FAQs Continuing Healthcare

No, you don’t have to be in a nursing home to receive continuing healthcare funding (CHC).  Eligibility for NHS CHC does not depend on where you receive the care.  You can receive NHS CHC in any appropriate setting whether this is in your own home, a care home or a nursing home.

Shockingly, this happens a lot!  The only way to know if a person is eligible for NHS continuing healthcare funding is for them to have an assessment.  No assessor (or care home nurse) can make a pre-determined judgment about funding without first doing an assessment.  You should first undergo a checklist assessment which will determine whether a full assessment (Decision Support Tool) is required.

No, where a person has been assessed as having a primary health need, the NHS pays for the package of care required in full, in whatever care setting the person resides within. The National Framework explicitly prohibits patients paying a ‘top-up’ fee.

This is incorrect. Eligibility for NHS continuing healthcare is not dependent  on a specific disease or diagnosis nor on who provides the care and where it is provided.

Continuing healthcare funding is not based on a patient’s life expectancy, but rather whether their needs are complex, intense or unpredictable in their nature.  There is no limit to the length of time you can receive CHC and it has nothing to do with how close you are to the end of life.

There is short term funding known as Fast Track Continuing Healthcare Funding which is provided to a patient that has a rapidly deteriorating condition that MAY be entering a terminal phase.  However,  this is separate to Continuing Healthcare Funding.

The “well-managed needs” principle emphasises that if a specific area of need is effectively managed by a care provider, it shouldn’t be disregarded or marginalised when deciding eligibility for NHS Continuing Healthcare Funding.

A degree of caution is required when applying this principle and considering the influence the care environment is having on the person’s needs. It is only when effective management permanently reduces or eliminates an ongoing need will it have an impact on eligibility for NHS continuing healthcare.

Guidance on this principle over the year is available in the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care (May 2022).

Continuing Healthcare is NOT means tested.  It is irrelevant what assets the patient has or if they own a home.  They are assessed purely on their health needs to determine if they are entitled to Continuing Healthcare Funding not on their financial position.

The first question should always be about a person’s health and care needs, not a person’s home, money or assets that determine whether they will pay for care.  It doesn’t matter how much or how little money a person has – if they have healthcare needs and are found eligible for continuing healthcare funding, they do not have to pay.

It is not lawful to pay a ‘top-up’ for eligible health and social care needs that are funded under continuing healthcare.  The only way that NHS continuing healthcare packages can be topped up privately is if you pay for additional private services on top of the services you’re assessed as needing from the NHS.  These private services should be provided by different staff and preferably in a different setting.

This would be an unreasonable stance to take by any professional involved in the process of arranging and  implementing the NHS continuing healthcare process. Next of kin can provide a supportive and valid insight into the needs of the person being assessed. However, consent is needed to share personal information collected for, and as part of, assessments (Checklist, Decision Support Tool (inclusive of FNC by default) and Fast Track) with third parties, such as family, friends or representatives, at the beginning of the process.

If someone lacks the mental capacity to consent to sharing of information with third parties (other than Care Teams or Health and Social Care Staff), the principles of the Mental Capacity Act will apply and a best interests decision may be needed.

If your relative is already paying care fees, and yet has never been assessed for NHS Continuing Healthcare funding, ask for a checklist assessment as soon as possible.  Also ask the NHS Continuing Healthcare team at the local NHS why this hasn’t happened before. You can also ask the care home manager, care provider or a social worker why this hasn’t been done before.

In terms of making a retrospective claim, you can generally now claim only as far back as 1st April 2012. However, if you were never told about Continuing Healthcare or you were not told how to appeal after the funding decision last time, you may have grounds to claim further back. You could argue that the care authorities failed in their duty to provide accurate information. Equally, if you were deliberately misled at the time about care funding, the health and social care employees you dealt with may well have been negligent in their professional duty. Plus, the local authority may have broken the law when it effectively took responsibility for care and asked the person in care to pay (see above).

Unfortunately, CHC funding is not given for life!  The Integrated Care Board (ICB) will regularly review your eligibility for NHS CHC.  The first review is after three months and thereafter they are annually.  The funding can be withdrawn on the basis that your needs have become stable and routine but you should always consider appealing a decision.

Funded Nursing Care (FNC) is paid by the NHS for the nursing element of nursing home fees. The contribution is paid directly to the care home and enables care home residents with specific healthcare needs to benefit from direct nursing care and services. 

A person is entitled to this contribution whether they are self-funding their care or not. Remember: eligibility for Funded Nursing Care (FNC) should only be agreed once a person has been through the NHS Continuing Healthcare process. 

FNC is paid to care homes in England by Integrated Care Boards (ICBs) as under section 22 of the Care Act 2014, registered nursing costs cannot be met by a local authority.

For people who live at home, you can ask a district nurse, social worker or another health professional who is involved in your mum’s care and is appropriately trained to complete a checklist.

This is extremely common!  If you are funding your own care (self-funders) you can ask the local authority to organise a screening checklist.  If you are subsequently found eligible for continuing healthcare funding, it is possible to reclaim backdated care fees for periods when you have paid full care fees but would have been eligible to receive NHS continuing healthcare funding.

Eligibility for NHS continuing care is not based on a diagnosis. It is based on an assessment of whether your needs are of a primary healthcare nature or a social care nature. Some people with Alzheimer’s or Dementia qualify for NHS continuing care but many hundreds of thousands of people do not.  People with an illness such as dementia or Parkinson’s may present with a number of health and social care needs some of which may well be intense, complex and/or unpredictable.  

Eligibility will be determined by assessing your day-to-day care needs and how those needs are being met.  If a particular health need is assessed as being of an intense, complex and unpredictable nature, your mum may be eligible for CHC funding.

Your dad would need to be assessed by NHS continuing healthcare to determine if his needs meet the primary health need threshold. Should his needs, having gone through the assessment process, indicate that the nature of his needs are of significant complexity, intensity or unpredictability then he will be eligible for NHS continuing healthcare funding.

If your dad, having gone through the assessment process, does not meet the primary health need threshold, he may  meet the threshold for  Funded Nursing Care  (FNC). This is funding paid directly to a nursing home by the NHS for the qualified nursing care provided within a nursing home setting. 

Preparation for a forthcoming assessment is key to ensure your loved one receives a well rounded assessment of their needs. We advise that if you are attending an assessment on behalf of a loved one that you familiarise yourself with the DST document which can be downloaded from the Department of health website, and which will be used by the nurse assessor at the assessment. 

If the person being assessed is cared for in a care home or at home through a package of care then it is important that you check as far as reasonably possible that the care records are up to date, and provide an accurate account of the person’s individual needs and the interventions required to meet their needs. This may also involve you having a discussion with the care providers prior to the assessment.  It is often the case where care records can fall short when providing evidence regarding a person’s needs. For example if behaviour is an issue, we would expect there to be behaviour charts informing of why, when and how the need is managed, and crucially whether the level of intervention is meeting the need effectively..  

In order to appeal a non eligible decision you will need to provide sufficient grounds:

-    That the assessment was not carried out in line with guidance set out in the NHS National Framework;
-    That  the MDT did not apply the right levels  of need within the domains;  
-    That the needs were not duly considered and did not provide an accurate portrayal of the person's needs in the context of the 4 key characteristics of Nature, intensity, complexity and unpredictability.  

This is incorrect.  As long as the care home is able to look after your mum and she meets the eligibility criteria in terms of her healthcare needs, there is generally no reason why the NHS continuing healthcare funding cannot be paid.  We are aware of clients who are in top-end care homes who receive fully-funded NHS Continuing Healthcare.

Sadly, this is very typical.  The only way to determine if someone is eligible for continuing healthcare funding is for them to be assessed.  The needs of other patients are irrelevant and should not be compared.  If a person has complex health care needs, they should be assessed.