Individuals with a primary health need are entitled to fully funded care from the NHS.
What is NHS Continuing Healthcare?
NHS Continuing Healthcare is a complete package of ongoing care arranged and funded by the NHS for individuals found to have significant, ongoing healthcare needs as a result of an accident, disability or illness.
If you are living in a care home, the NHS will make a contract with your provider to pay the fees in full, including your accommodation and care.
If you receive care at home, the NHS will fund an appropriate package of provision for your health and personal care needs to suit your circumstances.
The National Framework 2018
The National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care 2018 sets out the principles and processes for establishing your eligibility for NHS Continuing Healthcare.
When assessing a patient for NHS Continuing Healthcare funding, the National Framework provides guidance to be followed. It sets out a national assessment process and provides the assessment tools to support and streamline decision making: the Checklist Tool, the Decision Support Tool and the Fast Track Tool.
One of the core values of the National Framework is that access to assessments, decision making, and provision should be fair and consistent. It considers your own particular circumstances when shaping the assessment process, ensuring you are able to participate in making good, informed decisions about your ongoing and future care.
The assessment process
Establishing eligibility for NHS Continuing Healthcare funding rests with the specific Clinical Commissioning Group (CCG) holding the contract with your GP practice at the time of any assessment. Eligibility decisions for NHS Continuing Healthcare rest on whether or not your need for care is primarily due to a health need. There are two stages in the assessment process:
- Checklist Assessment
- Multi-disciplinary Assessment
There is also a Fast Track process for individuals who require urgent consideration.
The Checklist Tool has been designed to help healthcare providers identify those patients who need a full assessment for NHS Continuing Healthcare. It can be carried out by a nurse, doctor or other healthcare or social care professional on behalf of the CCG.
Once it has been agreed that a full assessment is required, there will be a second and more comprehensive multi-disciplinary assessment of your health and social care needs. Twelve distinct care domains or areas of need have been identified. These are sub-divided into different bands for scoring purposes (priority, severe, high, moderate, low and no needs). The levels will reflect the nature, intensity, complexity and unpredictability of your condition.
The twelve care domains are:
- Skin integrity
- Psychological/emotional needs
- Drug therapies, medication and symptom control
- Altered states of consciousness
- Other significant care needs
In order to complete this stage of assessment, a multidisciplinary team (MDT) meeting will be held to discuss your levels of need and complete a Decision Support Tool (DST). To ensure all physical, mental health and social care needs are taken into account, an appropriate mix of health and social care professionals will be invited to contribute to the assessment, particularly those who are involved in your existing care provision. You and/or your representatives may be invited to attend the MDT and contribute to the discussion, making oral or written representations where appropriate.
The CCG is responsible for making the final decision about whether or not you are eligible for NHS Continuing Healthcare. Once a decision has been made, it should be communicated to you as soon as possible.
To be eligible for NHS Continuing Healthcare, it must be shown through your assessment that the nursing care you receive goes beyond nursing care that is merely incidental to or ancillary to the provision of your accommodation.
A clear recommendation of eligibility to NHS Continuing Healthcare would be expected in each of the following cases:
- A level of priority needs in any one of the four care domains (as listed above) that have priority weighting
- A total of two or more incidences of identified severe needs across all care domains
- A primary health need may also be indicated in a case where there is:
- One care domain recorded as ‘severe,’ together with needs in a number of other domains, or
- A number of care domains with high and / or moderate needs
This will require careful consideration by the CCG, taking into account the combination of needs. If assessed as eligible, your needs ought to be reviewed after three months and thereafter on an annual basis.
The National Framework states the time between Checklist Assessment and a final decision on eligibility should be no longer than 28 days, unless there are exceptional circumstances.
Challenging a decision
Decisions on eligibility can be challenged in writing to the CCG requesting a review, no later than six months from the date on which the decision was communicated.
How Moore Barlow can help
There are many individuals who are not awarded NHS Continuing Care funding following assessment who should be entitled to full funding. We specialise in assisting individuals and their families with the assessment process to ensure that the assessment is robust and takes into account all of that person’s care and support needs. Alternatively, if the NHS has decided not to fund your care, our expert community care team can also advise you on the prospects of making a successful appeal or challenge.