Last Updated: December 16, 2024
This guide is designed to explain what NHS Continuing Healthcare (NHSCHC) funding is, how to apply for it and appeal if necessary, how to qualify, and the difference between NHSCHC and NHS-funded nursing care (NHSFNC).
What is NHSCHC funding?
NHSCHC is available to those who are found to have a ‘primary health need’ during a comprehensive assessment process. It is funded by the NHS and is payable whether you live at home or in a care home.
NHSCHC is not automatically awarded for certain health conditions, and it is not means tested. The only criteria is that you are found to have a primary health need. During the application process all care and medical records are reviewed and these therefore need to be detailed and full to be of value. Sadly, a lot of applications are not successful due to incomplete records.
Any package of care must meet your assessed health and associated social care needs.
The application process
The National Framework for NHS Continuing Healthcare and NHS funded nursing care applies in England. This sets out the principles and processes for deciding eligibility and can be viewed here.
If a person has long term needs a CHC checklist is completed. This determines if a full assessment via a decision support tool (DST) is needed. The checklist can be completed by a social worker, GP or a health and care professional. The checklist and the DST consider 12 domains in total including:-
- Cognition;
- Behaviour;
- Communication;
- Nutrition;
- Skin viability;
- Psychological and emotional needs;
- Mobility;
- Breathing;
- Drug therapies and medication;
- Altered states of consciousness (ASC); and
- Any other significant needs
The checklist rates the need in each domain as A (high), B (moderate) or C (no and low needs). If there are two or more A’s or five or more B’s or one A and four Bs or A in any of the domains that has a priority level of need (breathing, behaviour, drug therapy and medication or ASC) then you will require a full assessment (DST).
A referral is made to your local Integrated Care Board (ICB) and the DST should be completed within 28 days of that referral. The DST will be considered at a multidisciplinary assessment (MDT) which should consist of two health professionals from different professions or one healthcare professional and one community care assessor. These assessors should have knowledge of your health and social care needs and have been involved in your care.
You and your representative or attorney should be given the opportunity to attend and contribute. Your view is important to the assessment and appropriate weight should be given to this.
It is a good idea to have your own notes and records ready to contribute to the assessment. Keep details of all conversations with the various professionals as very often the records relied on at this assessment can fall short. Sometimes carer turnover can be high, and this can contribute to shortcomings in the record keeping. If the person’s behaviour is unpredictable, it needs to be recorded every time. Very often the care records fail to accurately reflect the true level of need as the carers soon become conditioned to dealing with it. It is therefore important that you/your carer keep your own records and encourage carers to record every detail. In addition, spend some time preparing for the assessment by completing a DST yourself to have an idea of the process and what you think the levels of need are. Always report the level of need as it is on the persons worst day. The assessment is a negative one and focuses on what someone can’t do.
At the MDT the DST is completed and a summary of your needs recorded at every domain. A rating is then recorded for each domain. This should cover everyone’s views on the rating. Once this is complete the MDT make a recommendation to the ICB as to your eligibility. In addition to the record of needs they also look at the four key characteristics which are:-
- NATURE – the type and features of your physical, mental and psychological needs;
- COMPLEXITY – how the needs interact to affect the management required to treat them;
- INTENSITY – the severity of your needs and how that increases the level of support required;
- UNPREDICTABILITY – how this affects the level of support to manage your needs and how it can impact on the safety of all those involved.
The MDT give a clear recommendation of a primary health need if there is:-
- a priority level need in any domain;
- two or more severe levels of need in any domains.
In addition, a primary health need can be evidenced by a finding of one severe level together with needs in several other domains or a number of domains with high or moderate needs.
The needs should always be linked in to the four characteristics mentioned above.
As an example, someone who fights on occasion if they are receiving personal care, refuses medication, lashes out at other residents or carers, is unable to reliably communicate their needs at any time, takes more than 30 minutes to eat a meal or is disorientated in time and place at all times, might be found to have a primary health need and be eligible for NHSCHC. This would be because the level of need in behaviour might be priority or severe and high and severe in the other domains. Considering the levels with the key characteristics could show a primary health need.
The ICB is expected to respond to the MDT recommendation within two working days and only departs from the recommendation in exceptional circumstances.
The decision will be communicated in writing along with details of the period of eligibility or how to appeal if not found eligible. No decision is permanent and can be overturned if your needs change.
If approved, the ICB will pay for your care from the date of the decision however, if there is undue delay by the ICB (more than the 28 days) it should reimburse for funds paid from day 29.
As at 31st March 2024, the previous quarter showed the standard referral success rate was 16%
The appeal process
In the event of a negative response, you have just six months to appeal.
The letter of appeal should very carefully set out the reasons for appeal and why you feel levels are incorrect. Your notes and records will be invaluable here and you should refer to evidence to support your claims.
In addition, you should also refer to any failures to consider the four characteristics and how they apply to the needs overall.
Any failure to follow the Framework should be pointed out. For example, did the MDT consist of at least two professionals? One from healthcare and one from socialcare? Did they refer to all the care and medical records, was notice given? Did you get invited to attend or get spoken to? Did at least one of the assessors know your case sufficiently well? All of these are highly relevant and need to be pointed out in your letter of appeal.
There are two stages of the appeal process. First a Local Resolution (LR) managed by the ICB, and they will publish their LR process. They try to resolve informally first and if no resolution a meeting will be arranged. They will share its decision with you and if you still don’t agree you have another six months to ask NHS England to independently review. They will arrange an independent review panel to review the process and decision. As at the 31st March 2024 for the previous quarter, only 13% of appeals to the LR were successful.
The IRP decision should be followed by NHSE and ICB. If you still disagree you can refer to the Parliamentary and Health Ombudsman within 12 months.
A retrospective review can be carried out and if approved the ICB will reimburse you for the period NHSCHC should have been applied.
If you are not eligible for NHSCHC, you may still be entitled to NHSFNC (NHS-funded nursing care) which is a fixed rate and paid to your nursing home by the ICB. The standard rate of NHSFNC from 1st April 2024 is £235.88. Find out more about NHS funded nursing care here.
Fast track tool for NHSCHC
If you have a rapidly deteriorating condition that is entering a terminal phase you may be eligible for fast tracking for NHS CHC removing the need to go through the DST process.
Statistics
As at 31st March 2024 there were 52,096 people in receipt of NHSCHC and of those 34,055 were eligible via the standard DST process and 18,041 eligible via the fast track tool.
Summary
It is important to remember that none of the NHSCHC or NHSFNC funding is means tested and can be applied for even if you own your own home and have savings.
Another misconception is that you must have a diagnosed condition or that you must live in a care home. None of these assumptions are true.
The statistics show that the process is difficult and NHSCHC is awarded to those with the greatest health need.
For further information, contact Associate Lucie Glover, Furley Page Solicitors: Tel 01227 763939 or email [email protected]. Visit www.furleypage.co.uk
