NHS continuing healthcare claims


What is NHS continuing healthcare?

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.

Should I be paying care home fees?

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

What is a ‘primary health need’?

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.

How does the NHS establish whether an individual has a primary health need?

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.

How is the assessment for NHS continuing healthcare carried out?

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.

What's the difference between health care and social care?

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

I applied for NHS continuing care, but didn’t qualify. Can I appeal?

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).

Can retrospective NHSCH claims be brought?

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.

How long will a NHSCH claim take?

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.


Familiarise yourself with the NHS Continuing Healthcare (NHSCHC) process

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

Familiarise yourself with the NHS Continuing Healthcare assessment documents/forms and the care domains

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

Get an assessment carried out as soon as possible

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.

Speak with the carer(s) or care home manager

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.

Keep detailed records as these may be needed to support the claim or any future claim.

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.

Request medical records from the GP or hospital

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.

Remember that a NHS Continuing Healthcare claim can still be made after the person’s death

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.

Be persistent – the NHS Continuing Healthcare process can be very lengthy and frustrating

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

The contents of this article are intended for general information purposes only and shall not be deemed to be, or constitute legal advice. We cannot accept responsibility for any loss as a result of acts or omissions taken in respect of this article.

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