NHS Continuing Healthcare – what do I need to know?

What is NHS continuing healthcare?

Some people with health needs qualify for free care, provided outside of hospital, arranged and funded solely by the NHS. This is known as ‘continuing healthcare’, and is usually provided as a package of care from carers and/or registered nurses. It can be provided in a variety of settings, but is often arranged in a person’s own home or in a care home.

It is important to make sure that you are receiving continuing healthcare if you think you may be entitled to it. Unlike social care, which is provided by a Local Authority, continuing healthcare is not means tested and is always free of any charge. This is particularly important now that the government has postponed the introduction of a ‘cap’ on the amount individuals are required to pay towards social care. When a person has to live in a care home for many years, (for example, if they have dementia), or if they need a long-term package of social care in their own home, this can, in some cases, be extremely costly.

Continuing healthcare is commissioned by Integrated Care Boards, which are local NHS bodies. Until July 2022, they were known as Clinical Commissioning Groups.

Am I eligible for continuing healthcare?

The first step is usually for a social care or healthcare professional to complete a ‘continuing healthcare checklist.’ This is a short assessment to check whether you may need a referral for a full assessment of eligibility for NHS continuing healthcare. You should be given the opportunity to participate in the checklist assessment.

If the assessor concludes that you do not need a full assessment, you can challenge this decision.

In a full assessment for continuing healthcare, a multi-disciplinary team of professionals will assess your eligibility. They must comply with the National framework for NHS continuing healthcare and NHS-funded nursing care when completing their assessment and will use a ‘decision support tool’ as the basis for the assessment. The decision support tool assesses the following 12 ‘domains’ of need:

• Continence
• Mobility
• Breathing
• Nutrition
• Skin Integrity
• Mobility
• Communication
• Cognition
• Psychological & Emotional Needs
• Behaviour
• Drug Therapies and Medication
• Altered States of Consciousness
• Other Significant Care Needs.

The assessors will attribute a level of need to each domain, from no needs to a low, moderate, severe, or priority need. The assessors must also consider the complexity, unpredictability, intensity and nature of the needs.

You, and others involved in your care such as members of your family, should be invited to be involved in the assessment.

You may wish to seek legal advice before an assessment for continuing healthcare takes place, to make sure that you are fully prepared for the assessment.

If you are eligible for continuing healthcare, the NHS and/or the provider of your care package should produce a care plan setting out how your needs will be met. The NHS will arrange and pay for a package of care to meet your needs.  You could also request a ‘personal health budget’, or a ‘direct payment’ where the NHS pays you or your representative a sum of money which you must use to pay for your care.

Continuing healthcare appeals

If you are found to be ineligible for continuing healthcare, you can appeal this decision. You usually need to notify the NHS within 6 months of the date of the decision that you are ineligible, that you intend to appeal. You may wish to seek legal advice on whether there are grounds to appeal the decision.

It is important that you are provided with a copy of the decision support tool, as you will need to provide the NHS with an explanation of why you disagree with their eligibility decision, in writing. You may wish to instruct a solicitor to prepare these reasons for you. It may also be advisable to obtain medical records and/or care records in support of your appeal, and in some cases it may also be helpful to obtain independent expert evidence.

At the first stage of the appeal, the NHS usually holds a ‘Local Resolution Meeting’ to discuss your concerns. If this does not resolve the matter, you can ask for the NHS to arrange an Independent Review Panel. This is a meeting where you will have the opportunity to explain why you disagree with the eligibility decision. You may wish to instruct a solicitor to represent you at the Panel.

If you disagree with the outcome of the Independent Review Panel, you can refer your appeal to the Parliamentary and Health Service Ombudsman. You may also wish to seek legal advice as to whether there are grounds to appeal to the Ombudsman.

Children and continuing care

Children may also be eligible for care other than in hospital from the NHS, and this is known as ‘continuing care’, which is governed by the Children and young people’s continuing care national framework. Many of the same principles set out above apply, although some of the procedures are differ.

Legal advice

We are experts in continuing healthcare, and have a strong track record of succeeding in continuing healthcare appeals. At Rook Irwin Sweeney you will only ever have qualified solicitors advising you. Please contact us if you would like to discuss your case.

December 2022

Photo by Georg Arthur Pflueger on Unsplash