NHS Continuing Healthcare

Nearly all treatment provided by the NHS is free and un-beknown to many this can also include long term care, but only if your need is primarily a medical or health need not just a social need to help with maintaining independence.

This is called NHS Continuing Healthcare or “Hospital Based Complex Clinical Care” in Scotland and can be provided in any setting (your own home, hospice, or care home) although if you live in Scotland, it will only paid all the time your needs can only be met in hospital or NHS Hospice.

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Who is eligible for NHS Continuing Healthcare?

Eligibility is not means tested but only assessed on whether you primarily have a health need, not just needing help with activities of daily living (such as needing help to get dressed or use the toilet). If it is your care would be fully funded by the NHS.

Key indicators as to what may constitute a primary health need include the nature, intensity, complexity and unpredictability of the need.

Everyone who needs care should therefore ensure they are assessed. to see if they would qualify for NHS Continuous Care as then the care needed would be fully funded entirely by the NHS.

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How do you qualify for NHS Continuing Healthcare?

Firstly, you need an assessment.

This will normally be carried out after any discharge from hospital if it’s clear you may need some further assistance, but if not, haven’t been in hospital but need care and feel you might qualify, you can request one by ask your Local Authority Adult Social Care team to arrange one, or if residing in a care home, ask the Manager to request one. Alternatively, you can contact your local Integrated Care Board.

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What are the criteria for NHS Continuing Care?

In England an initial assessment is carried out by a single trained assessor using an new initial checklist to assess whether there is any chance of qualifying and if so a more detailed assessment is carried out by 2 or more professional using a more detailed Decision Support Tool.

If this more indepth assessment deems you should qualify, a recommendation is made to your Integrated Care Board, who will be ultimately responsible for deciding whether you qualify or not.

Both the initial checklist and the more detailed decision support tool looks at 12 different domains or need areas and the support tool also rates you as either low (L), moderate (M), high (H), severe (S) or in some cases priority (P) in each domain:-

Behaviour - L,M, H, S, P
Cognition - L,M, H, S, P
Psychological and emotional needs L,M,H
Communication L,M,H
Mobility_ L,M,H, S
Nutrition – food and drink - L,M,H, S
Continence – L,M,H
Skin and tissue viability – L,M,H,S
Breathing - L,M, H, S, P
Drug therapies and medication: symptom control - - L,M, H, S, P
Altered states of consciousness - L,M, H, S, P
Other Significant Care Needs – L,M,H,S

Results
If this preliminary checklist results in;-

• 2 or more of the above categories being assessed as "High" (or just one if it is a need which carries a priority rating), or
  
• Being assessed as "Moderate" in 5 or more categories (unless there is also one which meets the high level when only 4 need to be "Moderate").
  

A full assessment using the decision Support Tool should be undertaken.
Should this more detailed assessment indicate

• There is a priority need in any of the four domains carrying this level or
  
• There is a total of two or more incidences of identified severe needs across all domains."
  

A recommendation of eligibility for NHS Continuing Care should then be made to your Integrated Care Board . Likewise if the assessment suggests that there is:-

• One domain recorded as severe, together with needs in a number of other domains; or
  
• A number of domains with high and / or moderate needs
  

This can also indicate a primary health need.

However please note neither of the above outcomes on their own will determine whether you are eligible, with the final decision being taken by your Integrated Care Board after also taking into account the healthcare's experience and judgement.

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Terminal illness

If your claim for NHS Continuing Healthcare is because you or your relative is entering a terminal phase due to a rapidly deteriorating condition and you need a package of care to be put in place urgently, you can ask a Ward Sister or GP to consider an immediate provision of NHS Continuing Healthcare provision under the Fast Track process. If an assessment makes a recommendation for urgent care your Integrated Care Board should accept it and provide it immediately but can then reassess using the usual decision making support too

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For how long will you continue to receive NHS Continuing Healthcare?

If your health merits it, you may receive NHS Continuing Healthcare indefinitely, but your ongoing entitlement will be subject to regular reviews.

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Reviews

Even if successful and you are awarded funding a review of eligibility will be carried out after three months and then again each year.

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Appealing a decision

If at the checklist stage you are told you do not meet the criteria for NHS Continuing Healthcare and are therefore not given a full assessment, you can first ask to see your paperwork and then challenge the assessment through the NHS Complaints process.

Should your appeal be successful, the cost of services they deem you need and you have incurred should be refunded to you.

Should you still be unhappy you could take your complaint to the Parliamentary and Health Service Ombudsman (PHSO) The PHSO can be contacted on 0345 015 4033 or via their website www.ombudsman.org.uk.

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Will my pensions and benefits be affected if I receive NHS Continuing Healthcare?

The affect receiving NHS Continuing Healthcare will have on other benefits will depend on where you receive your care.

Care at Home – Social Security Benefits and State Pensions shouldn't be affected, so you will still be able to claim AA or DLA as long as you meet the eligibility criteria for these benefits.

Living in a Care Home – State pensions not affected (nor any private or occupational ones) but you will lose Attendance Allowance or care component of DLA /PIP after 28 days. Any mobility element of DLA or PIP can continue to be received but only if in a Residential Care Home but would be lost if it is a Nursing Home.