Accessing Continuing Healthcare Funding Factsheet

When a relative can no longer live at home for health reasons, you may face the prospect of securing a care home placement. NHS funding may be available to meet the cost of care in a home or in your relative’s own home, but the criteria are complex and the process frustrating.

This factsheet is designed to help you access NHS continuing healthcare funding (sometimes called fully funded care) in England (see the bottom of the page for Scotland, Northern Ireland and Wales).

The basics of continuing healthcare funding v social care funding

Eligibility for fully funded care in England is determined by the local Primary Care Trust (PCT). An individual’s care needs must be deemed not merely incidental to the provision of residential accommodation to qualify for healthcare funding. These are difficult concepts, but basically distinguish a person’s ‘social needs’ – help to get dressed, have meals prepared, etc – from their ‘primary health needs’. People talk about nursing needs instead of primary health needs, but establishing eligibility for continuing healthcare is not as simple as showing that nurses look after an individual.

PCT’s and the national framework for NHS continuing healthcare

Many elderly people have wrongly paid for healthcare due to inadequate guidance and flawed or non-existent assessments of their needs. The National Framework and Decision Support Tool introduced in England on October 1, 2007 aim to establish a fairer and more consistent system for determining whether an individual’s care should be funded by the NHS. However, the same basic qualification principles apply: the individual must require healthcare services that are not merely incidental to the provision of accommodation or which are not of a nature that Social Services could be expected to provide.

How need is assessed

Central to the National Framework is the primary health need test. Unfortunately, the phrase is not defined. The concepts of nature, intensity, unpredictability and complexity of the individual’s need are still relevant, but the PCT will use the Decision Support Tool to assess the level of need in 11 care domains. This is used alongside other evidence to determine whether an individual has a primary health need as opposed to a social care need alone, where costs are not covered by the NHS.

So what should you do to ensure the right decision is made with respect to continuing healthcare funding?

1.Request a healthcare needs assessment
Make sure the PCT assesses healthcare needs at an early stage – preferably at the time of, or before, Social Services assesses finances. PCTs now have to take reasonable steps to ensure an assessment is carried out in all cases where there may be a healthcare need. However, this may not happen automatically and you should ask. If this is refused, ask for a needs checklist to determine if a full assessment is necessary and consider seeking advice if the PCT refuses this request or if it rejects a full assessment.

2.Check the assessment
Ask for the Decision Support Tool document usually completed by the PCT’s nurse assessor after consulting with the multidisciplinary team involved in your relative’s care (you may need Enduring or Lasting Power of Attorney for this). You or your relative may be asked to comment. Check the document and any supporting evidence to ensure it is an accurate picture of your relative’s healthcare needs taking all relevant factors into account. For instance:

• Does it take into account supervision or specialist mental health nursing requirements as a result of dementia or Alzheimer’s?

• Is a need defined as moderate when it should be high, severe or priority?

3.Have your say
Put your comments in writing and ask for them to be presented to the PCT alongside the Decision Support Tool and the multidisciplinary team’s recommendations. The decision on NHS continuing healthcare funding will normally be made by the PCT panel at a closed meeting.

4.Get specialist advice
If the correct assessment procedure has not been followed or the assessment or the funding decision is wrong, ask the PCT to register a review – it costs nothing and you can withdraw if a solicitor or specialist local charity suggests you have no prospect of success. Act quickly as PCTs set deadlines for registering appeals.

5.Request reassessments
If your relative does not qualify for NHS continuing healthcare funding ask the PCT to re-assess their eligibility if their health declines and their healthcare needs increase.

6.Investigate all possibilities
If the PCT decides your relative does not qualify for fully funded care and Social Services suggests you should sell your relative’s home to pay fees, ask a specialist if there is any way the value of the family home should be ignored by the financial assessment. Social Services has discretion to ignore the value of a home in assessing an individual’s ability to pay for care, but they will not exercise it unless asked to do so. Check your relative is getting all of the benefits to which they are entitled as a self-funding resident.

See Challenging Continuing Care Funding Decisions Factsheet for help with applying for continuing healthcare funding.

The National Framework applies to continuing healthcare funding in England. Different guidance operates in Wales and Northern Ireland. Anyone seeking funding should consider seeking specialist advice. A different approach applies in Scotland where nursing and personal care costs (but not accommodation costs) are funded at set levels.