their totality, are:

‘(a)    where that person is, or is to be, accommodated in a care home, more than incidental or ancillary to the provision of accommodation which a social services authority is, or would be but for a person’s means, under a duty to provide; or

(b)      of a nature beyond which a social services authority whose primary responsibility is to provide social services could be expected to provide ’

3.4     The LA can only meet nursing/healthcare needs when, taken as a whole, the nursing or other health services required by the individual are below this level. If the individual’s nursing/healthcare needs, when taken in their totality, are beyond the lawful power of the LA to meet, then they have a ‘primary health need’.

3.5     Whilst there is not a legal definition, in simple terms an individual has a primary health need if, having taken account of all their needs (following completion of the DST), it can be said that the main aspects or majority part of the care they require is focused on addressing and/or preventing health needs.

3.6     Primary health need is not about the reason why someone requires care or support, nor is it based on their diagnosis; it is about their overall actual day-to-day care needs taken in their totality. Indeed it could be argued that most adults who require a package of health and social care support do so for a health-related reason (e.g. because they have had an accident or have an illness or disability). It is the level and type of needs themselves that have to be considered when determining eligibility for NHS continuing healthcare.

26 The National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) Regulations 2012

3.7     Each individual case has to be considered on its own merits in accordance with the principles outlined in this Framework, which cautions against drawing generalisations about eligibility for NHS continuing healthcare from general information about cases reported from court decisions, or by the Parliamentary and Health Service Ombudsman.

3.8       Four     characteristics    of need, namely ‘nature’, ‘intensity’, ‘complexity’ and ‘unpredictability’ ‘may help determine whether the ‘quality’ or ‘quantity’ of care required is beyond the limit of an LA’s responsibilities, as outlined in the Coughlan case (a summary of the case can be found at Annex B). It is important to remember that each of these characteristics may, alone or in combination, demonstrate a primary health need, because of the quality and/or quantity of care that is required to meet the individual’s needs.

3.9     It may be helpful for MDTs to think about these characteristics in terms of the sorts of questions  that  each  generates.  By  the  MDT  answering  these  questions  they  can develop a good understanding of the characteristic in question. The following questions are not an exhaustive list and are not intended to be applied prescriptively.

’Nature’  is about the characteristics of both the individual’s needs and the interventions required to meet those needs.

Questions that may help to consider this include:

•     How does the individual or the practitioner describe the needs (rather than the medical condition leading to them)? What adjectives do they use?

•   What is the impact of the need on overall health and well-being?

•   What types of interventions are required to meet the need?

•     Is there particular knowledge/skill/training required to anticipate and address the need? Could anyone do it without specific training?

•   Is the individual’s condition deteriorating/improving?

•   What would happen if these needs were not met in a timely way?

‘Intensity’ is about the quantity, severity and continuity of needs. Questions that may help to consider this include:

•   How severe is this need?

•   How often is each intervention required?

•   For how long is each intervention required?

•   How many carers/care workers are required at any one time to meet the needs?

•   Does the care relate to needs over several domains?

‘Complexity’ is about the level of skill/knowledge required to address an individual need or the range of needs and the interface between two or more needs.

Questions that may help to consider this include:

•   How difficult is it to manage the need(s)?

•     How problematic is it to alleviate the needs and symptoms?

•     Are the needs interrelated?

•     Do they impact on each other to make the needs even more difficult to address?

•     How much knowledge is required to address the need(s)?

•     How much skill is required to address the need(s)?

•     How does the individual’s response to their condition make it more difficult to provide appropriate support?

‘Unpredictability’ is about the degree to which needs fluctuate and thereby create challenges in managing them.

Questions that may help to consider this include:

•     Is the individual or those who support him/her able to anticipate when the need(s) might arise?

•     Does the level of need often change? Does the level of support often have to change at short notice?

•     Is the condition unstable?

•     What happens if the need isn’t addressed when it arises? How significant are the consequences?

•     To what extent is professional knowledge/skill required to respond spontaneously and appropriately?

•     What level of monitoring/review is required?

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