Who is eligible for Continuing Healthcare?

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We take a brief look at who is eligible for Continuing Healthcare and answer some frequently asked questions

Can I Claim the Costs of my Care?

If you have long term care needs, whether you are living in your own home or in a residential care home, you often require a mix of services provided by the local authority Social Services department and/or the National Health Service.

NHS continuing health care is a package of care that can be arranged and funded by the NHS to meet physical or mental health needs which have arisen because of illness.

The Primary Care Trust (PCT) in the area where your GP practice is located is responsible for deciding your eligibility under the NHS continuing healthcare scheme. The PCT is also responsible for arranging and, more importantly, for funding your care. The National Framework for NHS continuing healthcare was published by the Department of Health in June 2007. It is a guidance document setting out clear principles and processes to be followed throughout England for establishing whether your need for care is primarily because of your physical and/or mental health needs as opposed to personal care needs. The National Framework is applied throughout England to minimise local variation and to improve the consistency of decision making.

Who is eligible for Continuing Healthcare?

There is often considerable confusion about who is eligible for Continuing Healthcare. You will be eligible for NHS continuing healthcare if it is established that you have a primary health need based on your physical and mental needs. This is determined by following the principles and processes set out in the National Framework.

Eligibility for NHS Continuing Healthcare may vary from time to time during a patient’s life. Eligibility should be considered, or reconsidered, if the patient has a rapidly deteriorating condition, before or immediately after discharge from hospital, particularly if it is apparent that a permanent place in a care home is going to be necessary. Additionally, it should be considered at a patient’s annual care needs review and if the patient’s physical or mental health deteriorates significantly, in the period between regular reviews.

What is the process for obtaining funding?

To determine whether a patient is eligible for NHS Continuing Healthcare the PCT must undertake an assessment. The assessment should involve both patient and carers. Before an assessment is carried out the consent of the patient should be obtained and the views of family and carers taken into account.

The assessment itself is carried out using one of more of the three assessment tools namely:

1. Fast track tool

2. Checklist tool

3. Decision support tool

The fast track tool is used for patients who have a rapidly deteriorating position and/or who appear to be entering the final phase of life and therefore need urgent consideration.

The Checklist tool is used once it is agreed that fast tracking is unnecessary. Its purpose is to encourage assessments appropriate to need and to help health and care professionals identify who is most likely to be eligible for NHS continuing healthcare and so need full consideration of their case.

The decision support tool has 11 areas of need (described as “domains”). The patient is assessed and each domain is given an appropriate priority level ranging from “no need” through low, moderate, high and severe to “priority”.

The domains in the decision support tool are:

1. Behaviour
2. Cognition
3. Psychological and emotional needs
4. Communication
5. Ability
6. Nutrition
7. Continence
8. Skin and tissue viability
9. Breathing
10. Drug therapies and medication
11. Altered states

The decision support tool has a section allowing the patient or carers to summarise a section of the needs to be taken into account.

After the assessment process has been completed the PCT should tell you verbally and in writing what decision has been reached. Typically this will be within two weeks of referral. Whatever the outcome of the assessment the decision is not necessarily permanent and may alter as the patient’s condition changes.

What if my application is rejected?

If you are unhappy with the decision of the PCT this can be challenged. You may be unhappy that the PCT has not followed the correct procedure to reach the decision; alternatively you may feel that the evidence collected and the application of the guidance has not been properly interpreted.

In the first instance the PTC will usually have a local resolution process to be followed. If local procedures have been exhausted and you are still not happy with the outcome you can ask that your case be referred to the appropriate Strategic Health Authority for an independent review of the decision.

If you are not eligible for NHS Continuing Healthcare then your needs may be met through a joint health and social care package. Your PCT and local Social Services will need to agree where the funding responsibility lies and you will be means tested for services that are the responsibility of Social Services which, subject to your resources, will result in you being asked to contribute to some or all of the costs of your care.

I am not happy with the decision of the PCT

If you have any queries about who is eligible for Continuing Healthcare or believe that you or a relative have been wrongly denied NHS Continuing Healthcare funding, either because of a failure to consider eligibility or due to an incorrect assessment of the information, we can help you to formulate your case to the PCT for reconsideration or preparation of the case to put before the Independent Health Authority for independent review.

If you would like to discuss who is eligible for Continuing Healthcare then please contact us on 0800 052 3620, email [email protected] or complete our dedicated Continuing Healthcare Questionnaire.