For individuals with long-term, complex health needs, the prospect of managing and funding necessary care can be daunting. In the UK, the National Health Service (NHS) offers a vital support system known as NHS Continuing Healthcare. This fully funded care package is designed to cover health and social care needs outside of a hospital setting, whether in your own home or a care facility. Navigating the process to access this support involves understanding the Continuing Health Care Assessment Tool, a critical instrument in determining eligibility. This guide will provide a detailed overview of this tool, its purpose, and how it impacts access to NHS Continuing Healthcare.
Where NHS Continuing Healthcare Can Be Provided
NHS Continuing Healthcare isn’t confined to hospital walls. It extends to various environments that are more comfortable and conducive to long-term care. This can include the familiarity of your own residence or within the supportive environment of a care home. The flexibility in location ensures that care is tailored to individual needs and preferences, promoting a higher quality of life outside of a traditional hospital setting.
Eligibility for NHS Continuing Healthcare: Who Qualifies?
NHS Continuing Healthcare is specifically designed for adults with significant health needs. While children and younger individuals might not qualify for NHS continuing healthcare directly, they may be eligible for a “continuing care package.” This tailored support system addresses needs stemming from disability, accidents, or illnesses that surpass the capabilities of standard universal or specialist services.
Download the Decision Support Tool for NHS Continuing Healthcare from GOV.UK (PDF, 194KB)
Eligibility for NHS continuing healthcare hinges on a comprehensive assessment conducted by a multidisciplinary team of healthcare professionals. This team meticulously evaluates your care requirements, focusing on several key aspects:
- The type of assistance you require: What specific help is needed to manage your health condition?
- The complexity of your needs: How intricate and multifaceted are your care requirements?
- The intensity of your needs: How substantial and demanding is the level of care needed?
- The unpredictability of your needs: How variable are your needs, and what are the potential health risks if care isn’t consistently available?
Crucially, eligibility is determined by your assessed needs, not solely based on a specific diagnosis or medical condition. This needs-based approach ensures that individuals with varying conditions, but similar care requirements, are fairly evaluated. It’s also important to note that eligibility can evolve. If your health needs fluctuate, your entitlement to NHS continuing healthcare may also change, necessitating periodic reviews.
Throughout the assessment process, your active participation is paramount. You should be kept fully informed at every stage, and your perspectives regarding your needs and desired support should be carefully considered. Where relevant, carers and family members will also be consulted to provide a holistic understanding of your situation.
A timely decision regarding eligibility for a full NHS continuing healthcare assessment is crucial. Typically, this decision should be reached within 28 days of an initial assessment or a formal request for a comprehensive evaluation.
If NHS continuing healthcare isn’t deemed the appropriate pathway, referral to your local council is the next step. They can explore your potential eligibility for support services they administer. In situations where health needs are present but don’t fully meet the criteria for NHS continuing healthcare, a “joint package” of care might be arranged, with the NHS contributing to a portion of the overall support costs.
Accessing Information and Advice
Navigating the NHS continuing healthcare assessment process can indeed be complex. For individuals seeking clarity and guidance, Beacon offers invaluable free and independent advice. Beacon is an organization dedicated to providing support and information related to NHS continuing healthcare.
You can explore the Beacon website for comprehensive resources or contact their free helpline at 0345 548 0300 for personalized assistance.
The NHS Continuing Healthcare Assessment Process: Step-by-Step
Integrated Care Boards (ICBs), the NHS bodies responsible for commissioning local health services, are tasked with initiating NHS continuing healthcare assessments when there is an indication that an individual might require this level of care.
For most individuals, the process begins with an initial checklist assessment. This preliminary assessment serves as a screening tool to determine if a full, more detailed assessment is necessary. However, in urgent situations, such as for individuals who are terminally ill, a fast-tracked assessment process is available to expedite care provision.
The Initial Assessment: Using the NHS Continuing Healthcare Checklist
The initial checklist assessment is designed to be a brief screening process. It can be conducted by a range of healthcare professionals, including nurses, doctors, other healthcare practitioners, or social workers. It’s essential that you are informed when an assessment is being initiated and understand what the process entails.
The outcome of the checklist assessment will determine the next steps. You will either be informed that you do not meet the criteria for a full NHS continuing healthcare assessment, and therefore are not eligible, or you will be referred for a full assessment of eligibility. It’s important to understand that referral for a full assessment does not guarantee eligibility for NHS continuing healthcare. The checklist’s primary function is to ensure that anyone who might be eligible has the opportunity to undergo a thorough evaluation.
The healthcare professional completing the checklist is required to document the rationale behind their decision in writing, including their signature and the date. You are entitled to receive a copy of the completed checklist for your records.
You can download a blank copy of the NHS continuing healthcare checklist from GOV.UK (PDF, 122KB)
The Full Assessment: Delving Deeper with the Multidisciplinary Team
Full assessments for NHS continuing healthcare are conducted by a multidisciplinary team (MDT). This team comprises a minimum of two professionals from different healthcare disciplines. Ideally, the MDT includes both health and social care professionals who are already involved in your care, ensuring a comprehensive understanding of your needs.
You should be informed about who is coordinating your NHS continuing healthcare assessment, providing a point of contact throughout the process.
The MDT’s assessment is a detailed evaluation of your needs across twelve specific domains:
- Breathing
- Nutrition (food and drink)
- Continence
- Skin (including wounds and ulcers)
- Mobility
- Communication
- Psychological and emotional needs
- Cognition (understanding)
- Behaviour
- Drug therapies and medicine
- Altered states of consciousness
- Other significant care needs
Each of these needs is assigned a weighting, ranging from “priority” and “severe” to “high,” “moderate,” “low,” or “no needs.” These weightings reflect the severity and impact of each need on your overall care requirements.
Generally, if you are assessed as having at least one “priority” need, or “severe” needs in at least two areas, you can anticipate being eligible for NHS continuing healthcare. Eligibility can also be established with a combination of needs, such as a “severe” need in one area coupled with other needs, or a cluster of “high” or “moderate” needs. The determination depends on the specific nature, intensity, complexity, and unpredictability of these combined needs.
Ultimately, the decision regarding NHS continuing healthcare provision considers your overall needs, the interplay between different needs, and evidence from risk assessments. Your perspectives, as well as those of your carers, are integral to the assessment process. Following the assessment, you will receive copies of the decision documents, accompanied by clear explanations for the outcome.
Fast-Track Assessment: Expediting Care in Urgent Situations
In situations where an individual’s health is rapidly deteriorating and they are approaching the end of life, the NHS continuing healthcare fast-track pathway should be considered. This expedited process aims to put an appropriate care and support package in place as swiftly as possible, typically within 48 hours, ensuring timely and compassionate support during critical times.
Care and Support Planning: Tailoring Support to Your Needs
Once eligibility for NHS continuing healthcare is confirmed, the next crucial step is developing a care and support package that directly addresses your assessed needs. The specific nature of your situation will dictate the most suitable options, which could range from receiving support in your own home to exploring the possibility of a personal health budget. Personal health budgets offer greater control over how your care is delivered and managed.
If a care home environment is deemed the most appropriate setting, there may be multiple suitable local care homes to consider. Your ICB will collaborate with you, taking your preferences into account when agreeing upon your care and support package and the location where it will be provided. However, it’s important to note that ICBs also consider other factors, such as the cost-effectiveness and value for money of different options, to ensure responsible resource allocation.
NHS Continuing Healthcare Reviews: Ensuring Ongoing Appropriateness
For individuals receiving NHS continuing healthcare, regular reviews are a standard part of the process. Typically, the initial review of your needs and support package occurs within three months of the package being implemented, followed by annual reviews thereafter. These reviews serve to assess whether your current care and support package continues to meet your assessed needs effectively. Furthermore, if your needs have evolved, the review will also determine if you remain eligible for NHS continuing healthcare, ensuring that support remains appropriate and responsive to changing circumstances.
Refunds for Delays in NHS Continuing Healthcare Funding: Addressing Unjustifiable Delays
ICBs are expected to make timely decisions regarding NHS continuing healthcare eligibility. The standard timeframe for a decision is within 28 days of receiving a completed checklist or a request for a full assessment, unless extenuating circumstances beyond the ICB’s control arise.
If the ICB determines that you are eligible but exceeds the 28-day timeframe without justifiable reasons for the delay, they are obligated to refund any care costs incurred from the 29th day until the date of their decision. This provision aims to ensure accountability and minimize the financial burden on individuals awaiting NHS continuing healthcare decisions.
What Happens If You Are Not Eligible for NHS Continuing Healthcare?
If you are not eligible for NHS continuing healthcare but are assessed as requiring nursing care within a care home registered to provide such care, you may be eligible for NHS-funded nursing care. This form of support entails the NHS contributing financially towards the cost of your registered nursing care within the care home setting. Importantly, NHS-funded nursing care is available regardless of who is responsible for funding the remaining care home fees, providing crucial assistance with nursing care costs.
Find out more about NHS continuing healthcare and NHS-funded healthcare from NHS England
Frequently Asked Questions about NHS Continuing Healthcare
Impact on Existing Local Authority Support Packages
Question: I currently receive a local authority support package that works well. If I become eligible for NHS continuing healthcare, will my support package change?
Answer: If you have concerns about potential changes to your care package due to transitioning to NHS continuing healthcare, your ICB should engage in open communication with you. They should explore options to maximize your choice and control over your care arrangements. This might involve utilizing a personal health budget, with the possibility of a “direct payment for healthcare” as one option.
Refusing an Assessment and Local Authority Services
Question: Can I refuse an assessment for NHS continuing healthcare? If I do, will I still be able to access services from my local authority?
Answer: Consent is not required for conducting assessments like CHC Checklists, Decision Support Tools (including FNC by default), and Fast Track assessments, or for the sharing of information within Care Teams and Health and Social Care Staff. However, consent is necessary to share personal information collected during these assessments with third parties, such as family, friends, or representatives, at the outset of the process.
Local authorities have legal limitations on the types of services they can provide. If you have reservations about undergoing an NHS continuing healthcare assessment, it’s advisable to discuss your concerns with the ICB. They should address your worries and provide clarification.
In cases where an individual lacks the mental capacity to consent to sharing information with third parties (excluding Care Teams or Health and Social Care Staff), the principles of the Mental Capacity Act will be applied. Decisions regarding information sharing will be made in their best interests.
Care Home Fees and Relocation Concerns
Question: My relative is in a care home and has become eligible for NHS continuing healthcare. The ICB states that the current care home fees exceed their usual payment rates and has suggested moving to a different care home. I am concerned that a move will negatively impact my relative. What are our options?
Answer: If you have evidence suggesting that a relocation is likely to have a detrimental effect on your relative’s health or overall well-being, it’s crucial to discuss these concerns with the ICB. They are obligated to consider your concerns when determining the most appropriate care arrangements.
Should the ICB proceed with arranging an alternative care home placement, they should offer a reasonable selection of homes for you to consider.
Top-Up Fees for NHS Continuing Healthcare
Question: Is it possible to pay top-up fees to enhance NHS continuing healthcare packages?
Answer: No, unlike local authority care packages, NHS continuing healthcare packages cannot be supplemented with top-up fees. The only permissible way to privately augment NHS continuing healthcare is by independently funding additional private services that are distinct from the services assessed as necessary and funded by the NHS. Ideally, these private services should be delivered by different staff and, preferably, in a separate setting to maintain clear boundaries between NHS-funded and privately funded care.
Requesting Assessment for Previously Unassessed Care Periods
Question: Can I request an assessment for a period of care in the past that was not previously assessed?
Answer: You may be able to request a Previously Unassessed Period of Care (PUPoC) assessment to determine eligibility for NHS continuing healthcare for a past period if you meet the following criteria:
- You should have been considered for NHS CHC eligibility during the period in question, but were not assessed at the time.
- You have fully or partially funded your care during that period.
Typically, PUPoC requests are only considered for care periods dating back to April 2012 or later.
Read more information and guidance on how to make a request for a PUPoC assessment on GOV.UK
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Media last reviewed: 12 January 2024
Media review due: 12 January 2027
