NHS continuing healthcare funding

NHS Continuing Healthcare Funding (“CHC”) is a package of care arranged and funded solely by the NHS to those over 18 who are found to have what is called a “primary health need”.

The term “primary health need” means where a person’s care needs are primarily aimed at addressing or preventing health needs, it is not just about diagnosis. CHC is provided by your local Clinical Commissioning Group “CCG” in any setting, including at home.

A Personal Health Budget can be set up where the NHS transfer the money to a representative who contracts for necessary services and expenditure. The funding must cover a package meeting all health and personal care needs but must not pay for other things like rent, food and utility bills. However, if specialist equipment must be run and substantially adds to utility bills then a contribution towards these may be appropriate.

Can we get Continuing Healthcare Funding?

Eligibility decisions are “needs based” and the aim is to determine whether the majority of an individual’s need for care is to manage, address or prevent health needs. Having a particular diagnosis or condition does not itself determine eligibility, each assessment is focused on the individual and whether they have a “primary health need”. The NHS has published a national framework as guidance which sets out the procedure for determining eligibility and the criteria for Continuing Healthcare Funding.

Where a person’s needs are very serious there is a “fast-track” process but for others the below procedure must be followed.

The national framework sets out that eligibility is not to be determined by:

  • A persons diagnosis
  • The placement or setting in which care is provided
  • The fact that a need is well managed
  • The use of any staff to provide care
  • The need for or presence of special staff and care delivery

Assessments are a holistic process where a person’s needs are considered in the whole.

How do we get Continuing Healthcare Funding?

The assessment is a two stage process, the first being the completion of a checklist which effectively works as a screening process. Once the checklist is passed, stage 2 is a “decision support tool” (“DST”). The tool will then be put to a panel at the CCG with a recommendation and they will make the final eligibility decision. Both assessments consider 12 “domains” or areas of needs and has its own criteria to be applied.

Continuing Healthcare Funding assessment Stage 1 – Checklist

In order to pass the Continuing Healthcare Funding checklist hurdle an individual’s needs are compared to 12 areas of need and given a score of “A” which represents a high need, “B” a moderate need, or “C” for low needs. In order to pass the checklist they should have two or more “A” scores in domains relating to their care needs or one “A” score in a domain marked with a star.

The following care domains must be explored:

  1. Behaviour*
  2. Cognition
  3. Psychological and emotional needs
  4. Communication
  5. Mobility
  6. Nutrition
  7. Continence
  8. Skin (including tissue viability)
  9. Breathing*
  10. Drug therapies and medication: symptom control*
  11. Altered states of consciousness*
  12. Other significant care needs

Once the checklist is passed the individual will be referred for a full assessment and arrangements will be made for a DST to be completed.

Continuing Healthcare Funding assessment Stage 2 – Decision Support Tool

The Decision Support Tool (DST) explores the domains set out above in much greater detail; each of them must be considered by a multidisciplinary team and a decision made in respect of each domain about whether, in each area, the individual has no need, low need, moderate need, high need, and in some domains a severe or priority level need.

The framework states that a clear recommendation of eligibility to NHS continuing healthcare would be expected in each of the following cases:

  • A level of priority needs in one of the four domains that carry this level
  • A total of two or more incidences of identified severe needs across all care domains

The following may indicate a primary health need:

  • One domain recorded as severe, together with a number of other domains; or
  • A number of domains with high and/or moderate needs.

Those domains are then considered in the whole to determine whether the care is of a nature, intensity, complexity and unpredictability that requires primary healthcare rather than support which a local authority social services authority could provide (if that person was financially eligible to receive such services).

Continuing Healthcare Funding assessment – The recommendation

A recommendation on eligibility will then be provided. When considering NHS Continuing Healthcare Funding eligibility, assessors consider the following characteristics of need and their impact on the care required to manage them alongside the domains. The indicators are:

Nature – the type and features of a person’s needs – physical, mental or psychological, and the type of support or treatment needed to manage them.

Intensity – relates to the severity of needs, how frequently and to what extent they vary and the resulting level of support required.

Complexity – how different needs present and interact with each other to increase the knowledge and skills staff need to a) monitor symptoms b) treat any multiple conditions and how this affects management of care. How a person responds to their condition impacts their overall physical and mental health needs could be a factor to consider.

Unpredictability – how much, how often and how unexpectedly changes in a person’s condition create challenges because of the timeliness and skills required to manage needs that arise. It can affect the level of monitoring required to ensure they and others are safe and the level of risk to them or others, unless they receive adequate, timely care. Someone with unpredictable healthcare needs is likely to have either a fluctuating, unstable or rapidly deteriorating condition. Each of the characteristics may on their own, or in combination, demonstrate a ‘primary health need’ because the ‘quantity’ and / or the ‘quality’ of care, required to meet them exceeds the limits of a local authorities’ responsibilities.

This means that even where a person has a higher score they may not be eligible because the professional judgement of the panel does not consider the needs to be a “primary health need” taking into account the above indicators. There are occasions where a panel will go against the MDT’s recommendations.

Can we appeal if we have been denied Continuing Healthcare Funding?

There is an appeals process against a negative decision. This is a two stage process of requesting a “local resolution meeting” and then escalating this to an “independent review panel” should the first stage be unsuccessful.

Continuing Healthcare Funding funding is increasingly difficult to secure and the assessment procedure itself can be complex and daunting. It is important to be prepared for any assessment or meeting and to ensure that the professionals are given as much up to date evidence as possible so that an informed decision can be made.

The NHS Guidance is a really helpful tool and Beacon, a social enterprise company, are able to offer 90 minutes of free advice with issues relating to CHC funding. There are many other charities and information sources available.

More information on Funding Care

How to fund care

Produced by Jemma Garside of Boyes Turner Solicitors

Jemma Garside is an associate solicitor with Brain Injury Group member firm Boyes Turner. Jemma specialises in Community Care, advising individuals with disabilities on issues related to their care needs.

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