What is NHS Continuing Healthcare?

NHS continuing healthcare is free care which can be provided in any setting (your own home, hospice, or care home) that is arranged and funded by the NHS to meet physical and/or mental health needs that have arisen because of disability accident or illness. NHS continuing healthcare is also sometimes described as NHS Continuous Care or fully funded NHS care.

NHS Continuing Healthcare who is eligible?

Anyone who is assessed as having a certain level of needs may receive NHS Continuing Healthcare. It is not dependent on disease; diagnosis or who or what care is provided. Providing your need is primarily a health need and not just a social care need, you could be eligible for NHS continuing healthcare.
Key indicators as to what may constitute a primary health need include the nature, intensity, complexity and unpredictability of the need. It can also take into account the likelihood of any increase in your needs prior to any next scheduled review.

How do you qualify for NHS Continuing Healthcare?

Firstly you need an assessment. If you are being discharged from hospital an initial assessment using the NHS Continuing HealthCare Checklist should be done as part of the discharge process unless it is deemed that it would be better to defer doing one in order to arrange some intermediate care or care at home to allow for rehabilitation when it would be done after a short period.

The Primary Care Trust should ensure that a full assessment is carried out once it is possible to assess you, but will remain responsible for paying for your care during any interim period. You should check that an assessment has been done and if not you should ask for one to be done.

If you are already resident in a nursing home and feel that you should be entitled to continuing care, ask the home manager to arrange an assessment which will be done by a nurse, doctor or other qualified healthcare professional.

What are the criteria for NHS Continuing Care?

In England a new National Framework for NHS Continuing Care was introduced in Oct 2007 and with it a new initial checklist to assess whether a more detailed assessment is even necessary and if so a more detailed Decision Support Tool to be used by a multi-disciplinary team of professionals (comprising at least 2 different people from different disciplines) to try and avoid the inconsistencies previously encountered around the country and therefore more fairly assess people's entitlement to NHS Continuing Care.

The Primary Care Trust (PCT) in whose area your GP practice is located, is responsible for deciding whether you qualify or not.

Both the initial checklist and the more detailed decision support tool looks at 12 different domains or need areas and the support tool also rates you as either low (L), moderate (M), high (H), severe (S) or in some cases priority (P) in each domain:-

Behaviour - L,M, H, S, P
Cognition - L,M, H, S, P
Psychological and emotional needs L,M,H
Communication L,M,H
Mobility_ L,M,H, S
Nutrition – food and drink - L,M,H, S
Continence – L,M,H
Skin and tissue viability – L,M,H,S
Breathing - L,M, H, S, P
Drug therapies and medication: symptom control - - L,M, H, S, P
Altered states of consciousness - L,M, H, S, P

Other Significant Care Needs – L,M,H,S

The preliminary checklist will ask the person doing it (which can be either a GP or nurse visiting a patient at home or in a residential home, a nurse in a hospital prior to discharge or even social worker who is carrying out a community care assessment), whether the person being assessed simply exceeds the high level of need statement, meets it or "clearly does not meet it".

  • If this preliminary checklist results in;-
  • 2 or more of these categories being assessed as "exceeds the standard" (or just one if it is a need which carries a priority rating), or
  • in 5 or more categories the person meets the standard (unless there is also one which meets the high level when only 4 need to meet the standards).

A full assessment using the decision support tool should be undertaken to assess more comprehensively the persons physical, mental, psychological and emotional needs.

Should this more detailed assessment indicate

  • There is a priority need in any of the four domains carrying this level or
  • There is a total of two or more incidences of identified severe needs across all domains."

A recommendation of eligibility for NHS Continuing Care should be made to the Primary Care Trust. Likewise if the assessment suggests that there is:-

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

This can also indicate a primary health need.

However please note neither of the above outcomes on their own will determine whether you are eligible, with the final decision being taken by the Primary Care Trusts after also taking into account the healthcare's experience and judgement.

Terminal illness

If your claim for NHS Continuing Healthcare is because you or your relative is entering a terminal phase due to a rapidly deteriorating condition and you need a package of care to be put in place urgently, you can ask a Ward Sister or GP to consider an immediate provision of NHS Continuing Healthcare provision under the Fast Track process. If an assessment makes a recommendation for urgent care the PCT should accept it and provide it immediately but can then reassess using the usual decision making support tool.

For how long will you continue to receive NHS Continuing Healthcare?

If your health merits it, you may receive NHS Continuing Healthcare indefinitely, but your ongoing entitlement will be subject to regular reviews

Reviews

Even if successful and you are awarded funding a review of eligibility will be carried out after three months and then again each year.

Appealing a decision

If at the checklist stage you are told you do not meet the criteria for NHS Continuing Healthcare and are therefore not given a full assessment you can first ask to see your paperwork and then challenge the assessment through the NHS Complaints process.

Should your appeal be successful, the cost of services they deem you need and you have incurred should be refunded to you.

Should you still be unhappy you could take your complaint to the Parliamentary and Health Service Ombudsman (PHSO) The PHSO can be contacted on 0345 015 4033 or via their website www.ombudsman.org.uk.

If you live in Scotland you should initially ask the individual assessor for a second opinion. Thereafter appeal to the NHS Board (within 14 days) and they should appoint another competent professional to review the case. If you still disagree ask the Works Department for a final decision carried out by a competent person,

In either country should you want a specialist solicitor to appeal on your behalf, let us know and we can arrange this for you.

Will my pensions and benefits be affected if I receive NHS Continuing Healthcare?

The affect receiving NHS Continuing Healthcare will have on other benefits will depend on where you receive your care.

Care at Home – Social Security Benefits shouldn't be affected nor your pensions, so you will still be able to claim AA or DLA as long as you meet the eligibility criteria for these benefits. However any benefits which are based on local social services paying for caring might be affected they stop being responsible for your care if you receive NHS
Continuing Healthcare.

Living in a Care Home – State pensions not affected (nor any private or occupational ones) but you will lose Attendance Allowance or DLA after 28 days.

Alternative funding – Long Term Care or Care Fee Annuities

Should your appeal finally be unsuccessful and you do not qualify for Continuous NHS funding and your capital precludes you from Local Authority funding then one way you can help cap the cost of care is to consider a Long Term Care Annuity or Care Fee Annuity which is a plan provided by specialist insurers where they guarantee to meet the cost of care indefinitely in return for a single one off premium.

We are specialists in long term care annuities. If you would like us to obtain a free no obligation quotation, please complete our enquiry form and we will call you back to discuss it further. To simply find out more about Long Term Care or Care Fee Annuities then click here