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NHS Continuing Healthcare Funding is a term that is often spoken about when it comes to paying for care fees, but many people are unaware as to how it actually works, due to the complex criteria required for eligibility.

With this in mind, Compass CHC Director Tim Davies has outlined a “back to basics” summary regarding continuing healthcare funding.

NHS Continuing Healthcare Funding is a form of funding provided by the National Health Service to meet the costs of an individual’s care in its entirety where it can be established that the need for care is primarily a health need. It is in no way means tested and meets the cost of the care wherever the individual is located. It is irrelevant whether they are receiving care in their own home, in a nursing home, or in a residential home; the key point is that the need for care is due to a health need.

Before any determination as to whether an individual should have to pay for their care and how much they should have to pay is decided – or even considered – it must first be determined that their needs are primarily health needs. This package of care can be received in any setting outside of hospital including care homes, hospices or even within your own home. It is incorrect to state that a person can only be eligible for continuing healthcare funding if they are in a nursing home. Their health needs, not their location, is the key factor.

How is NHS Continuing Healthcare Funding secured?

The entitlement to continuing healthcare funding is made up of a two-stage assessment process.

Stage 1 – NHS Continuing Healthcare Funding Checklist

The checklist assessment may be conducted by a variety of health and social care practitioners who can complete the checklist in a variety of settings. This can include NHS Registered Nurses, General Practitioners or other clinicians, or local authority staff such as Social Workers and Social Care Assistants. The checklist can be conducted in the individual’s own home, in hospital pending discharge or in a community care setting. The circumstances of who is responsible for completing the NHS Continuing Healthcare checklist is dependent upon the particular preferences and practices adopted by the local Clinical Commissioning Group.

The checklist is intended to be a relatively quick and straightforward process. Accordingly, it is not necessary to submit detailed evidence with the checklist; however, it is expected that there should be references to evidence that has been used to support statements selected in each of the domains of assessment. It is, therefore, not appropriate to say that a checklist cannot be conducted due to evidence not being available at that time. In such circumstances, a checklist should not be delayed, and the assessment process should proceed.

The checklist assessment looks at 11 domains which are:

1. Behaviour

2. Cognition

3. Psychological & Emotional Needs

4. Communication

5. Mobility

6. Nutrition

7. Continence

8. Skin Integrity

9. Breathing

10. Drug Therapies & Medication, Symptom Control

11. Altered States of Consciousness

An individual’s needs in each of these areas are scored on the basis of either being A, B or C in their severity, with A being the highest scoring. Whether somebody is deemed as being suitable for a referral for a full assessment of eligibility will depend on how many As and Bs are scored by an individual. The criteria are as follows.

2 or more A scores

1 A and 4 B scores

5 B scores

In such circumstances, an individual will then be referred for a full Decision Support Tool assessment of eligibility for NHS continuing healthcare funding.

Stage 2 – What is a Decision Support Tool NHS Continuing Healthcare Funding Assessment?

A multi-disciplinary team (MDT) is defined as being two professionals who are from different healthcare professions, or one professional from a healthcare profession and one who is responsible for assessing individuals for community care services under Section 47 of the National Health Service and Community Care Act 1990. This is ordinarily a Social Worker on behalf of the local authority.

The process of the completion of the Decision Support Tool by the MDT involves working through each of the 11 domains that mirror those contained within the continuing healthcare funding checklist assessment. The difference is, however, that rather than being scored on an A, B or C basis, the individuals needs in each domain are scored as being either no needs, low needs, moderate needs, high needs, and in the instance of certain domains, severe or priority needs.

What happens if MDT members cannot agree on a scoring level within the domain of the DST?

Where it is the case that there is disagreement between a particular scoring on a specific level on a certain domain, the National Framework for NHS Continuing Healthcare Funding dictates that the individual should not be penalised, and the level decided upon should be the higher of the two in dispute between the MDT members.

The MDT DST recommendation should include a summary of the individuals needs in light of the identified domain levels, as well as statements regarding the nature, intensity, complexity and unpredictability of the individual’s needs. Dependent upon this summary there should be a recommendation as to whether or not the individual has a primary health need in the view of the multi-disciplinary team.

What if I do not agree with the decision regarding the entitlement to NHS Continuing Healthcare Funding?

There are two stages involved with dealing with any requests for a review of an eligibility decision for NHS Continuing Healthcare Funding.

Firstly, a local review process at CCG level and secondly, a request to the board which they then may refer the matter to an Independent Review Panel. Accordingly, if there is any dispute on the part of the family regarding the eligibility outcome and recommendation for NHS Continuing Healthcare Funding, there is an appeal process available to challenge the decision.

Should you or a relative have any concerns or queries regarding NHS Continuing Healthcare Funding and whether a relative should be paying for their care costs then, please do not hesitate to contact Compass Continuing Healthcare Team directly on 0121 227 8940. Our team will be happy to provide a free, no obligation, and confidential service discussing the particular circumstances and advising you as to what, if anything, may be done.