What is NHS Continuing Healthcare?
NHS Continuing Healthcare is care arranged and fully funded by the NHS, for individuals who have a need for significant, ongoing health care outside of hospital. Continuing Healthcare packages are available in England, Northern Ireland and Wales.
There isn’t a specific set of conditions that are covered by the scheme. Eligibility is based on the level and complexity of an individual’s health care needs.
Who can get Continuing Healthcare?
Anyone aged over 18 years who is assessed by the NHS as having ‘a primary health need’ (where health care is considered to be that person’s primary care need) is eligible for Continuing Healthcare.
This form of care is most often awarded to people in care homes who have the most complex or unpredictable medical care needs due to disability, accident or illness. It means that the full cost of the care home fees are covered, including room and board. In some cases it can also be awarded for care in the home.
Although the criteria for Continuing Healthcare funding are strict and complex, it’s always worth pursuing if you think you may qualify. To apply for the scheme, ask your GP or social worker to arrange an NHS Continuing Healthcare assessment.
In the end I rang Continuing Healthcare and asked if the funding could be transferred to a residential home. They said yes, and that I could choose the home if I found one that had vacancies. I was amazed!
What is a primary health need?
The concept of ‘primary health need’ is the key factor used to decide whether someone’s care needs should be met by the NHS or the local authority. Put simply, you have a primary health need if dealing with health issues is the most important aspect of your care needs, over and above your need for social care.
Only people deemed to have a primary health need are eligible for NHS Continuing Healthcare. But deciding whether someone is eligible is not as straightforward as it may sound.
A strict assessment process is used to identify whether or not there is a primary health need. The assessment looks at the following aspects of your health needs:
- Nature: the type of health needs you have and the impact they have on you.
- Intensity: how serious your needs are and the level of support needed to meet them.
- Complexity: the level of medical expertise required to manage your condition.
- Unpredictability: to what extent your needs are likely to fluctuate, making them more difficult to manage.
We explain the assessment process below.
How Continuing Healthcare eligibility is assessed
The assessment is usually a two-step procedure, with an initial screening process followed by a full assessment of eligibility.
All assessments should be completed in line with the National Framework, which sets out the criteria that each local NHS Clinical Commissioning Group (CCG, led by GPs and other health professionals, responsible for buying and arranging care packages for patients in England) should be basing their decisions on.
A member of the NHS or social services staff will carry out a brief assessment of your health needs to see if it would be appropriate to undertake a full eligibility assessment. This part of the process is known as the Checklist Tool.
If the Checklist produces a positive result, you’ll be referred for a full assessment, carried out by a multi-disciplinary team (MDT) of two or more health/social care professionals. With permission, they might interview other professionals involved in your care to build up a full picture of your needs. Sometimes, the multi-disciplinary team will ask for more detailed specialist assessments from these professionals.
The multi-disciplinary team will then use the information they have gathered to complete a Decision Support Tool. This looks at 12 different types of need (for example, mobility, nutrition and behaviour) to help decide on the nature, complexity, intensity and unpredictability of your needs.
The multidisciplinary team will then make a recommendation to the relevant CCG as to whether or not you have a primary health need. This will determine whether or not you are eligible for Continuing Healthcare.
More information about the assessment
You are allowed to have someone with you during your assessment. It can be very helpful to have a family member or friend present to help you communicate your needs and take notes.
For more detailed information about the Checklist and the Decision Support Tool, read the national framework for NHS Continuing Healthcare.
Making the decision
Within 28 days of completing the assessment, the NHS should decide if you’re eligible for Continuing Healthcare. If it takes longer than this and you are then deemed eligible for this support, the NHS should backdate payments to cover the period starting 29 days after the assessment.
The NHS should make a decision within 28 days of it being decided that your loved one needs a full assessment for continuing healthcare.
Getting help when applying for NHS Continuing Healthcare
Which? analysis shows that there appears to be an element of a ‘postcode lottery’ to qualify for Continuing Healthcare. According to the latest NHS England Statistics, the chances of patients receiving the funding can depend on where they live.
If you believe that you or a loved one should be eligible for CHC, the Which? Money Helpline experts assist and guide Which? members with all aspects of social care and local government and NHS funding for care.
You can also contact Beacon, an independent NHS Continuing Healthcare information and advice service, commissioned by NHS England. Trained staff provide free advice for up to 90 minutes through their information and advice service.
Other law firms also offer specialist Continuing Healthcare funding advice. While we can't recommend any firms, when you search online you're likely to see the names Farley Dwek Solicitors (also behind the Care to be Different website), Humphries Kirk Solicitors and Hugh James high in the listings.
Challenging a decision
There are examples of people who are turned down for Continuing Healthcare who then go on to successfully challenge the decision. If you or your loved one is refused NHS funding, you should be given information by the NHS about how to challenge the decision.
What are my options if I’m not eligible for Continuing Healthcare?
If you don’t qualify for NHS Continuing Healthcare, but have been assessed as requiring the services of a registered nurse, you may be eligible for NHS funded Nursing Care (FNC). This is a fixed contribution toward the cost of nursing care paid directly to a care home by the NHS.
Depending on your financial circumstances, you may also qualify for support from your local authority towards the cost of care at home or in a residential care home.
Fast Track Tool
If you’re looking after someone who has urgent needs – because their condition is deteriorating rapidly due to a terminal illness, for example – a Fast Track Tool (known as a Fast Track Assessment in Wales) is used instead of the Decision Support Tool to confirm eligibility.
If your loved one is found to be eligible, their funding from the NHS should be provided as quickly as possible.
Their needs may subsequently be reviewed using the Decision Support Tool. It’s possible that this could result in a different decision and the NHS Continuing Healthcare could be withdrawn.
What happens next?
Following any assessment, you should get a statement of the decision outcome and why it was made.
If you are found to be eligible for NHS Continuing Healthcare, the NHS will pay for:
- At home: healthcare, such as services from a community nurse or specialist therapist; associated social care needs, such as personal care and domestic tasks; help with washing, dressing, preparing meals and shopping.
- In a care home: care home fees, including board and accommodation.
When someone is eligible for Continuing Healthcare, the NHS should take their wishes and those of other family members into consideration when making care arrangements. However, the NHS will make the final decision about where and how care should be delivered.
The NHS has a duty to meet the needs of the individual so they should ensure that common social and psychological needs, such as finding a care home close to the family, are met.
Is it possible to top up NHS Continuing Healthcare with private payments?
Unlike a local authority care package, if you’re awarded NHS Continuing Healthcare it is not possible to pay top-up fees to get a more expensive care package.
The only way to top up a Continuing Healthcare package would be to pay for additional private services on top of the care you’re assessed as needing from the NHS. These additional services would usually need to be provided by different staff and in a different setting.
Will my eligibility be reassessed?
Once you have been granted Continuing Healthcare, you should have an initial review of your care package within three months. This is designed to ensure that suitable arrangements have been put into place. Further reviews should then take place at least once a year. These may be more frequent if your needs are likely to change.
Reviews should focus on whether the care arrangements remain suitable for your needs. They should not normally re-examine your eligibility for support. However, in some circumstances, following a review it may be recommended that your eligibility should be reconsidered – because of a change to your health needs, for example. This would involve a full assessment process being carried out again.
Continuing Healthcare in Scotland
In June 2015 NHS Continuing Healthcare was replaced in Scotland by a new scheme called Hospital Based Complex Clinical Care.
Under the new scheme, NHS funding is limited to patients who need to be in hospital in order for their care needs to be properly met. This means that anyone who lives at home, in a care home or in a hospice that isn’t run by the NHS, doesn’t qualify.
Assessments for Hospital Based Complex Clinical Care are carried out by a multi-disciplinary team. They aim to establish the best place for the patient to have their health care needs met.
Patients with complex needs who don’t qualify for NHS funding will have to have to pay some or all of their care and accommodation costs (depending on their financial circumstances). The NHS will still be responsible for meeting the patient's health needs, free of charge.
Anyone assessed as eligible for NHS Continuing Healthcare in Scotland before June 2015 will continue to receive the funding as long as they remain eligible.
For more information about the assessment process in Scotland, visit the Care Information Scotland website.
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