This section is relevant to you if you have a medical condition requiring ongoing care and you think you may be entitled to continued NHS treatment. It combines summaries of, and extracts from, the Government's National Framework for NHS Continuing Healthcare and Funded Nursing Care.
'Continuing Healthcare can be very difficult to secure and budgetary restrictions add to the challenge. This page has been prepared to give you as much information as possible in an abridged form. Please don't underestimate the difficulty of accessing Continuing Healthcare; even if you have an acute need it can be a complex process, so the more you know in advance, the better.'
According to the Government website: 'Where a person has been assessed to have a primary health need, they are eligible for NHS Continuing Healthcare (CHC) and the NHS will be responsible for providing for all of that individual’s assessed health and associated social care needs, including accommodation, if that is part of the overall need.'
'A person becomes eligible for NHS Continuing Healthcare once a decision on eligibility has been made by the CCG (Clinical Commissioning Group). Prior to that, any existing arrangements for the provision and funding of care should continue, unless there is an urgent need for adjustment.'
'There should be no gap in the provision of care. People should not find themselves in a situation where neither the NHS nor the relevant local authority will fund care, either separately or together.'
The process to determine eligibility is thorough and so can be time-consuming. Influenced by complexity of needs, it involves several different stages of evaluation, the application of specific support tools and a relevant multi-disciplinary team (MTV), to evaluate your condition and requirements.
If you are the person being assessed for Continuing Healthcare, you should expect the following:
For this first phase in the process, the NHS uses a screening tool to help practitioners identify the people who may need a full assessment of eligibility for NHS Continuing Healthcare.
If you need a long-term care home placement with nursing, or have significant support needs, a Checklist will be completed, probably by a variety of health and social care practitioners who have been trained in its use. It is for each CCG and local authority to identify and agree who can complete the tool but it should, as far as possible, include staff involved in assessing or reviewing your needs as part of their day-to-day work.
A positive Checklist means that you require a full assessment of eligibility for NHS Continuing Healthcare. It does not mean that you are eligible.
Whatever the outcome of the Checklist, it will be communicated clearly and in writing to you or your representative, as soon as is practically possible. You shouldn't worry about being left without appropriate support whilst you are waiting for the outcome of the assessment process and you can be assured that your consent will be secured for every element.
Once you have been referred for a full assessment of eligibility for NHS Continuing Healthcare, then a multidisciplinary team must assess whether you have a ‘Primary Health Need.’
The core purpose of the MDT is to ‘make a recommendation on eligibility for NHS Continuing Healthcare, drawing on the multidisciplinary assessment of needs and following the processes set out in the government’s National Framework’.
In this context, an MDT comprises a team of at least two people from different healthcare specialisms. It should ideally include both health and social care professionals who are knowledgeable about your health and social care needs and who have recently been involved in your assessment, treatment or care.
The CCG will consult with the relevant local authority before making any decision about your eligibility for NHS Continuing Healthcare and in doing so cooperate with that local authority in arranging for relevant people to participate in the MDT.
The involvement of local authority colleagues as well as health professionals in your assessment process should streamline the process of care planning and will make decision-making more effective and consistent.
Note: As with any assessments that they carry out, a local authority should not allow an individual’s financial circumstances to affect its participation in a joint assessment.
The MDT works together to collate and review all relevant information on your health and social care needs. As part of the process, and to ensure consistency in process and evaluation, it completes the Decision Support Tool (DST), and then works collectively to make a professional judgement about eligibility for NHS Continuing Healthcare.
This process is known as a ‘Multi-disciplinary Assessment of Eligibility for NHS Continuing Healthcare.’
What is the ‘Decision Support Tool’?
The DST was developed to aid consistent decision making. It supports practitioners in identifying the individual’s needs. It is not an assessment of needs itself, but a way of bringing together and applying evidence in a single practical format, to facilitate consistent, evidence-based assessment regarding recommendations for NHS Continuing Healthcare eligibility.
Your involvement throughout the process; How Continuing Healthcare interacts with Hospital Discharge; Intermediate Care; Case Management and Ongoing Review
Patient involvement through effective, consultative communication, is seen as vitally important:
'Assessments of eligibility for NHS Continuing Healthcare and NHS-funded Nursing Care (FNC) should be organised so that the individual and their representative understand the process and receive advice/information that helps them participate in the process in an informed way.'
'Where the individual concerned has capacity, their informed consent should be obtained before the start of the process to determine eligibility for NHS Continuing Healthcare.'
In the majority of cases, it is preferable to consider eligibility for NHS Continuing Healthcare after discharge from hospital when the person’s ongoing needs should be clearer. The aim in most cases will be for the patient to return to the place from which they were admitted to hospital, preferably their own home.
Clinical Commissioning Groups (CCGs) are responsible for making sure that local protocols are developed between themselves, other NHS bodies, local authorities and other relevant partners. These protocols should set out each organisation’s role and how responsibilities are to be exercised in relation to hospital discharge, including intermediate or interim arrangements.
It is widely acknowledged that where someone is ready to be discharged from an acute hospital, it should happen without delay, so the assessment process for NHS Continuing Healthcare should not be allowed to delay discharge.
Intermediate care is a programme of care provided for a limited period of time to assist a person to maintain or regain the ability to live independently.
It is aimed at individuals who would otherwise face unnecessarily prolonged hospital stays or inappropriate admission to acute or longer-term in-patient care or long-term residential care.
It should form part of a pathway of support.
For example: Intermediate care may be appropriately used when you have received other residential rehabilitation support following a hospital admission and, even though you have improved, you still need support before returning to your own home.
The National Framework states that it should also be used where an individual is ‘at risk of entering a care home’ and requires their needs to be assessed in a non-acute setting with rehabilitation support provided where needed. 'Individuals should not be transferred directly to a long-term residential care setting from an acute hospital ward unless it is clearly appropriate under the circumstances.'
The decision-making rationale should not marginalise a need just because it is successfully managed: well-managed needs are still needs. Only where the successful management of a healthcare need has permanently reduced, such that active management is reduced or no longer required, will it have a bearing on eligibility for NHS Continuing Healthcare.
If you are found to be eligible for NHS Continuing Healthcare, the CCG is responsible for your case management, including monitoring the care you receive and arranging regular reviews.
You should always be encouraged to play an active role in your care, be provided with information or signposting to enable informed choices, and supported to make your own decisions.
Once you have been awarded Continuing Healthcare a review should be undertaken within three months of the eligibility decision being made. After this, expect further reviews to be made on at least an annual basis (but note that some people require more frequent reviews in line with clinical judgement and changing needs).
The reviews should primarily focus on whether the care plan or arrangements remain appropriate to meet your needs. It is expected that in the majority of cases there will be no need to reassess for eligibility.
The most recently completed Decision Support Tool (DST) should be available at the review and used as a point of reference to identify any potential change in needs. Where there is clear evidence of a change in needs to such an extent that it may impact on your eligibility for Continuing Healthcare, then the CCG should arrange a full reassessment.
If this happens, a new DST must be completed by a properly constituted multidisciplinary team (MDT). Where appropriate, comparison should be made to the information provided in the previous DST.
The National Framework emphasises that "when undertaking NHS Continuing Healthcare reviews, care must be taken not to misinterpret a situation where the individual’s care needs are being well-managed as being a reduction in their actual day-to-day care needs", and adds: "This may be particularly relevant where the individual has a progressive illness or condition, although it is recognised that with some progressive conditions care needs can reduce over time."
For more detailed information, we advise that you visit the Government website.