What is NHS Continuing Healthcare?
NHS Continuing Healthcare (CHC) is care arranged and fully funded by the NHS, for individuals who have a need for significant, ongoing health care outside of hospital. CHC 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.
In 2015 NHS Continuing Healthcare was replaced in Scotland by a new scheme called Hospital Based Complex Clinical Care. Under this scheme, NHS funding is limited to patients who need to be in hospital to have their care needs properly met. This means that anyone who lives at home, or in a care home or a hospice that isn’t run by the NHS, won’t qualify. For more information about the assessment process in Scotland, visit the Care Information Scotland website.
Who can get Continuing Healthcare?
Anyone aged over 18 years who is assessed by the NHS as having a ‘primary health need’ is eligible to apply for NHS Continuing Healthcare (CHC). (We explain this in more detail in the next section.)
This form of support 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 cost of the care home is fully covered by the NHS, including room and board. Although it is less common, CHC packages can also be provided to care for someone in their own home.
The criteria for CHC funding are strict and complex, but 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.
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.
How is CHC eligibility assessed?
The CHC assessment is usually a two-step procedure, with an initial screening process followed by a full assessment of eligibility. Here is what you can expect from the assessment process.
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 multidisciplinary team of two or more health or 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 team will ask for specialist assessments from these professionals.
The 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 NHS Clinical Commissioning Group (CCG) as to whether you have a primary health need. This will determine whether 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.
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 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?
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.
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.
How to get help with a Continuing Healthcare application
The application process for Continuing Healthcare (CHC) is complex, and many applicants who believe they may be eligible do not succeed in getting the funding. In addition, our analysis has shown that there can be an element of a ‘postcode lottery’ to qualifying for Continuing Healthcare. The chances of receiving the funding can vary significantly depending on where you live.
There are various organisations who offer support with the application process, but keep in mind that this will usually involve paying substantial fees and will not guarantee that your application is successful.
Beacon (www.beaconchc.co.uk) is an independent Continuing Healthcare support service, which has been commissioned by NHS England. Trained staff provide free advice for up to 90 minutes through their information and advice service. If you require more specific assistance with an individual CHC application, this is not covered by their free advice service and will involve a fee.
There are a number of law firms who provide support with CHC applications and appeals – some advertise their services prominently online. Using a specialist firm to guide you through the process may be beneficial, but you’ll have to pay for their service.
The Which? Money Helpline experts assist and guide Which? members with all aspects of funding long-term care.
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.
How to complain about an NHS assessment
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.
If you’re unhappy with the decision not to offer a full assessment, or feel the outcome of an assessment isn’t right, you can ask the CCG to reconsider its decision. You’ll need to write to the CCG within six months of receiving the assessment.
Ask to see it and ask for an explanation as to the criteria on which the decision was based. If you can’t resolve the issue with the CCG, you can escalate your challenge by requesting a referral to an Independent Review Panel (IRP), arranged by NHS England. If you’re still dissatisfied with the decision of the IRP, then you should be given information on how to refer the case to the Parliamentary and Health Service Ombudsman, which makes final decisions on complaints about the NHS in England, including where there is a dispute about what happened.
For further advice about an NHS complaint:
- In England and Wales, contact the NHS Complaints Advocacy.
- In Northern Ireland, contact the Patient and Client Council
- In Scotland, appeal to the professional that made the decision and the appropriate NHS board. NHS Inform has information on your rights when making a complaint. The Scottish Public Services Ombudsman also has information on making a complaint.
Getting help appealing against a Continuing Healthcare decision
If you or a loved one has been assessed as not eligible for NHS Continuing Healthcare and you want to consider appealing, Beacon has a paid-for service. You can read more about it on this page of their website.
You might also want to let your local Healthwatch know about your issue. Healthwatch is the independent national champion for people who use health and social care services.
Can I 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.
There have been cases of care home providers requesting extra fees for residents who are funded through Continuing Healthcare. This practice is controversial and it has resulted in the Competition and Markets Authority taking action against at least one major care home provider.
- Find out more: Care home provider forced to refund unfair fees
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.