Continuing Healthcare Adults

NHS Continuing Healthcare means a package of ongoing care that is arranged and funded solely by the National Health Service (NHS) for the relatively small number of people who have a ‘primary health need’ (see more in Primary Health Need section below).  This care is provided to people aged 18 or over to meet health and associated social care needs due to disability, accident, or illness.

NHS Continuing Healthcare is free, unlike support provided by local authorities, which may involve you making a financial contribution depending on your income and savings.  The Integrated Care Board (ICB) in each area is responsible for deciding the appropriate package of support for someone who is eligible for NHS Continuing Healthcare.

If you are over 18 years of age and are assessed as having a ’primary health need’, you are entitled to NHS Continuing Healthcare.  Eligibility is not dependent on a particular disease, diagnosis, or condition, nor on who provides the care or where that care is provided.

We have a process using a Checklist followed by a full assessment of eligibility for NHS Continuing Healthcare.  More information can be found later in this guide.

You can receive NHS Continuing Healthcare in any setting (apart from some hospitals) – including in your own home or in a care home.  If you are found to be eligible for NHS Continuing Healthcare in your own home, the NHS will pay for a package of care and support to meet your assessed health and associated social care needs.  If you are found to be eligible for NHS Continuing Healthcare in a care home, the NHS will pay for your care home fees, including board and accommodation.

No.  The NHS care package provided should meet your health and associated social care needs as identified in your care plan.  The care plan should set out the services to be funded and/or provided by the NHS.  In some circumstances you might wish to buy extra private care services, but this decision must be voluntary.  Any additional services that you choose to purchase should not be meeting the assessed needs the ICB is responsible for.

Not necessarily.  If you are eligible for NHS Continuing Healthcare, your care will be funded by the NHS.

You should normally have a review of your care package after 3 months, and then every 12 months.  The focus of these reviews should be on whether your care plan or arrangements are still meeting your needs.

If your needs have changed to such an extent that they might impact on your eligibility for NHS Continuing Healthcare, then a full reassessment of eligibility may be arranged.  This may mean your funding arrangements change, as eligibility for NHS Continuing Healthcare is based on needs rather than on the condition and/or diagnosis (See more in ‘Reviews’ section below.)

The concept of a ‘primary health need’ helps decide which health services the NHS should provide to meet your needs, and which services may be provided by local authorities.  We understand that this is not straightforward.  However, to decide whether you have a primary health need, we will assess your eligibility by looking at all your relevant needs in relation to four key characteristics:

• Nature: describes the characteristics and type of your needs and the overall effect they have on you, including the type of interventions needed to manage them.
• Intensity: the extent and severity of your needs and the support required to meet them, including the need for sustained/ongoing care.
• Complexity: how your needs present and interact and the level of skill needed to monitor the symptoms, treat the condition(s) and/or manage the care.
• Unpredictability: the amount your needs fluctuate and create challenges in managing them, including the risks to your health if adequate and timely care is not provided.

If you have a primary health need, you will be eligible for NHS Continuing Healthcare.

You can read more about primary health need in the National Framework

The assessment of eligibility and decision-making should be person-centred.  This means placing you at the heart of the assessment and planning of your care.

We also make sure you can play a full role in your assessment process and receive the support to do this if you need it.  You could do this by asking a friend or relative to act as your representative and help explain your views.

The full assessment for NHS Continuing Healthcare usually involves two steps: screening using the Checklist Tool, and a full assessment of eligibility using the Decision Support Tool (DST).  There is also a ‘Fast Track’ process which is described below.

The first step in the assessment process for most people is screening using the Checklist Tool.  The Checklist can be used in different settings to help practitioners identify people who may need a full assessment of eligibility.

The Checklist does not indicate whether you are eligible for NHS Continuing Healthcare, only whether you require a full assessment.  It is important to be aware that many people who ‘screen in’ (i.e., have a ‘positive Checklist’) are found not to be eligible once the full assessment has been done.

The Checklist threshold has deliberately been set low to make sure people who may need an assessment have this opportunity.

Screening for NHS Continuing Healthcare should be at the right time and place for you and when your ongoing needs are known.  A Checklist can be completed when you are in hospital or in a community setting.

You should normally be given the opportunity to be there when the checklist is completed, together with any representative you may choose.

Not everyone will need to have a Checklist completed.  There are many situations where it is not necessary, particularly when there is no suggestion that you might need NHS Continuing Healthcare or where you are recovering from a short-term illness and your longer-term needs are not yet clear.

There are two potential outcomes:

• A negative Checklist, meaning you do not require a full assessment of eligibility, and you are not eligible for NHS Continuing Healthcare; or
• A positive Checklist meaning you now require a full assessment of eligibility for NHS Continuing Healthcare.  It does not necessarily mean you are eligible for NHS Continuing Healthcare.

A negative Checklist means you do not require a full assessment of eligibility and therefore you are not eligible for NHS Continuing Healthcare.  If you believe this Checklist outcome is inaccurate, then you can ask us to look at it again.

A positive Checklist means that you require a full assessment of eligibility for NHS Continuing Healthcare.  We will arrange for this full assessment to take place.  Having a positive Checklist does not necessarily mean you will be found eligible for NHS Continuing Healthcare.

For the full assessment of eligibility, a multidisciplinary team of professionals (usually referred to as the MDT) will assess whether you have a primary health need using the Decision Support Tool (DST).

An MDT is made up of two or more professionals and will usually include both health and social care professionals who know about your health and social care needs, and, where possible, have recently been involved in your assessment, treatment, or care.

We will identify a Clinician to co-ordinate the assessment process and this person should be your main point of contact.

The assessment will, with your permission, involve contributions from a range of professionals involved in your care to build an overall picture of your needs.  This is known as an ‘assessment of needs’.  Your own views will be given appropriate weight alongside professional views to help achieve an accurate picture of your needs.  The MDT will then use the information from your assessment of needs to complete a DST.

Eligibility for NHS Continuing Healthcare is based on your needs, not on your diagnosis or condition.  The DST collates and presents the information from your assessment of needs in a way that helps consistent decision-making about eligibility.  The DST brings together and records your various needs in 12 ‘care domains’, which are broken down into a number of levels.

The purpose of the tool is to help the MDT assess the nature, complexity, intensity, and unpredictability of your needs – and so recommend whether you have a ‘primary health need’.

The MDT will make a recommendation to the ICB as to whether you have a primary health need, which will determine your eligibility for NHS Continuing Healthcare.  The ICB should usually accept this recommendation, except in exceptional circumstances and with clearly articulated reasons for their decision.

The eligibility decision regarding NHS Continuing Healthcare should normally be made within 28 calendar days from the date we received notification that you needed a full assessment of eligibility (normally through a positive Checklist), though in some situations it will take longer than 28 days for a decision to be made.  You will be informed in writing as soon as we can, giving clear reasons for the decision.  We will also explain your right to request a review of the decision.

If you have a rapidly deteriorating condition which may be entering a terminal phase, then you may require a fast track assessment to receive urgent access to NHS Continuing Healthcare funding.

On the Fast Track Pathway there is no need to complete a Checklist or the DST.  Instead, an appropriate clinical practitioner will complete the Fast Track Pathway Tool to establish your eligibility for NHS Continuing Healthcare.

This clinician will send the completed Fast Track Pathway Tool directly to us (or the ICB).  A care package should then be arranged for you, normally within 48 hours from receipt of the completed Fast Track Pathway Tool.

We will review your care needs and the effectiveness of your care package.  Sometimes, we will need to reassess your eligibility for NHS Continuing Healthcare using the DST.  If this is necessary, we will explain the process to you.

If you are not eligible for NHS Continuing Healthcare, we can refer you to your local authority who can discuss with you whether you may be eligible for support from them.  If you are not eligible for NHS Continuing Healthcare but still have some health needs, then the NHS may still pay for part of your package of support.  This is known as a ‘joint package of care’.  One way in which this is provided is through NHS-funded Nursing Care.  The NHS might also provide other funding or services to help meet your needs.

If the local authority is funding some of your care package, then depending upon your income and savings, you may have to pay them a contribution towards the costs of that part of your care package.  There is no charge for the NHS elements of a joint package of care.

Whether or not you are eligible for NHS continuing healthcare, you are still entitled to make use of all the other services from the NHS in your area in the same way as any other NHS patient.

Please see the ‘Individual Requests for a Review of an Eligibility Decision’ section below for more information on your rights if you are dissatisfied with the outcome of your eligibility decision.

If you are eligible for NHS Continuing Healthcare, we will plan your care, commission services and manage your case.  We will discuss options with you as to how your care and support needs will be best provided for and managed.

When deciding how your needs will be met, we will consider your wishes and preferred outcomes.  This will include discussions about your preferred setting to receive care (such as at home or in a care home) as well as how your needs will be met and by who.

The NHS care package provided should meet your assessed health and associated social care needs, as identified in your care plan.

You should normally have a review of your care package within 3 months of a positive eligibility decision being made.  After this you should have further reviews at least once a year or when there are any changes in your needs.

The focus of these reviews should be on whether your care plan or arrangements are still appropriate to meet your needs.  If not, your care plan will be adjusted.

The most recently completed DST will normally be available at the review and is used as a point of reference to identify any potential change in needs.

If your needs have changed in a way that may impact on your eligibility for NHS Continuing Healthcare, then the ICB may arrange a full reassessment of eligibility.

Neither the NHS nor the local authority should withdraw from an existing care or funding arrangement without a joint reassessment of your needs, and without first consulting with one another, and with you, about any proposed change in arrangement.  We will also make sure that alternative funding or services are put into effect.

If you disagree with a decision not to proceed to full assessment of eligibility for NHS Continuing Healthcare following screening using the Checklist, you can ask the ICB to reconsider the decision.

If you disagree with the eligibility decision (after a full assessment of eligibility including the completion of the DST), or if you have concerns about the procedure followed to reach the decision, you can ask us to review your case through a local resolution process (see Appeals section).

Where it has not been possible to resolve the matter through the local resolution process, you can apply to NHS England for an independent review of the decision.  NHS England can consider asking the ICB to try to resolve your case before the independent review.

Following an independent review, if the original decision is upheld but you remain dissatisfied, you have the right to make a complaint to the Parliamentary and Health Service Ombudsman (PHSO) who are independent of the NHS.

Any patient has a right to complain about any aspect of the service they receive from the NHS, the local authority or any provider of care.  Details of the complaints procedure will be available from the relevant organisation.

For people in care homes with nursing, registered nurses are usually employed by the care home itself.  To fund the nursing care by a registered nurse, the NHS makes a payment direct to the care home.  This is called ‘NHS-funded Nursing Care’ and is a standard rate contribution towards the cost of providing registered nursing care for those individuals who are eligible.  Local authorities are not permitted to provide or fund registered nursing care (except in very limited circumstances).

Registered nursing care can involve many different aspects of care.  It can include direct nursing tasks as well as the planning, supervision and monitoring of nursing and healthcare tasks to meet your needs.

Determining Eligibility for NHS-funded Nursing Care;

Your eligibility for NHS Continuing Healthcare should always be considered before a decision is reached about your need for NHS-funded Nursing Care.

You are eligible for NHS-Funded Nursing Care if:

• you do not qualify for NHS Continuing Healthcare but have been assessed as needing the services of a registered nurse and it is determined that your overall needs would be most appropriately met in a care home with nursing; and
• you live in a care home that is registered to provide nursing care.

You may not need to have a separate assessment for NHS-funded Nursing Care if you have already had a full MDT assessment of eligibility for NHS Continuing Healthcare, as in most cases this process will give sufficient information for the ICB to decide on the need for NHS-Funded Nursing Care.

If necessary, your ICB can arrange for an assessment to help determine whether you are eligible for NHS-funded Nursing Care.  This decision could be based on a nursing needs assessment which specifies your day-to-day care and support needs.  People who do not require a full assessment of eligibility for NHS Continuing Healthcare can still be eligible for NHS-funded Nursing Care.

NHS-funded Nursing Care is based on a single-band rate.  This rate is the contribution provided by the NHS to support the provision of nursing care by a registered nurse.  If you are eligible for NHS-funded Nursing Care we will arrange for a payment at the nationally agreed rate to be made directly to your care home.  The balance of the care home fee will then be paid by you, your representative, or your local authority (or a combination of these) unless other contracting arrangements have been made.

We will usually review your need for NHS-funded Nursing Care after 3 months, then at least annually.  At these reviews we will also consider whether your needs have changed such that you are either no longer eligible for NHS-funded Nursing Care or that you might now be eligible for NHS Continuing Healthcare.  To decide whether you might now be eligible for NHS Continuing Healthcare, a Checklist will normally be completed at the NHS-funded Nursing Care review.  However, where a Checklist and/or DST have previously been completed and there has been no material change in your needs then it should not be necessary to repeat the Checklist or the DST.