Nearly all treatment provided by the NHS is free. This continues at any age and will apply to any hospital treatment you receive as an in patient but it can also apply in limited cases, to more ongoing or long term care you need when older where there is an ongoing medical issue. This is called NHS Continuing Healthcare.
NHS continuing healthcare is free, non means tested care which can be provided (if you live in England or Wales in any setting your own home, hospice, or care home) and 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. However, if you live in Scotland since June 2015 it has been re-named "Hospital Based Complex Clinical Care" to reflex the fact that for any new Scottish residents who wish to apply, it is only available if you need to remain living in a hospital or NHS hospice . If you are able to be discharged, even if you still need a care home or any private/charitable hospice, any Hospital Based Complex Clinical Care previously awarded, will cease and apart from Scotland's free Personal Care Contribution ( and if necessary Nursing Care contributions), you will be financially means tested to see if you need to pay for your accommodation costs. However any previously awarded former NHS Continuing Healthcare award will still be paid all the time your needs still merit it.
In England and Wales anyone who is assessed as having a certain level of needs may receive NHS Continuing Healthcare. It is not dependent on disease; diagnosis or (in England and Wales where 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. Therefore everyone who needs long term care should ensure they are assessed to see if they would qualify as then the care needed would be fully funded by the NHS
Key indicators as to what may constitute a primary health need for anyone living in England or Wales 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. In Scotland it is simply offered now only when your needs couldn't be met in any other setting than a hospital.
Firstly you need an assessment. If you live in Scotland this would only be carried out by a consultant or specialist whilst in hospital. For English or Welsh residents, 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 you would benefit from some interim rehabilitation when it would be done during this.
Your Local Clinical Commissioning Group should ensure that a full assessment is carried out once it is possible to assess you, and will remain responsible for paying for your care during any interim period. To find the address of your local CCG check find your Clinical Commissioning Group.
If you are already resident in a nursing home and feel that you should be entitled to continuing care, ask the home manager or your GP to arrange an assessment which will be done by a nurse, doctor or other qualified healthcare professional.
In England a new National Framework for NHS Continuing Care was introduced in Oct 2007 and with it a new initial checklist the 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.
Your local Clinical Commissioning Group, 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
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, 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;-
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
A recommendation of eligibility for NHS Continuing Care should then be made to the Clinical Commissioning Group . Likewise if the assessment suggests that there is:-
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 local Clinical Commissioning Group after also taking into account the healthcare's experience and judgement.
In England or Wales 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 CCG should accept it and provide it immediately but can then reassess using the usual decision making support tool. In Scotland only if you need to remain in hospital or an NHS Hospice will you qualify for Hospital Based Complex Clinical Care but any other NHS or local authority services should still be provided free.
In England or Wales if your health merits it, you may receive NHS Continuing Healthcare indefinitely, but your ongoing entitlement will be subject to regular reviews. As we have already seen, if you live in Scotland and new Complex Clinical Care award will only last whilst you need to remain living in hospital or an NHS Hospice.
Even if successful and you are awarded funding a review of eligibility will be carried out after three months and then again each year.
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. If you are denied to see a copy of the completed assessment contact either a solicitor specialising in care fees, the Independent Complaints Advocacy Service (ICAS) or Citizens Advice Bureau.
If the full assessment suggests you do not qualify for NHS Continuing Healthcare or you disagree with the type and/or choice of service offered, if you live in England ask your Clinical Commissioning Group to refer it to review it. The CCG should attempt to resolve this issue by meeting with you or your solicitor and explain why you have been declined and / or explain the procedures undertaken in greater detail. If you are still unhappy and feel the criteria has been wrongly applied or the process flawed, you can ask your CCG to get in touch with the NHS National Commissioning Board or you can contact them yourself and they should have your case heard by an Independent Review Panel (IRP).
Should your appeal be successful and the IRP overturns the CCG, 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 Director of the relevant NHS Board (within 14 days) and they should appoint another competent professional to review the case.
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 the care might be affected if they stop being responsible for your care when 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.
Should you not qualify and any appeal is unsuccessful, your need for care becomes the responsibility of your local authority, not the NHS and your local authority is duty bound to financially assess you to see if you can pay for your own care.
They will only provide any help towards your care if your assessable capital is below just (£23,250 England, £24,000 Wales or £26,250 Scotland 2015/16).
These thresholds includes all bank accounts, savings, investments, national savings you have in your own name, plus where married or in a civil partnership, also 50% held in any joint accounts. It also includes any money believed to have been deliberately given away over any time period (not just 7 years) if at the time care could have been foreseen and the net value of any main residence (unless a spouse or civil partner or certain qualifying relatives) will remain living in it. Consequently many people do not qualify and have to fund their own care.
There are a number of ways self-funders can fund their care (visit Paying for care – understanding your choices if you need to be a self-funder), but there not many better ways of ensuring ongoing quality care can continue and putting a cap on the total cost than a care fees funding plan (previously called a care fees annuity).
These are specialist care fee plans which you can buy with just a one off single premium and in return get a guarantee income for life to pay the fees. Not only this, but as the benefits are normally paid directly to any care provider by the insurer, the income is TAX FREE. It is also portable, so no matter whether you need to change care providers, it will continue to pay for the rest of your life.
Find out for yourself just how affordable a care fees funding plan could be. Get you free market comparison from ALL providers easily by completing your details here and one of our advisers will call you back to discuss them.
Please note: These plans are not offered direct by the insurers
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