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Understanding and Applying Eligibility Criteria (Occupational Therapy)

1. When to use this Procedure

This procedure should be used by anyone working in the Occupational Therapy service:

  1. After an assessment of holistic needs has been carried out; and
  2. After the level of need has been agreed by the Local Authority; and
  3. A determination of eligibility under the Care Act is required.

If you will be providing equipment or minor works under the duty to Prevent, Reduce or Delay Needs there is no legal requirement to apply the national eligibility criteria.

This procedure is also inapplicable to adaptations subject to HGCRA eligibility.

2. Understanding the National Eligibility Criteria

The National Eligibility Criteria for People with Care and Support Needs is defined in Section 13 of the Care Act.

The National Eligibility Criteria for People with Care and Support Needs

The National Eligibility Criteria for People with Care and Support Needs

3. Applying the Eligibility Criteria

When to apply the criteria

The criteria must be applied after needs have been established.

The responsibility for applying the criteria

Under the Care Act the Local Authority is responsible for applying the criteria and making the final decision about eligibility. As such this is your responsibility as you are the Local Authority's representative.

How to apply the criteria

There are 3 steps to applying the criteria as set out below. For a person to be eligible you must be able to answer 'Yes' to every step. As soon as you answer 'No' the person is not eligible under the Care Act.

Step 1: Do the person's needs arise from a physical or mental impairment or illness?

The duty to meet eligible needs under the Care Act only applies when those needs arise from (or are the result) of a physical or mental impairment or illness (diagnosed or undiagnosed at the point of assessment).

This step is therefore seeking confirmation that the person's needs do not arise from, or are the result of destitution (poverty so extreme that a person lacks the means to provide for themselves).

A key question to ask:

A key question to ask

Example 1:
Mary has arthritis. She has contacted adult Care and Support for an assessment because she is finding it difficult to use the toilet, dress appropriately and maintain her home. During the assessment it is established that Mary's arthritis is not the cause of her problems. Her toilet is broken but if it were working she would be physically able to use it despite having arthritis. She has clothing but it is in a poor state and not appropriate for the current weather conditions, and her vacuum cleaner has been broken for some time, meaning she has not been able to clean her home. Under the Care Act the Local Authority has no duty to meet Mary's needs because they have not arisen from her arthritis, but because of her destitution. The Local Authority does have a duty to provide Mary with good information and advice about how any needs for Care and Support could be prevented or delayed and to signpost her to local organisations that may be able to help her financially.
Example 2:
Mary has arthritis. She has contacted adult Care and Support for an assessment because she is finding it difficult to use the toilet, dress appropriately and maintain her home. During the assessment it is established that her toilet is broken but even if it were working she would find using it difficult because of her arthritis. She doesn't have many clothes but those that she does have she is finding it increasingly difficult to take on and off. Her vacuum is not working but even if it was Mary would not be able to clean certain areas of her home, particularly her bathroom and kitchen. Under the Care Act the Local Authority has a duty to meet Mary's needs because they have arisen from her arthritis, and not because she is destitute. Mary's needs for Care and Support would be present regardless of her destitution.

The outcome of step 1 will be one of the following:

  1. None of the person's needs arise from, or are the result of a physical or mental impairment or illness;
  2. The person's needs all arise from, or are the result of a physical or mental impairment or illness; or
  3. Some needs arise from a physical or mental impairment or illness.
Need to know

The care and support statutory guidance defines physical or mental impairment or illness as either physical, mental, sensory, learning or cognitive disabilities or illness, substance misuse or brain injury.

Needs that do not arise or result from a mental or physical impairment or illness are not eligible under the Care Act, although the person is likely to need good information and advice about the measures they can take and support that may be available to them in their situation.

See: Providing Information and Advice, which includes access to local and national information and advice resources (general and specialist).

If a person has all or some needs arising, or resulting from a physical or mental impairment or illness you should continue to step 2 in respect of these needs.

Step 2: Do the needs that the person has mean they are unable to achieve 2 or more of the listed outcomes?

This step should be carried out after step 1, where you will have confirmed that the person's needs arise or result from a mental or physical impairment or illness.

There are 10 needs-related outcomes listed under the Care Act:

  • Manage and maintain nutrition;
  • Maintain personal hygiene;
  • Manage toilet need;
  • Being appropriately clothed;
  • Be able to make use of their home safely;
  • Maintain a habitable home environment;
  • Develop/maintain family and other personal relationships;
  • Access/engage in work, training, education or volunteering;
  • Make use of community services;
  • Carry out caring responsibilities for a child.

You need to consider how the needs that have been identified through the assessment process impact on the person's ability to achieve each of the listed outcomes above.

There are likely 3 possible options:

  1. The person is able to achieve the outcome;
  2. The person is unable to achieve the outcome; or
  3. The outcome is not relevant to the person (and therefore their ability to achieve it or not should be disregarded).

Unable to achieve

Under the Care Act a person is deemed 'unable to achieve' a listed outcome if they are:

  1. Unable to achieve it without assistance;
  2. Able to achieve it without assistance but doing so causes them significant pain, distress or anxiety (this is a determination made using your own professional judgement about the impact that achieving the outcome has on the person based on the available evidence);
  3. Able to achieve it without assistance but doing so endangers or is likely to endanger the health and safety of the person or others (if this is unclear there should be supporting evidence available regarding risk); or
  4. Able to achieve it without assistance but takes significantly longer than would normally be expected (this is a determination made using your own professional judgement).

If the person is unable to achieve 2 or more outcomes then you should proceed to step 3 to consider the impact of this on their Wellbeing.

If the person's needs do not affect their ability to achieve 2 or more of the listed outcomes then they do not have eligible needs under the Care Act, although the person is likely to need good information and advice about the measures they can take and the support that may be available to them in their situation.

Fluctuating needs

Where the level of a person's needs fluctuates you must be satisfied that you established the level of need over an appropriate timeframe. You will know this if you have sufficient evidence to demonstrate:

  1. The nature and frequency of fluctuations;
  2. The impact of the fluctuations on other areas of need and Wellbeing.

It is important that there is a consistent approach to applying eligibility criteria when a person has needs that fluctuate. This should allow for flexibility to capture specific needs but should also ensure a fair application to avoid variances in eligibility outcomes for people who have similar needs.

Step 3: Is there a significant impact on Wellbeing?

This step should be carried out after steps 1 and 2 have identified:

  1. That the person's needs arise from, or are the result of a physical or mental impairment or illness; and
  2. That the person is unable to achieve 2 or more of the listed needs-related outcomes as a result of the needs identified in step 1.

Step 3 involves understanding and making a judgement about the impact of the person's inability to achieve the 2 or more outcomes identified on their individual Wellbeing. If the impact on Wellbeing is not significant then the need is not eligible under the Care Act.

Need to know

When deciding whether the impact on Wellbeing is significant or not you should be aware that the term significant impact can be defined in several ways:

  1. A single impact on a single area of Wellbeing that is seen as significant;
  2. A cumulative effect, where several areas of Wellbeing are impacted significantly or where the overall impact is significant.

In some cases, the impact on Wellbeing may not yet be significant, but ongoing instability in the situation means that the impact on Wellbeing is likely to become significant in the near future if support is not provided.

There are 9 domains of Wellbeing described under the Care Act. See: Wellbeing Domains.

The impact of needs on Wellbeing for people with similar needs in similar situations can be very different and you should not make assumptions. A range of factors will influence the impact of needs, including:

  1. Personal resilience;
  2. The personal preferences of the person about how they live their life;
  3. The strength and support of any informal networks of support;
  4. The duration that the needs have been present;
  5. The financial circumstances of the person; and
  6. The accommodation type and area in which the person lives.
Example 1:

Chris has needs that arise from a physical impairment. He has a need for support with personal care each day and with household chores. Chris spends most of his time at home watching television and his reduced mobility means that he also finds it difficult to stand in the kitchen preparing food, having become increasingly reliant on microwave meals.

Chris's family are worried that he is not going out and would like for him to be supported into the local community each week. They would also like for Chris to be supported to prepare a main meal, as this is something he always used to do.

Chris's social care practitioner applies the national eligibility criteria, which establishes that Chris's needs do prevent him from achieving more than 2 of the listed outcomes. However, when talking to Chris about the impact on his Wellbeing he says that he prefers to stay at home watching the television and is enjoying box sets and films, sometimes with his friends who stop by every few days. He also says that, after a few weeks of shopping around has now found some nice ready meals that he is enjoying and finding easier than cooking from scratch.

The social care practitioner finds that Chris has eligible needs in relation to personal care and household chores but not in relation to accessing the community and managing nutrition. This is because the impact on Chris's Wellbeing in those areas is not significant.

Example 2:

Tracy has needs that arise from mental illness. She is employed in a public facing role but after neglecting her personal care needs recently she has been issued with a verbal warning about her appearance at work. Tracy relies on her job to meet the rent for her flat and to ensure that her car is maintained so she can visit her family. The situation she is in is very stressful for Tracy and her motivation to maintain her appearance and also her home environment is deteriorating.

Even though Tracy is physically able to manage her personal care her social care practitioner deems her eligible under the Care Act because she is not currently able to achieve the outcome adequately, neither is she able to access and sustain her employment without some support. This is posing a significant cumulative risk to her Wellbeing in a number of areas. If she loses her job she will be at risk of losing her home, car and being unable to maintain important and therapeutic relationships with her family.

Meeting Ineligible Needs

Under the Care Act the Local Authority has a power to meet needs that have not been deemed eligible, normally under the remit of preventing a crisis or longer term needs through a short term intervention. However, this power should not be used routinely or without authority and you should familiarise yourself with the local policy for meeting ineligible needs.

Where a decision is made to meet an ineligible need the arrangements to do so should be in line with the meeting of eligible needs.

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