NHS Continuing Care

NHS continuing healthcare or fully funded NHS care is when a package of care is provided solely by the NHS which can be provided in hospital, care home or in an individual’s own home. Applying for this funding is a very grey area and not an easy process to go through or understand because it is awarded depending upon whether a person’s primary need is a health need.

Regardless of a person's financial circumstances, it is the responsibility of the NHS to arrange and fund services to meet all the needs in any setting, of people whose health needs have been assessed under the national guidelines as critical, unstable and unpredictable and where their primary need is a health need. Primarily, people who need a high level of supervision and equipment to preserve their life on an ongoing basis are likely to fall into this category.

A review of eligibility for Continuing Care should be taken at 3 months and then annually to ensure that a person continues to qualify for fully funded care.

If, following an assessment , you disagree with the outcome and feel that care should remain fully funded, you should refer to the Health Authority review procedure. The nursing home co-ordinator who may be employed by either the Primary Care Trust, Local Authority or Health Authority, is responsible for ensuring that a person's nursing care needs are met in full and this is the person you should contact and inform of your concerns. The involvement of the nursing home co-ordinator may lead to the Health Authority's continuing care panel reviewing their decision.

There is no cost to you if you qualify for NHSCHC.

If your overall care needs show that your primary need is a health one you should qualify for continuing healthcare. This will be assessed by 4 key indicators:

There is a very useful public information booklet produced by the Department of Health entitled NHS Continuing Healthcare and NHS Funded Nursing Care which covers eligibility, how assessments are carried out and decisions made, reviews and NHS funded nursing care. For those living in Wales, there is an equivalent booklet entitled Continuing NHS Healthcare for Adults in Wales.

People are eligible for NHS continuing healthcare where it can be said that their ‘primary need is a health need’. The decision as to whether a person has a primary health need takes into account the legal limits of Local Authority provision. In order to arrive at the correct decision, use is made of a 'Decision Support Tool' which should support the application of the National Framework.

Using the Decision Support Tool correctly should ensure that all needs and circumstances that might affect an individual’s eligibility are taken into account in making this decision. Further information is available from NHS Continuing Healthcare and there is a very useful page of frequently asked questions that is well worth a read.

What if I still have health needs?

If you’re not eligible for NHS continuing healthcare but you have health needs, the NHS may still pay for part of your care. This is sometimes known as a joint package of care.

One way in which this happens is through NHS-funded nursing care. For more information, see What is NHS-funded nursing care?

Another way is for the NHS to provide other funding or services as part of your care plan. Whether you’re eligible for NHS continuing healthcare or not, you can still use all the NHS services in your area, in the same way as any other NHS patient.

Will there be a charge?

There is no charge for the NHS part of a joint package of care.

Local authorities are allowed to charge for the services they provide, and most of them do so. If your local authority is part-funding your care package, you may have to pay towards the cost of their part of the care, depending on your income and savings. Some authorities have set maximum amounts that you can be charged, which varies from area to area. Further information

If you do not qualify for NHS continuing care and require further information on funding care please see our page entitled 'Paying for Care'.

For further help and advice concerning your eligibility to NHS Continuing care funding, you can request a call from our solicitor by contacting us.

What Is NHS Continuing Health Care?

In England, NHS Continuing Health Care (NHSCHC) is care funded by the NHS. It is available for people aged 18 and above and is provided to meet physical or mental health care needs that have arisen through disability, accident or illness. NHSCHC is care that takes place away from a hospital. Care can be provided in your home or in residential accommodation.

Who Qualifies for NHS Continuing Health Care?

You will qualify for NHSCHC if you are assessed as having a primary health need. The NHS Choices website provides a very unhelpful circular definition of this. A primary health need, it is explained, is one that is on-going and substantial and is related to your health. An assessment will take into account the nature and complexity of your needs; the intensity and severity of your needs, and the unpredictability of your needs.

How Do You Get NHS Continuing Health Care?

In short, you need to be assessed. The assessment is carried out by a multidisciplinary NHS team. There is no right to an assessment, but if it seems that you might need NHSCHC then the Clinical Commissioning Group (CCG) for your area must carry out an assessment.

The fact that you have a long term medical condition is not, of itself, a qualification for NHSCHC. However, the following circumstances are likely to suggest that an assessment is appropriate. 1. Where you are due to be discharged from hospital and you have long term needs, 2 Where a period of intermediate care has come to an end, 3. Where your health declines significantly, 4. Where you are approaching the end of your life, 5. Where you reside in a nursing home and your health care needs are under review and 6. Where your health and social care needs are being assessed as part of a community care assessment.

In most circumstances, there is a two stage assessment process. The first stage is an initial assessment. The purpose of this is to decide if you need a full assessment. The initial assessment may be completed by a doctor, social worker or other health care professional.

The full assessment is carried out by two or more health and/or care professionals. The assessment looks at the following criteria: behaviour; cognition (understanding); communication; psychological/emotional needs; mobility; nutrition (food and drink); continence; skin (including wounds and ulcers); breathing; symptom control through drug therapies and medication; altered states of consciousness; other significant needs.

Each of those criteria (or domains) is assessed on the following scale: no needs; low needs; moderate needs; high needs; severe needs or priority needs. The criteria in bold are assessed, on the full scale, from low through to priority. The criteria in italics are assessed from low to severe. The remainder are assessed from low through to high.

You will be eligible for NHSCHC if one or more criteria are assessed at the priority level or two or more criteria are assessed as severe. You may also be eligible if one criteria is assessed as severe and you have needs assessed in a number or other criteria or a number of criteria are assessed as high and/or moderate.

A two stage assessment is obviously a little time consuming. It can take 28 days from the initial assessment to determine you eligibility by way of a full assessment. Clearly in some cases this is far too slow. There is, therefore, a fast track procedure that can be used where your condition is worsening and/or you are terminally ill.

Who Provides NHS Continuing Health Care Services?

NHSCHC services can be provided by any number of health professionals including physiotherapists, occupational therapists, speech therapists and domiciliary carers. When you are assessed as being eligible for NHSCHC, you will be allocated a personal health budget. This is an amount of money that is used to support the needs that you have. It is similar to the personal budgets allocated by social services to support social care needs.

Just as with a social care personal budget, you can ask for your personal health budget to be paid to you in the form of a direct payment. A direct payment puts you in control of choosing who supplies your services. You don’t have to do this. You may, however, enjoy the freedom and choice that direct payments give you. You can find out more about personal health budgets and direct payments on this page.

Update from 1st October 2018

New National Framework for NHS Continuing Healthcare and NHS Funded Care

The revised 2018 National Framework and will be implemented on 1 October 2018

It sets out the principles and processes of NHS Continuing Healthcare and NHS-funded Nursing Care. This guidance replaces the previous version of the National Framework, published in November 2012.

It is important to note that none of the revised guidance actually changes the Eligibility Criteria

This Guidance is intended to :

  1. Provide greater clarity to individuals and staff, through a new structure and style
  2. Reflect legislative changes since the 2012 National Framework was published, primarily to reflect the implementation of the Care Act 2014
  3. Clarify a number of policy areas, including:
    1. Setting out that the majority of NHS Continuing Healthcare assessments should take place outside of acute hospital settings. This will support accurate assessments of need and reduce unnecessary stays in hospital.
    2. Providing additional advice for staff on when individuals do and do not need to be screened for NHS Continuing Healthcare in order to reduce unnecessary assessment processes and respond to a call for greater clarity on this.
    3. Clarifying that the main purpose of three and 12 month reviews is to review the appropriateness of the care package, rather than reassess eligibility. This should reduce unnecessary re-assessments. d) Introducing new principles for CCGs regarding the local resolution process for situations where individuals request a review of an eligibility decision. The aim is to resolve such situations earlier and more consistently.
    4. Providing clearer guidance, including dedicated sections, on: the roles of CCGs and local authorities, NHS-funded Nursing Care, inter-agency disputes, well-managed needs, and the Fast Track Pathway Tool.

It includes Practice Guidance to support staff delivering NHS Continuing Healthcare. As well as updated Annexes

This revised. The 2018 National Framework has been collaboratively written by the Department, NHS-England and Local Authorities.