NHS continuing healthcare claims Knowledge & Resources

NHS continuing healthcare (NHSCH) is a package of on-going care that is arranged and funded solely by the NHS where the individual has been found to have a primary health need as set out in the National Framework. The NHS is responsible for providing all of the individual’s assessed health and social care needs including accommodation, if that is part of the overall need.

You shouldn’t pay care fees if you have a primary health need which is set out in the national framework.

A ‘primary health need’ means that the main or primary need for care must relate to the health of the individual. This doesn’t depend on a specific health condition or illness, who provides the care or where the care is provided.

The NHS continuing healthcare assessment takes into account the individual’s needs across 12 care domains and considers the nature, intensity, complexity and unpredictability of their needs. Each of these characteristics may, in combination or alone, demonstrate a primary health need, because of the quality and or quantity of care required to meet the individual’s needs.

The first step is for a checklist tool to be completed. This is a screening tool to help identify individuals who should be referred for full assessment. This checklist can be completed by a variety of health and social care practitioners. It can be completed in a hospital prior to discharge, in an individual’s own home or in a community care setting.

Social care is providing assistance for daily living activities, for example helping to get washed and dressed. Health care is everything medical.

If an application for NHS continuing healthcare is rejected this can be challenged through the appeals process. The formal responsibility for informing individuals of the decision about eligibility for the NHS continuing healthcare and their right to request a review lies with the relevant Clinical Commissioning Group (CCG).

Yes. However, in 2012 the Department for Health introduced deadlines for claims for unassessed periods of care to put a stop to claims going as far back as 1 April 2004. As things stand, it is unlikely that the CCG will allow the period of the claim to go back further than 1 April 2012.

The national framework states that the time between the initial checklist being received by the CCG and the funding decision being made should, in most cases not be more than 28 days, less, if the fast track pathway is followed. However, retrospective claims by an executor can take years to complete due to the high volumes of these types of claims.

In England, the relevant guidance is the Department of Health’s National Framework for NHSCHC and NHS-funded nursing care. A copy can be obtained from their website. https://www.gov.uk/government/publications/national-framework-for-nhs-continuing-healthcare-and-nhs-funded-nursing-care

This includes the Checklist (the initial screening tool) and the Decision Support Tool, and the care domains are set out in these.

If it is evident that further care is going to be required, insist that a nurse, doctor or other suitably qualified healthcare professional completes the Checklist before discharge from the hospital back home or to a care home. Even if the person being discharged is found not to be eligible for NHS Continuing Healthcare (NHSCHC) at that stage, the Checklist can be used to prepare for assessments in the future.

Sit down with those who are providing the care and discuss NHSCHC with them. If it is evident that an assessment should be carried out, badger them into arranging this. If social services are involved, take it up with them.

Record the date, time, and a note of all conversations with the GP, hospital, care home, social services or Clinical Commissioning Group. Put as much as possible in writing and keep all correspondence. Find out and make a note of the care that is being received and notable events, for example, when there has been physical or verbal abuse (including to friends, family and carers) or of any fall. Ensure that the home is also keeping detailed notes and up-dating care plans.

If a decision has to be challenged, having sight of and reviewing the medical records from the various parties concerned and involved in the care of that person is very important.

It is possible to make a retrospective claim for NHSCHC, by the person receiving the care, their attorney, or if that person has died, their executor.

Often the National Framework is simply not being followed. If there is a case for NHSCHC, continue to pursue it.