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Introduction: NHS Continuing Healthcare Funding
The National Health Service (NHS) in England offers a specialized funding program known as NHS Continuing Healthcare (CHC) Funding or NHS Continuing Care Funding This initiative, often referred to as NHS CHC, is designed to cover the entire spectrum of social care costs for individuals with complex, ongoing health needs that may necessitate substantial, round-the-clock care and support through CHC funding.
Unlike means-tested social care services, eligibility for NHS Continuing Healthcare is not contingent upon an individuals’ financial status. Instead, it hinges on a comprehensive assessment of the individual’s health condition, the complexity of their care requirements, and the intensity of support needed to address their unique needs effectively.
It’s crucial to understand that having a terminal illness alone does not automatically qualify someone for NHS Continuing Healthcare. The key determinant is the presence of a complex medical condition that demands substantial, ongoing care, as determined through a rigorous assessment process.
Geographical Availability of NHS Continuing Healthcare Funding
NHS Continuing Healthcare Funding is readily available to eligible individuals residing in England and Wales. However, the assessment process and eligibility criteria may vary slightly between these two regions.
In Northern Ireland, a similar program known as Continuing Healthcare exists, but the assessment procedures and guidelines differ from those outlined in this guide.
Unfortunately, NHS CHC Funding is not available in Scotland, as the country operates under a distinct healthcare system with its own set of provisions for social care funding.
Scope of Coverage: What Does NHS Continuing Healthcare Funding Encompass?
If individuals are deemed eligible for NHS Continuing Healthcare, their local NHS authority, which is now managed by an Integrated Care Board (ICB) within the Integrated Care System (ICS), will take full responsibility for organising and funding their care package. This comprehensive care package is tailored to address the specific needs identified during the assessment process, ensuring effective care planning, care coordination, and care management.
Since July 2022, Clinical Commissioning Groups (CCGs) have been replaced by Integrated Care Boards (ICBs) as part of the Integrated Care Systems (ICSs) established under the Health and Care Act 2022. More information about ICBs can be found here. Also, see this blog from 2022 about ICBs.
The responsibility of organising and funding care packages for individuals eligible for NHS Continuing Healthcare lies with the ICBs. These boards are tasked with ensuring that the care packages meet the specific needs identified during the assessment process.
For individuals residing in care homes, the funding from NHS Continuing Healthcare covers the entirety of the care home fees, including costs associated with personal care, specialised equipment, and any other related expenses. If the chosen nursing home’s fees exceed the NHS’s typical rate, the individual may be asked to relocate to an alternative facility. However, if such a move poses a potential risk to their health or well-being, the NHS is obligated to take this into consideration.
Conversely, for those living independently in their own homes, NHS Continuing Healthcare covers the costs of professional carers who assist with daily living activities such as eating, bathing, dressing, and other essential tasks. Additionally, the program covers laundry services and any necessary equipment, such as hoists or mobility aids.
It’s important to note that NHS Continuing Healthcare does not cover expenses related to food, clothing, rent or mortgage payments, or utility bills. These costs remain the responsibility of the individual or their family.
The Assessment Process: A Step-by-Step Guide
Accessing NHS Continuing Healthcare involves a comprehensive CHC assessment process designed to evaluate an individual’s eligibility. This assessment criteria typically unfolds as follows:
1. Initial Consideration
Health and social care professionals regularly assess individuals’ needs during various situations, such as hospital discharges, care assessments, annual reviews in care homes, or instances of rapid health deterioration. If they identify a potential need for NHS Continuing Healthcare, they will initiate the care assessment process by notifying the local care commissioning organisation.
Individuals or their family members can also request an assessment directly from their doctor, district nurse, or social worker, without waiting for a professional recommendation. Consent is required for this process.
2. The Checklist Assessment
The initial stage of the assessment process involves the completion of a checklist by a trained health or social care professional. This Checklist Tool evaluates various aspects of the individual’s condition, including breathing, nutrition, continence, skin integrity, mobility, communication, mental capacity, behaviour, symptom control, and medication management. During this assessment, the individual’s consent is required, and they have the right to have a family member or carer present. Additionally, they should receive an informational leaflet about NHS Continuing Healthcare. For further details visit this website.
Based on the checklist assessment, there are two possible outcomes:
- The individual does not meet the criteria for NHS Continuing Healthcare, or
- The individual passes this initial assessment and proceeds to a full assessment.
3. The Full Assessment
If the individual progresses to the full assessment stage, a multidisciplinary team comprising at least two different health or social care professionals involved in their care will conduct a comprehensive evaluation. In Wales, a representative from the local council will also participate in this process, utilising the Decision Support Tool.
The team will review the individual’s needs across various care domains, including behaviour, cognition (understanding), communication, psychological well-being, mobility, nutrition, continence, skin integrity, breathing, symptom control, and any other relevant needs.
For each category, the assessors will assign a rating of ‘priority’ (the most urgent), ‘severe,’ ‘high,’ ‘moderate,’ ‘low,’ or ‘no needs,’ based on the CHC scoring system.
If the individual scores ‘priority’ in at least one area or ‘severe’ in at least two areas, they may be eligible for NHS Continuing Healthcare Funding. Additionally, eligibility may be granted if the individual scores:
- “Severe” in one area and “high” or “low” in several other areas, or
- “High” or “moderate” in numerous areas.
The assessors will then provide their care recommendation regarding the individual’s eligibility for NHS Continuing Healthcare to the care commissioning authority.
4. Final Decision
The care commissioning authority holds the final authority to award or deny NHS Continuing Healthcare based on the assessors’ recommendation. They will communicate their decision to the individual in writing as soon as possible, along with an explanation of the reasons behind their decision, ensuring they have the individual’s consent.
Expedited Assessment: The Fast-Track Pathway
In cases where an individual’s condition is rapidly deteriorating, and they may be approaching the end of their life, they may be eligible for the fast-track assessment process. This streamlined pathway, known as Fast Track CHC funding, aims to ensure that appropriate care and support are put in place as quickly as possible, typically within 48 hours, using the Fast Track Tool.
Successful Applications: What Happens Next?
If individuals are deemed eligible for NHS Continuing Healthcare, the care commissioning authority will collaborate with them to develop a comprehensive care and support plan. This plan will be reviewed after three months to ensure its effectiveness and continued alignment with the individual’s needs. Thereafter, annual care reviews will be conducted to assess the plan’s ongoing suitability.
The care commissioning authority should assign a dedicated contact person to oversee the individual’s NHS Continuing Healthcare support. While the authority can manage the continuing healthcare budget on behalf of the individuals, they also have the option to request a personal health budget. This alternative allows people to exercise greater control over how the funds are allocated and spent, empowering them to tailor their care according to their specific preferences and requirements.
Appealing a Denial: Your Rights and Options
If an individual’s application for NHS Continuing Healthcare is denied, they have the right to appeal the decision. The specific appeal process varies depending on the stage at which the denial occurred. For more information about appeals, a very useful website to look at is Care to Be Different.
Initial Assessment Denial
If the application is rejected at the initial checklist assessment stage, the individual can request a reassessment or a full assessment from the care commissioning authority.
Full Assessment Denial
In the event of a denial following the full assessment, the individual can request a review of the decision from the care commissioning authority. If they remain dissatisfied after the review, they can escalate their case to an independent review panel.
Alternative Funding Options
Even if an individual does not qualify for NHS Continuing Healthcare, they may still be eligible for other forms of support:
- NHS-Funded Nursing Care If the individual requires nursing care in a care home but does not meet the criteria for NHS Continuing Healthcare, the NHS may contribute a flat-rate payment to the care home to help cover the costs of their nursing care. This is known as NHS funded nursing care.
- Joint Package of Care In some cases, the NHS and the local council may share the costs of the individual’s care through a joint package arrangement, without the need for an additional assessment.
- Local Council Support If individuals are ineligible for NHS Continuing Healthcare, they can request a care needs assessment from their local council. Based on the assessment results, the council may recommend various support services, such as paid carers, home modifications, or assistive equipment, to help people maintain their independence and quality of life.
Claiming Reimbursement for Past Care Costs
In certain circumstances, it may be possible to make a retrospective claim for NHS Continuing Healthcare on behalf of a deceased loved one, provided they passed away on or after April 1, 2012. If the claim is successful, the individual’s estate may be eligible for a refund of some or all of the care costs incurred, such as nursing home fees.
However, it’s important to note that the processing of these claims can be time-consuming due to a backlog of cases. The Parliamentary and Health Service Ombudsman provides further guidance on pursuing complaints related to continuing healthcare funding.
Impact on Benefits and Entitlements
For individuals receiving NHS Continuing Healthcare while living independently in their own homes, their entitlement to benefits such as Attendance Allowance, Disability Living Allowance, and Personal Independence Payment remains unchanged.
However, if the NHS is covering the costs of a care home placement, the care component of Disability Living Allowance and the daily living component of Personal Independence Payment and Attendance Allowance will typically cease after 28 days. It’s important to note that pension payments are generally unaffected by NHS Continuing Healthcare funding.
To obtain further information and guidance regarding the impact on benefits and entitlements, individuals can contact the government’s Disability Service Centre or seek assistance from charitable organisations like Turn2Us.
Preparing a Compelling Case: Tips and Strategies
Navigating the application process for NHS Continuing Healthcare can be complex and challenging. To increase the chances of a successful outcome, it’s advisable to take the following steps:
1. Gather Comprehensive Documentation
Compile a thorough dossier of medical records, assessments, and any other relevant documentation that substantiates the individual’s health condition, primary health need, and the impact on his or her daily life. This evidence will be crucial in demonstrating the complexity and intensity care requirements.
2. Seek Professional Guidance
While it is not mandatory to engage the services of a solicitor or representative to pursue an NHS Continuing Healthcare claim or appeal, some individuals may find it beneficial to seek professional expertise. Experienced professionals with a deep understanding of the framework can provide valuable guidance and support throughout the process, potentially increasing the likelihood of a successful outcome with proper consent.
3. Involve Family and Carers
Actively involve family members, friends, and carers who have firsthand knowledge of the individual’s condition and care needs. Their input and perspectives can provide invaluable insights and corroborate the assessment findings with proper consent.
4. Maintain Detailed Records
Meticulously document all interactions, communications, and decisions related to the NHS Continuing Healthcare application process. This record-keeping will not only aid in tracking progress but also serve as a valuable resource in the event of an appeal or further action, ensuring all necessary consent is properly recorded.
5. Persist and Advocate
The application process for NHS Continuing Healthcare can be lengthy and frustrating, with potential setbacks or denials along the way. It’s essential to remain persistent, advocate for the individual’s rights, and exhaust all available avenues for appeal or reconsideration if necessary, ensuring that consent is always respected and documented.
Conclusion: Navigating the Complexities with Confidence
Securing NHS Continuing Healthcare funding can be a challenging endeavour, but with the right knowledge, preparation, and perseverance, it is possible to navigate the process successfully. By understanding the eligibility criteria, assessment procedures, and appeal options outlined in the National Framework, individuals and their families can confidently advocate for their rights and access the comprehensive care and support they need, especially when a primary health need is identified.
Remember, the key to a successful outcome lies in thoroughly documenting the individual’s condition, engaging professional guidance when necessary, and persistently pursuing all available avenues until a satisfactory resolution is achieved, particularly when addressing a primary health need as defined by the National Framework.
With this comprehensive guide, you now have the knowledge and tools to demystify the complexities of NHS Continuing Healthcare and ensure that those with complex, ongoing health needs receive the care and support they deserve, in line with the National Framework and their primary health need.