What Conditions Qualify for NHS Continuing Healthcare?

NHS continuing healthcare is a package of care provided by the NHS for people who have been assessed as having a ‘primary health need’. If eligible, the NHS will entirely arrange and fund your care. This article explains whether there are specific medical conditions that qualify for continuing healthcare, and other things you need to know about eligibility.

NHS continuing healthcare is available to people who require care in England, Wales and Northern Ireland. In Scotland, this was replaced by Hospital Based Complex Clinical Care in 2015 (this works very similarly to continuing healthcare).

In this article:

1. What medical conditions make you eligible for NHS continuing healthcare
2. Having a primary health need
3. Examples of things that could make you eligible for NHS continuing healthcare
4. How difficult is it to get NHS continuing healthcare?
5. Other things to know about eligibility
6. What happens if I’m not eligible for NHS continuing healthcare?
7. What happens during the NHS continuing healthcare assessment process?

What Medical Conditions Make You Eligible for NHS Continuing Healthcare?

Eligibility for NHS continuing healthcare isn’t determined by a particular condition you have or a diagnosis you’ve received. Instead, eligibility depends on whether you’re classed as having a ‘primary health need’.

While people with cognitive conditions or brain disorders such as Alzheimer’s disease or Parkinson’s disease often qualify for continuing healthcare, this isn’t guaranteed. Your daily care needs as a result of your condition and how these needs should be met will be considered.

Having a Primary Health Need

People with a primary health need have significant ongoing physical and/or mental health requirements, with any care you receive being focused on treating these needs. If you have a primary health need, your care requirements are beyond what your local authority can legally provide, which is where the NHS steps in.

The following will be considered when determining if you have a primary health need:

• The care and support you require on a regular basis
• How complex and intense your needs are
• How unpredictable your needs are

Examples of Things That Could Make You Eligible For NHS Continuing Healthcare

While there isn’t a set list of medical conditions to follow, people with any of the following are often eligible for NHS continuing healthcare:

• Cognitive conditions such as a form of dementia
• Challenging behaviour
• Life-changing injuries as a result of an accident
• Complex physical care needs, such as through advanced multiple sclerosis (MS) or motor neurone disease (MND)
• Complex wound care needs
• A muscular or respiratory disorder
• Limited movement or paralysis (a stroke may have brought this on)
• A different, rare genetic condition

How Difficult Is It To Get NHS Continuing Healthcare?

According to Nuffield Trust, only 21% of people who were assessed for continuing healthcare between January 1st 2024 and 31st March 2024 were found eligible.

This figure greatly varied from integrated care board to integrated care board (these organisations make the final decision about your eligibility).

For example, the eligibility rate in Gloucestershire was 7.3%, while it was just 42.5% in Leicester, Leicestershire, and Rutland.

Other Things To Know About Eligibility

• Eligibility for NHS continuing healthcare isn’t determined by age, so it’s available to older and younger adults
• It isn’t means-tested, meaning how much money you have doesn’t matter. This is where NHS funding and local authority funding differ
• If your needs or the nature of your condition changes, your eligibility may change as well. Your eligibility is usually reviewed three months after a decision is made, and then every year after this
• You can receive continuing healthcare in several settings, including care homes, through home care and in a hospice. In a care home, the NHS will pay for your care home fees, while through care at home, they’ll cover any care and support needed to meet your requirements, including personal care such as help with using the bathroom and getting dressed and undressed

What Happens If I’m Not Eligible For NHS Continuing Healthcare?

If you’ve been assessed as ineligible for NHS continuing healthcare and you’re unhappy with the decision, the decision letter you’ll receive will explain how to appeal. You can ask your local integrated care board to reconsider their decision. You can also ask for an independent review of your case.

You could be eligible for NHS-funded nursing care if you aren’t eligible for continuing healthcare, but you do require care and support from a registered nurse. You have to live in a nursing home to be eligible for funded nursing care.

You’ll be assessed for continuing healthcare before a decision is made about your eligibility for funded nursing care. This means that you usually don’t require a separate assessment for it.

What Happens During the NHS Continuing Healthcare Assessment Process?

Your eligibility for NHS continuing healthcare will be initially worked out by a team of care professionals. They’ll use the Continuing Healthcare Checklist to see how many different areas you require care in.

They’ll then make a recommendation to your local Integrated Care Board (ICB) about whether they think you’re eligible or not. If they think you may be eligible, your local ICB will give you a full assessment. They’ll consider various categories, such as ‘breathing’ and ‘continence’, grading each of these categories on how much care you require for it, before making a final decision about your eligibility.

If eligible, a care package will be created to meet your assessed needs. The NHS may work with your local authority to create this care package.

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