Accessing Continuing Healthcare Funding Factsheet

A factsheet of practical advice to help you understand the rules on NHS funded care

June 2011

What is continuing care?

Most individuals with care needs either pay for this care themselves or receive partial funding from social services. However if you, or a relative, have what is known as a primary health need, NHS continuing healthcare funding may be available. This is also sometimes referred to as continuing care, fully funded care and, erroneously, continuous care. Such funding will meet the cost of care in a nursing or care home, or in your own home, but the criteria for continuing care eligibility (sometimes referred to as continuing care criteria) are complex and the assessment process, including the continuing care checklist, is often frustrating.

This factsheet on NHS funding for continuing care is designed to answer the question: what is continuing care? It will also help you access NHS continuing healthcare funding in England. (See below for Scotland, Northern Ireland and Wales).

See also How to Challenge NHS Funded Continuing Care Decisions Factsheet

If you would like to speak to an expert on NHS fully funded care about problems accessing funding, please call Cate Searle on 01273 609911 to arrange a discounted fixed fee interview.

Basics of NHS continuing healthcare funding v ‘social care’ funding

Eligibility for continuing healthcare funding in England is determined against continuing care criteria by the local primary care trust (PCT). To qualify, an individual’s care needs must be not merely incidental to the provision of accommodation and not of a nature that social services could be expected to provide.

These are difficult concepts, but basically distinguish a person’s social needs (typically associated with older age and declining physical or cognitive functioning) from more complex, intense or unpredictable primary health needs. NB, anyone aged 18 or over with a primary health need should also qualify for fully funded care.

Establishing eligibility for continuing healthcare is not as simple as showing that nurses look after an individual. Nor is it as straightforward as having a certain medical diagnosis – there is no simple continuing care criteria.

PCTs and the national framework for NHS continuing healthcare

Historically many older or disabled people wrongly paid for healthcare, because of inadequate guidance and flawed or non-existent assessments of their needs. The
national framework and decision support tool, introduced in England on October 1 2007, aimed to establish a fairer and more consistent system for determining when an individual’s care should be covered by NHS continuing health care.

However the legal principles set out in the well known case of Pamela Coughlan still apply: the individual’s needs must be of a nature, complexity, intensity or unpredictability such that they are not merely incidental to the provision of accommodation and not of a nature that social services could be expected to provide.

How need is assessed – continuing care criteria

Central to the national framework is the primary health need test. Unfortunately, the phrase is not defined. The concepts of nature, intensity, unpredictability and complexity of the individual’s need are still relevant, but the PCT will use the decision support tool to assess the level of need in 12 care domains.

This continuing care criteria assessment process is used alongside other evidence to determine whether an individual has a primary health need, as opposed to a social care need (where costs are not covered by the NHS).

So what should you do to ensure the right NHS continuing healthcare decision is made?

Request a healthcare needs assessment
Make sure the PCT assesses healthcare needs at an early stage – preferably at the time of, or before, social services assesses finances. PCTs now have to take reasonable steps to ensure an assessment is carried out in cases where there may be a healthcare need – for example, when someone is discharged from hospital to a nursing or care home. However, this may not happen automatically and you should ask.The first stage should be the application of the continuing healthcare checklist (also referred to as the continuing care checklist) to determine if a full assessment is necessary.

The continuing healthcare checklist is a basic screening tool and may result in a person being told they do not qualify for funding or for a full assessment. Look carefully at the paperwork and seek advice if the PCT refuses to undertake a full assessment.

Check the assessment
Ask for a copy of the decision support tool document (DST). This is usually completed by the PCT nurse assessor, in consultation with the multi-disciplinary team involved in an individual’s care. You may be told you need an Enduring or Lasting Power of Attorney to get copy documents: seek advice if you do not have this formal authority. You or your relative should be asked to comment on the DST. Check the document and any supporting evidence to ensure it is an accurate picture of your relative’s healthcare needs. For instance:

• Does it take into account supervision or specialist mental health nursing requirements as a result of dementia or Alzheimer’s?
• Is a need defined as moderate when it should be high, severe or priority?
• Has the assessor under scored a need because it is well managed by the carers?

Have your say
Put your comments in writing and ask for them to be presented to the PCT, alongside the decision support tool and the multi-disciplinary team’s recommendations. The decision on NHS continuing healthcare funding will normally be made by a PCT panel at a closed meeting.

Get specialist advice
If the correct assessment procedure has not been followed, or the assessment or funding decision is wrong, ask the PCT to register a review – it costs nothing and you can withdraw if a solicitor or specialist advisor suggests you have no prospect of success. Act quickly as most PCTs set deadlines for registering appeals.

Request reassessments
If your relative does not qualify for NHS continuing healthcare funding ask the PCT to reassess eligibility if their health declines and their healthcare needs increase.

Investigate all possibilities
If the PCT decides your relative does not qualify for NHS funding and social services suggest you sell your relative’s home to pay fees, ask a specialist if there is any way the value of the family home should be ignored by the financial assessment. Social services have some discretion to ignore the value of a home in assessing an individual’s ability to pay, but they will not exercise this unless asked.

Check your relative is getting all the benefits they are entitled to as a self-funding resident, in particular attendance allowance and funded nursing care payments. Another alternative to selling the home is a deferred payment agreement (social services loan funding).

If you would like to discuss problems with accessing NHS funding for care (including what is sometimes referred to as continuous care funding and NHS funded care) please contact Cate Searle on 01273 609911 or email Cate@ms-solicitors.co.uk.