NHS Additional Funding Contribution Assessment Form1
Guidance to Professionals completing this assessment form
The NHS funds services to meet the child’s health needs regardless of where they live. In order to
be eligible for additional funding to support an individually commissioned placement/treatment
package, it is necessary to demonstrate why the child’s health need cannot be met from
mainstream NHS services.
The decision making body for these funding requests is the Children’s Complex Cases Panel
(CCCP). This form should be completed as fully as possible and relevant supporting evidence
attached. The documentation presented by NCC to the CCCP must include as a minimum a
report from either, a Consultant Clinical Psychologist, Paediatrician or Child Psychiatrist and
ensure that the questions below have been addressed.
All cases presented to the CCCP should have previously been discussed at and have full approval
from the relevant NCC CS’s County Panel.
There is no process in place for urgent decisions to be made outside of the CCCP for this group of
children.
If the health need is urgent the child will receive treatment in the normal way via A&E or be
admitted to an appropriate in-patient bed.
NHS professionals who are working with a child or young person who NCC is considering for a
specialist placement/care package should provide evidence based advice to support the CCCP
decision making.
Health professionals should be clear in all communications to NCC staff that, whatever their
recommendations, they are not able to commit resources and that this decision sits with the CCCP.
Their report should contain detailed information on the child’s health needs, the resource/therapy
requested and how it will meet the child’s health needs. It should also explain the limitations of
local child health services and why they are not able to support the child adequately.
Please note - where, e.g. a Clinical Psychologist provides advice to NCC on the suitability of a
placement in terms of meeting the child’s social care or educational needs, this in no way implies
that a child will be entitled to additional NHS funding.
1
This form is in draft and will be piloted for 6 months from March 2012
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Date of consent by person/s with Parental
Legal status of child
Responsibility to this assessment/information sharing
with NHS Complex Cases Panel __/__/__
(Written consent to be attached)
Child’s Name:
NHS No:
Address:
Date of Birth:
Tel no Mobile:
Family members
Relationship
D.O.B
Child lives with:
Height & Weight of Child:
Date Weight Recorded:
Summary of Family & Social Background: (please append relevant detailed reports)
Current health problems:
GP name and address:
Consultant(s):
Paediatrician/s
Psychiatrist
Psychologist
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Contact number
Ethnic origin:
School/Nursery:
Language spoken:
Why is a health contribution being requested?
INVOLVED PROFESSIONALS
NAME
Social worker
Health visitor/school nurse
Children’s community nursing
team
Learning disability nurse
Outreach nurse
Physiotherapist
Occupational therapist
Speech and language therapist
Dietician
Education professionals
Class teacher
Educational Psychologist
SEN Caseworker
Others – please specify
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TELEPHONE NUMBER
CARE REQUIREMENTS
Please complete the following sections or clearly signpost in each section to where
evidence can be found within reports attached (e.g. Assessment report from Darwin House
page .., paragraph …)
Behaviour
Does s/he have challenging
behaviour? Are there any specific
triggers for this? Describe the
specific behaviours and symptoms
including duration and severity and
ability to self regulate behaviours.
Does s/he have impaired capacity
for emotional regulation and
behavioural control and/or impaired
capacity for empathy and impulse
control leading to aggressive and
other behaviours that place the
young person and / or others at risk
and leading to significant impairment
in the young person’s life.
Detail level of supervision required
in various settings, day/night to
manage risk.
Communication
Describe the child’s ability to
communicate their needs in familiar
and unfamiliar situations.
How does he/she communicate?
(e.g. communication aids)
Is she/he visually impaired?
Does he/she wear glasses or a
hearing aid?
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Mobility
Is it normal for his/her age?
Is their sleep affected by their
problems?
Nutrition
.
Are there special dietary needs?
Are there problems with intake of
food of food or drink requiring skilled
intervention to manage nutritional
needs; recognised eating disorder
with self imposed dietary regime of
self neglect, e.g. depression leading
to intake problems placing young
person at risk?
Continence or Elimination
Is he/she continent?
Does she manage menstruation
appropriately?
Skin
Any areas of concern?
Eczema or other skin conditions?
Self Harm related problems?
Breathing
Any use of inhaler / nebulisers?
Is monitoring required?
Is overnight ventilation required?
Are sleep patterns affected?
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Drug Therapies & Medicines
Is he/she on regular medication?
Are there issues of non-compliance?
If so what level of
support/supervision is required?
Does he/she have emergency
medication? (epipen, buccal
midazolam etc)
Does pain affect sleep regularly?
Psychological
Are there:
-
Signs of unresolved emotional
distress/ low mood and an
inability to be comforted.
-
Fluctuating levels of distractibility
and poor attention
-
Anxiety with high levels of safety
behaviours and avoidance
-
Thought disorder
-
Rapidly fluctuating moods of
depression which have severe
impact on child’s health so that
individual can’t engage with daily
activities eg eating, sleeping or
which place them at risk.
-
Episodes of acute psychological
deregulation, poor impulse
control placing child at risk to self
and others, including high risk
intentional self harm.
Seizures
Description of type of seizure
What is the seizure pattern?
Is a recovery period required?
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Interventions to date.
What methods have already been
employed to try and resolve the
child’s difficulties?
Give full details of the placements
the child has lived in and medical
and therapeutic input received.
Please give names of professionals
involved and dates of treatment
What was the outcome of the
therapy/ treatment? What was
resolved? What difficulties remain?
Is further therapy/treatment
planned?
Proposed intervention
Why is this placement being
considered at this point in time?
What else has been considered?
Why where these deemed
unsuitable?
How will the proposed placement
benefit the child?
What are the components of the
package of care and treatment that
is requested? Please be specific.
What effects are these likely to have
on the child’s difficulties?
How long is the suggested package
of care needed for?
How long is the treatment needed
for? Please give an explanation for
the length predicted.
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What is the evidence to support a
likely positive health outcome?
Does the health professional treating
the child believe this likely?
Monitoring and Evaluation
How will the child’s progress be
monitored and evaluated?
Who will be responsible for
monitoring and what input will health
professional/s have into this?
How will it be decided that sufficient
improvement has been achieved
and the treatment or placement is no
longer needed?
What will be the plan for the child
following this placement?
Current situation
Where is the child living at the time
of this assessment, e.g. at home,
foster care, residential care,
hospital, hospice, short breaks
setting.
Views of person/s with PR about
proposed placement/intervention
Carers’ view if different
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Views of child about proposed
placement/intervention
Form Completed by:
Print Name:
Signed:
Designation:
Date:
Declaration (Paediatric consultant or panel signatory only)
This patient is ELIGIBLE for additional NHS funding in addition to the mainstream NHS
services already in place.
Please Tick
Yes
No
Print Name:
Signed:
Designation:
Date:
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