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NHS Continuing Healthcare

Introduction

This leaflet provides a brief overview to help you understand what Continuing Healthcare is all about. You can always talk to the professionals involved in your care about this. You can also ask for a copy of the Department of Health booklet NHS continuing healthcare and NHS-funded nursing care or locate the booklet on the internet at the following address: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_106230

What is Continuing Healthcare?

NHS continuing healthcare (CHC) is a package of healthcare, which may include elements of social care that is arranged and funded solely by the NHS. This funding is applicable when it is evident that your need for care is primarily due to your need for healthcare. Certain characteristics of your needs, in combination or alone, may demonstrate a ‘primary health need’ because of the quantity and/or quality of care needed to manage them. These characteristics have been devised through a framework by the Department of Health.

If you are eligible, you can receive NHS continuing healthcare in a range of settings including in your own home or in a care home. NHS continuing healthcare is free, unlike social and community care services provided by Local Authorities for which a charge may be made, depending on your income and savings. NHS continuing healthcare is sometimes called ‘fully funded NHS care’.

Who is eligible?

You must be over 18 years of age. You must need ongoing healthcare and meet a set of eligibility criteria. We use these criteria to help us assess your individual healthcare needs. If the assessment shows that you need a certain level of care, you may be eligible for NHS continuing healthcare. It is important to note that the assessment does not relate to a particular disease, diagnosis, condition or past history. It does not depend on who provides your care or where you receive it. If your overall care needs show that your primary need relates to a health need, then you may qualify for continuing healthcare. Eligibility decisions should be independent of any financial considerations. Of course, if you do not qualify for continuing healthcare, you will still receive other NHS services in the usual way, such as care from your GP, district nursing services and other healthcare professionals.

Eligibility criteria

The first step is the completion of a document called a Checklist. At this point the checklist allows us to consider all of your needs to determine if there is any likelihood of eligibility for CHC funding. Should the checklist indicate a likelihood that you may have a primary health need, then an assessment will be arranged together with health and social care professionals involved with your care.

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There are four key indicators that we consider:

1. The nature of the healthcare you need – how your needs affect your everyday life and what you require to help manage these needs. The frequency and level of skill required to care for you are also considered.

2. How complex your primary health care requirements are – for example, whether you have symptoms that interact, making them difficult to manage or control.

3. Whether you have one, or more, primary healthcare need that is so severe that it requires regular treatment or help.

4. Whether there are likely to be unexpected changes in your condition that are difficult to manage and present a risk to your health if you cannot receive adequate and timely care.

Please note that eligibility is based on your needs and not on your diagnosis. In some cases and/or with some conditions, even if you have a diagnosed illness, your needs may not be considered to be ‘primary’ health needs and, therefore, you may not be considered eligible for NHS continuing healthcare.

What sort of care is provided

You can receive continuing healthcare in any setting outside of a hospital. You might be living in a care home, a hospice, or in your own home. You receive a ‘package’ of care, which is a set of combined support and services that meet your assessed needs.

NHS Continuing Healthcare is free

It is not the same as any help you may receive from social services, who may ask you for a contribution, depending on your income and savings.

Your pension

Receiving NHS continuing healthcare does not affect your pension payments.

Your benefits

Receiving NHS continuing healthcare can affect your benefit payments. Please contact the relevant agency directly for information. You must tell the agency or the department that is paying benefits about the change in your circumstances.

What Continuing Healthcare does not cover NHS continuing healthcare does not cover things like dental care or eye tests but this will all be discussed with you on an individual basis if you are eligible for funding.

How long will the assessment process take? The CHC Team will usually process the checklist within one working day. If the checklist is screened in, the CHC Team will endeavour to undertake the multidisciplinary team meeting and submit the recommendation to the CHC Panel within 28 days, although this is dependent on how quickly it takes to gather the evidence required and the availability of people attending the multidisciplinary team meeting. If the CHC Panel decides you are eligible for CHC funding, a package of care is usually in place within 14 days, although this depends on the complexity of the package of care.

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As such, if all evidence is produced quickly and you, your representatives and the professional members of the multidisciplinary team are available, you should expect to have a decision within 28 days of the original referral and receive your package of care within 42 days of the original referral.

Regular reviews A decision that you are eligible for NHS continuing healthcare funding is not a permanent one. Your health needs will be reviewed at least annually to ensure the package of care you are receiving still meets your needs and that you are still eligible for healthcare funding. You will also receive a review within three months of starting your package of care, once you have settled into your changed lifestyle. If your needs have increased, this process ensures that your package of care is adjusted so that you receive exactly the care you need. It may appear contradictory but in some cases the need for qualified healthcare professional to administer health interventions diminishes as a disease progresses, for example with degenerative diseases such as dementia. As the need for health interventions diminishes, the balance between social needs and health needs change, particularly if the need for social intervention increases. As such, there are instances where a disease progresses but the patient no longer qualifies for continuing healthcare because their social care needs outweigh their health needs. In these instances, whilst the NHS may fund additional elements of care beyond existing services, it will no longer fund the social care elements. The Local Authority will then be responsible for determining eligibility for social care funding.

NHS Continuing Healthcare process in Northamptonshire

The process starts when a Checklist is received from a professional involved in your care. A CHC Nurse Assessor will review the information provided on the Checklist and determine whether there is enough evidence to support a full CHC assessment or not. The threshold at this point is deliberately set low to ensure patients who have the potential to be eligible for NHS continuing healthcare funding are screened in. If you are screened in, therefore, you may still not be considered eligible at a later stage. You will be informed in writing whether a full assessment will take place or not. If yes, then someone will be in contact with you to arrange a date and time for the assessment. If it is not possible for you or your representative to attend, you can submit written evidence in a form that we can provide. The assessment will be led by a CHC Nurse Assessor and will be attended by an appropriate range of health and social care professionals. We use the assessment to identify the care you need, both health care and social care. Assessing the balance of care needs, we then determine if your needs are predominantly health or social care. An experienced, qualified nurse carries out the full assessment, looking at your physical, mental, psychological, and emotional needs. They ask for involvement and reports from the health and social care professionals involved in your care so that they can build an overall picture of all your needs. They also work with you and your carers to understand your needs. The Department of Health has designed a framework that specifies the order of the assessment and the people who are responsible. It includes tools we use to ensure we are fair and consistent, regardless of the care you need or the reasons why.

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Once the assessment is complete, you should be verbally informed, by the Nurse Assessor, of the recommendation that will be presented to the CHC Eligibility Panel, based on the nationally set eligibility criteria. The Nurse Assessor should be able to clearly outline why the professionals have made the recommendation. The CHC Panel will review your case to ensure the correct process was followed and whether sufficient evidence was gathered to support the recommendation. The CHC Panel will then confirm the recommendation made by the multidisciplinary team or, in exceptional circumstances, ask for the assessment to be repeated. You will be informed in writing of the decision of the panel.

What to do if you are eligible for Continuing Healthcare You can now expect to hear from the CHC Placement Team to agree a care package to meet your assessed needs.

What to do if you are not eligible for Continuing Healthcare

If you live in a care home with nursing and require care from a registered nurse you may be entitled to NHS Funded Nursing Care (FNC). You can also apply for social services funding for accommodation, social care needs and any other requirements.

What is the difference between a healthcare need and a social care need? Whilst there is not a legal definition of a healthcare need (in the context of NHS continuing healthcare), in general terms it can be said that such a need is one related to the treatment, control or prevention of a disease, illness, injury or disability, and the care or aftercare of a person with these needs. The focus is on the health interventions the required to meet the needs, rather than viewing one disease as more significant than another. In general terms (not a legal definition) it can be said that a social care need is one that is focused on providing assistance with activities of daily living, maintaining independence, social interaction, enabling the individual to play a fuller part in society, protecting them in vulnerable situations, helping them to manage complex relationships and (in some circumstances) accessing a care home or other supported accommodation. Please note that where a person is eligible for NHS continuing healthcare the NHS is responsible for meeting their assessed health and social care needs.