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Practical advice to help you understand the rules on NHS continuing healthcare funding

Funding for care can be a confusing subject.  However, by carrying out a little research and utilising resources available to you, your options become clearer and easier to understand.  This web page is designed to help you appropriately access NHS continuing healthcare funding in England.  It will also provide guidance in the event that NHS continuing healthcare funding is not available to support your particular needs.

What is continuing care?

Most individuals with care needs either pay for their care themselves, or receive partial funding from social services.  However, if you have what is known as a primary health need, NHS continuing healthcare funding may be available.  This is also sometimes referred to as continuing care, fully funded care and continuous care.  Such funding will meet the cost of care in a nursing or care home, or in your own home.

Clinical Commissioning Groups (CCGs) and the national framework for NHS continuing healthcare funding

The national framework and decision support tool, introduced in England on October 1 2007, aimed to establish a fairer and more consistent system for determining when an individual’s care should be covered by NHS continuing healthcare funding.

How is a primary health need defined?

If your overall care needs show that your primary need is a health need, you should be eligible for NHS continuing healthcare funding.

Whether someone has a ‘primary health need’ is assessed by looking at all of their care needs and relating them to four key indicators:

  • Nature – this describes the characteristics and type of the individual’s needs and the overall effect these needs have on the individual, including the type of interventions required to manage those needs.
  • Complexity – this captures how the individual’s needs present and the level of skill required to monitor the symptoms, treat the condition and/or manage care.
  • Intensity – this is the extent and severity of the individual’s needs and the support required to meet them, which includes the need for sustained/on-going care.
  • Unpredictability – this is about how hard it is to predict changes in an individual’s needs that might create challenges in managing them, including risks to the individual’s health if adequate and timely care is not provided

How is a primary health need assessed?

The first step for most individuals is the Checklist Tool.  This is a screening tool to help health and social care staff work out whether needs might possibly be of a level or type that might make the individual entitled to NHS continuing healthcare funding.  The Checklist will usually be completed when someone is assessing or reviewing health or social care needs.  The Checklist does not indicate whether the individual is eligible for NHS continuing healthcare, only whether they require full assessment of eligibility for NHS continuing healthcare.

If a Checklist has been completed and suggests that there is a possibility that you, or your relative, might be eligible for NHS continuing healthcare funding, the individual completing the Checklist will contact your CCG which will arrange for a multidisciplinary team to carry out an up-to-date assessment of needs.

A multidisciplinary team is made up of two or more health and social care professionals who are involved in your care, or the care of your relative.  The assessment will, with your permission, involve contributions from all of the health and social care professionals involved to build an overall picture of your, or your relative’s needs.  In some cases, the multidisciplinary team will also ask for more detailed specialist assessments from these professionals.

The multidisciplinary team will use the information from the assessment to complete a Decision Support Tool which will assess your, or your relative’s, healthcare needs in 12 care domains including mobility, nutrition and behaviour.   The purpose of the tool is to help decide what is the nature, complexity, intensity and unpredictability of your needs, thereby defining whether your primary needs are health needs.  Each domain is sub-divided into statements of need which represent no needs, low, moderate, high, severe or priority levels of need.  You or your relative will be scored accordingly against these.

The multidisciplinary team will then make a recommendation to the CCG as to whether you are eligible for NHS continuing healthcare funding. A clear recommendation of eligibility for NHS continuing healthcare would be expected in each of the following cases:

  • A level of priority needs in any one of the four domains that carry this level.
  • A total of two or more incidences of identified severe needs across all care domains.

NHS continuing healthcare funding may also be provided if there is:

  • One domain recorded as severe, together with needs in a number of other domains
  • A number of domains with high and/or moderate needs

In these cases, the overall need and the interactions between needs in different care domains will be taken into account by your local NHS in deciding whether a recommendation of eligibility for NHS continuing healthcare should be made.

In all cases, you should be sent a written decision as to whether you are entitled to NHS continuing healthcare funding, together with reasons for the decision

What should you do if you are not happy with the outcome?

1. Request a healthcare needs assessment

Make sure that your local NHS assesses your healthcare needs at an early stage. The NHS has a duty to take reasonable steps to ensure that an assessment is carried out in cases where there may be a healthcare need.  However, this may not happen automatically and you should ask for an assessment to be made. The first stage of this assessment should see the application of the continuing healthcare checklist (also referred to as the continuing care checklist) to determine if a full assessment is necessary.

2. Check the assessment

A full assessment will be completed with the support of a decision support tool (DST).  This is usually completed by an NHS nurse assessor, in consultation with the multi-disciplinary team involved in your or your relative’s care.  You should be asked to comment on the DST and you should make sure that this happens. Check the document and any supporting evidence to ensure that it is accurately scored (See ‘How need is assessed’ section) and a true picture of your healthcare needs.  For instance:

  • Is a need defined as moderate when it should be high, severe or priority?
  • Has the assessor under scored a need because it is well managed by the carers?

3. Have your say

If you disagree with a decision which has been made then you can ask the CCG to register a review by putting your comments in writing.  You should ask for your comments to be presented to the CCG, alongside the decision support tool and the multi-disciplinary team’s recommendations.  The decision on NHS continuing healthcare funding will normally be made by a CCG panel at a closed meeting.  It will be important to act quickly as most CCGs set deadlines for registering appeals.

If the CCG review maintains the original decision, you can ask for the case to be referred to the CCGs independent review panel (IRP).  You can also apply directly to the IRP if the local resolution stage is taking too long.

If you’re still not satisfied with the outcome of an independent review, you can ask for your case to be reviewed by the Parliamentary and Health Service Ombudsman.

Next steps

Request reassessments

If you do not qualify for NHS continuing healthcare funding you should always ask the CCG to reassess eligibility in the event of your healthcare needs increasing.

Private Funding

Should you not be eligible for NHS continuing healthcare funding, or would simply prefer to fund your care privately, you will need to source your care independently.  Faced with so many different options and conflicting information, this can become both a time-consuming and overwhelming task.

If you are looking for support with financial planning, we would recommend that you contact an impartial Financial Advisor specialising in Care Fees.  They can discuss options such as:

  • Equity Release
  • Funding Care fees
  • Estate preservation
  • Wealth Preservation

Voyage Specialist Healthcare can support your care needs.

Whether your care is paid for by private or public funds, Voyage Specialist Healthcare can deliver a high quality, person centred, reliable and responsive homecare service to you.

If you would like to receive a quote for our care at home service, which is based on your, or your relative’s individual care needs, please contact our friendly team on  01429 239 616.


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