Introduction
The NHS is famed worldwide. Partly for its underlying principle that it should be "free at the point of access". So where does free care from the NHS stop and means-tested care from the local authority start, and who decides? Continuing Health Care funding is the bridge between care that the NHS must pay for and care that is the responsibility of a local authority.
If you require care or support services in the UK, you may have to fund this yourself. Whether your self-fund depends on the level of your assets and whether you meet the criteria outlined by Continuing Health Care.
Currently, if you have assets over £23,250, there is a strong likelihood you will be funding your care yourself; if you are in this position, it is always important to speak to a Social Worker to ensure a care assessment and care plan has been created to ensure you only pay for the care that you need.
Alternatively, if your needs arise from a primary health need, then you may not need to fund your own care, and you may be entitled to funding from the NHS in the form of Continuing Healthcare.
What is Continuing Health Care?
If your need for care and support arises from a primary health need as opposed to a social care need, then you may not need to fund your own care, and you may be entitled to funding from the NHS in the form of Continuing Healthcare.
NHS Continuing Healthcare (NHS CHC) provides a package of care for adults aged over 18 that is solely arranged and funded by the NHS. This service can only be accessed by individuals who meet specific requirements regarding their health needs as assessed by integrated commissioning boards (ICBs). According to legal guidelines, the determination process for assessing if an individual is eligible for such funding must follow a prescribed decision-making procedure.
What is a primary health need?
R v North and East Devon Health Authority (Coughlan Case) The "Coughlan" case was a ground-breaking application for a Judicial Review in the arena of NHS Continuing Healthcare Funding. This important judicial review explains a person has a 'primary health need' when the nature of their care is beyond that which a local authority can legally provide.
However, due to the language "health need," there is a common misconception that any diagnosed illness can constitute a primary health need. That is not the case, however.
As an example, Alzheimer's Dementia is considered a health issue, but the needs that arise from the diagnosis would be social care needs, for example, support with washing/ dressing or cooking. If an individual has a primary health need which determines that a medical professional is required, then the individual would likely receive Continuing Healthcare funding.
What are the steps involved in applying for continuing health care?
You would need to complete a Continuing Healthcare checklist and go through a decision support tool if the checklist identified that you met the criteria.
If a person has the physical and mental capacity to engage in the DST assessment and CHC Checklist themselves, then those completing these should ensure the person's involvement.
CHC Checklist
The CHC checklist is the initial tool for identifying if you could be entitled to continuing health care funding; depending on where you are when the checklist is completed depends on who will complete it, but it could be a Nurse, care home or Social Worker.
The CHC Checklist looks at eleven domains, assessing your needs against each domain; the person completing the checklist will assess you at levels A, B, or C on each domain.
If you have met two or more domains in column A and five or more in column B, you will qualify for a full assessment of the decision support tool (DST)
Decision Support Tool and Multidisciplinary Team Meeting
After a positive CHC Checklist, a comprehensive continuing healthcare assessment will take place in the form of a DST meeting. This doesn't guarantee an individual will receive funding, but it is the next necessary step in the process of identifying whether a person is eligible for NHS funding. Usually, a decision will be reached at the end of the DST meeting.
Decision support tools are incredibly helpful for making eligibility decisions concerning NHS continuing healthcare. By gathering together information regarding needs assessments and applying evidence-based practices, nurse assessors can provide consistent recommendations and ensure beneficial results.
The Local Integrated Care Board (LCIB, previously CCG) will assign a nurse to organise a multidisciplinary team Meeting and complete the assessment. The nurse and their teammates (the multidisciplinary team) will analyse all of the evidence regarding the patient's needs by identifying relevant evidence to each of the domains and criteria within the Decision Support Tool (DST).
If you are successful, you will be allocated funding dependent on your level of need.
Appeals can be stressful for all involved. However, so can having to find the funds for care if the NHS no longer funds the care. Understanding the rationale behind the decision not to fund NHS care can be confusing, and it does not help that jargon is often used, and reasoning is not always explained clearly. You can ask for this to be reconsidered. However, if it is reconsidered and the answer is the same, and you still disagree, you can appeal.
The Local Integrated care Board (previously CCG) decision can be appealed within six months of receiving the notification letter.
Once an appeal has been lodged, the Local Integrated care Board has three months to appraise and finalise the local review phase. This process can sometimes take up to a year, but the exact duration depends on geographical location. This local stage can allow you to provide additional evidence to the ICB, such as care records and independent social work assessments.
If the ICB local review again declines funding, then you have another six months from the time of being notified to request a review via an Independent Review Panel (IRP). Once your request is received, NHS England must convene this IRP within three months. Three decision makers will work together to decide on the outcome - an independent Chair along with one health and social care professional not associated with the original Local Integrated care Board who made the decision.
What happens if your needs change?
Continuing Healthcare Checklists should be carried out regularly; this can mean that even though you had not met the criteria for CHC funding previously, your needs have worsened, and there is now a primary health need that the NHS should fund. Conversely, your needs could change, and a continuing healthcare review could identify that you are no longer entitled to NHS funding.
This ongoing review of the funding highlights the importance of evidence gathering in the form of social care assessments and records from domiciliary or residential care providers, so if your needs change, you have evidence of this for any DST meetings.
What do we look for when considering if an appeal is possible?
Evidence. Whether this comes in the form of Care records, health records or independent assessments or care plans, evidence is key to identifying your care needs, their intensity, complexity, and unpredictability.
Your needs will be graded when you go through the original checklist and the DST meetings. If, when reviewing these documents alongside all of the available evidence, we find the grading was incorrect and have evidence to suggest this, then you could have a strong case. Without evidence, whether from care records, health records or new assessments, there is little chance of a positive argument.
Evidence can be any additional information which you did not have or disclose at the original DST, and it could be that you did not have access to an up-to-date needs assessment which identifies that there is a definite primary health need and the care which is required can only be provided by a health professional. Since the DST, the condition has become more complex, unstable or unpredictable due to the medical condition. At Nellie, we ask for the client's records, social care and medical and determine if we feel there is a good chance of success based on our evidence. The more relevant evidence that we have, the better the chance of success, as this will feed into our report, which we present to the independent panel. Of course, we will be honest and realistic about the chances of success at this point, as going through an appeal is time-consuming and can be very emotive.
For those that are self-funding their care, care recording can go by the wayside as they have little to no contact with the local authority, resulting in care needs assessments and reviews not being completed; the CHC process highlights the necessity and importance of ongoing reviewing and recording of a persons needs if this isnt being provided by your care rpovider or local auhtority independent provision is availible through Nellie+
Tips for engaging within the CHC process
Ask Questions!
Usually, if you ask the Health or social care professional questions, they would generally advise you the best they can. Make sure that you are clear that the need is a primary health need and that the care which results from this is not social care.
Do your research.
Look through the help and guidance on the website as it identifies the domains and gives clear instructions on the level of need. Have your up-to-date evidence.
Record everything
It is not just essential to ensure those caring for you or your loved one record as much as possible but also record what happens at the Checklist and DST meetings. This could be vital in understanding how or why an adverse decision was reached and can act as additional evidence.
Gain independent support and advice.
Talk to Nellie; we can offer expert advice and support you if you need to launch an appeal. We will be honest about your chances of success early on.
Continuing healthcare is free care if you meet the criteria for having a primary health need and your needs are intense, complex or unpredictable. You will be assessed against eleven domains and given a score to determine the magnitude of the need. You should be told if you do not meet the threshold and should be given the reasoning as to why you do not. At Nellie, we can support you through all of the stages of appeal if you are not satisfied with the decision and provide you with honest answers regarding your chances of success. Navigating Health and social care is highly complicated, so who better to ask than the social care professionals.
Find our more about the support we can offer here