If you have looked into care funding for yourself or a loved one you may have heard of NHS Continuing Healthcare. This guide will walk you through what it is, who is eligible and how to claim it.
For those who are assessed as having a ‘primary health need’, NHS continuing healthcare provides a care package that is arranged and funded by the NHS. This package covers the full cost of an individual’s care and residential accommodation as a result of a disability, accident or illness.
Also known as NHS CHC and fully-funded NHS care, this funding is available to adults living in England who are living with intense, complex and unpredictable care needs. Unsimilarly to local authority funding, NHS continuing healthcare is not means-tested.
For those who are receiving care in their own home and are eligible for funding, NHS continuing healthcare will cover the cost of care and the support you need to meet your assessed health and associated care needs. These needs include personal care such as washing, getting dressed and any other day to day tasks.
For those who are living in a care home and are eligible for NHS continuing healthcare, the NHS will cover the cost of your care home fees.
To find out if you are eligible for NHS continuing healthcare, you must undergo an assessment by a team of healthcare professionals. They will assess all of your care needs and find out what help you require, how complex your needs are, how intense they are and how unpredictable they are.
Your eligibility for NHS continuing healthcare is not dependent on any particular diagnosis or condition you are living with, they are based on your assessed needs. However, if your needs change, your eligibility status might also, so it’s best to keep updated.
Being informed and involved with the assessment process is important, you should convey your views about your needs. Any carers and loved ones should also be consulted if needed.
Within 28 days after the initial assessment, a decision regarding eligibility for a full assessment will usually be made.
As stated above, eligibility for NHS continuing healthcare is based on the extent, nature and intensity of your needs, not on diagnosis. However, if upon assessment your dementia needs make you eligible, you can get NHS continuing healthcare.
Unfortunately, there is no clear-cut list of health conditions or illnesses that may make you qualify for NHS continuing healthcare. The only way to find out if you qualify is to ask your GP or social worker to arrange an eligibility assessment. The professionals that carry out the assessment will then recommend whether or not you are eligible to your local Clinical Commissioning Group.
You may be eligible if you struggle with:
As eligibility depends on the complexity, intensity and unpredictability of your needs, here’s what they mean:
It’s important to note that most of those living with long-term care needs will not be eligible for NHS continuing healthcare as the assessment and eligibility criteria are rather strict. It’s also worth noting that the assessments can be complex, so here’s what you need to know.
If it seems like you need NHS continuing healthcare, clinical commission groups (CCGs) will assess you. These are the NHS organisations that commission local healthcare services.
Unless you are moved straight onto the full assessment due to being terminally ill or in need of care urgently, you will first face the initial checklist assessment, this is used to decipher if you will move onto the full assessment.
Upon being told that you are being assessed and you giving your consent, you will be faced with the initial checklist assessment, carried out by a nurse, doctor, social worker or another healthcare professional.
This checklist will cover:
Based on what has been found during the initial checklist assessment, you will either be told that you are not eligible and do not meet the criteria to move onto a full assessment for NHS continuing healthcare or you will be referred for the full assessment.
You should note that just because you have been referred for the full assessment, it does not guarantee that you will be eligible for NHS continuing healthcare. This initial assessment enables those who are eligible to get the opportunity to receive a full assessment.
No matter what the outcome, you will receive a copy of the completed checklist and the healthcare professional who carried out the assessment will record in writing the reasons for their decision and it will be signed and dated.
To see what’s on the checklist, download a blank copy from GOV.UK.
Whilst the assessment process can be quite complex, most people and their families who have been through it say it was worth it.
After your initial screening, you may be able to continue onto the full assessment. This one will be carried out by a team of two or more health and social care professionals who have an understanding of and are involved in your care needs.
The Decision Support Tool is a more detailed version of the checklist above, it will help the healthcare professionals assess the possibility of you being eligible and it will help decide if you should be referred to the next stage.
They will mark each of your care needs as no need, low, moderate, high, severe or priority. You will likely be eligible for NHS continuing healthcare funding if you have at least one priority need or severe needs in at least two areas.
If you have a severe need in one area as well as several other needs, you may still be eligible but it will depend on the complexity, intensity and unpredictability of them.
You and your carer’s views should be taken into consideration during this assessment and you should be provided with a copy of the decision documents, as well as clear reasons for the outcome.
If you are in a position where your health seems to be deteriorating quickly and you are nearing the end of your life, you will likely be considered for the NHS continuing healthcare fast-track pathway. This will help you receive the care and support package to help you with all of your care needs.
These packages are normally put into place as soon as possible, usually within 48 hours.
If you are eligible for NHS continuing healthcare, a care plan now needs to be arranged that meets your assessed needs. There are many different options available depending on your outcome, including support in the comfort of your own home and the option of a personal health budget.
If it is decided that moving into a care home is the best possible option for you, you may be provided with some suitable care homes in your local area. Your CCG will work with you to agree on the best care and support package for your needs.
Care and support packages are decided on depending on your personal care needs. NHS continuing healthcare funding covers:
For those who are eligible for NHS continuing healthcare, your care and support package will be reviewed within three months, then at least annually after this. The review process ensures your existing care package meets your assessed needs.
In the case that your needs have changed, the review will help adjust your package of care or will consider if you’re still eligible for NHS continuing healthcare.
If you are not eligible for NHS continuing healthcare funding but are assessed as requiring nursing care in a care home, you will most likely be eligible for NHS funded nursing care. This means that the NHS will contribute toward the cost of your registered nursing care.
Even if you are receiving other forms of funding or support, NHS funded nursing care is still available if you are eligible.
If you are not eligible and are unhappy with the decision made, you can appeal the decision by asking the CCG to reconsider your case or use the NHS complaints system to pursue your case. You can ask for an independent review of your case if you are still dissatisfied.
Alternatively, you can ask to be referred to your local authority, where they will look if you are eligible for care and support.
Speaking to your doctor or social worker if you think you may be eligible for NHS continuing healthcare is the first step. They can then refer you to the CCG, to whom you will explain why you believe you should be considered.
Your CCG should be able to discuss with you ways that you can have as much choice and control over your care as possible. For example, you could include the use of a personal health budget, which you can use to directly pay for healthcare.
If you or your loved one is happy to move to a different care or nursing home, then this will be okay. However, if moving will harm you or your loved one, you should discuss the move with the CCG.
They will then help figure out the most appropriate arrangements or provide a reasonable choice of homes.
It’s up to you whether you go through the NHS continuing healthcare assessment, it will not be carried out without your consent. However, if you refuse, you may still be eligible for an assessment by the local authority, but there is no guarantee that you will be provided with services.