We are often asked, ‘Does the NHS pay care home fees?’ We summarise the legal position and explain how we can help with appeals and retrospective claims.
When someone moves into a residential care home or requires home-care due to a deterioration in their condition, there is often no mention of NHS Continuing Healthcare funding, despite the fact that the NHS has an obligation to assess whether a patient is eligible for it. In this article we look at what the assessment process involves and the appeal process for challenging incorrect decisions. We also look at retrospective claims for care home fee refunds made after an eligible patient has passed away.
The right to a care home fee funding assessment
If your loved one is not offered an assessment for NHS Continuing Healthcare funding, you can request one by contacting your local Clinical Commissioning Group.
How patients are assessed for NHS funding
The National Framework for NHS Continuing Healthcare funding sets out the obligations of the Clinical Commissioning Groups who are responsible for the assessments of NHS Continuing Healthcare Funding within their local community.
Under the National Framework for NHS Continuing Healthcare funding, there are two types of funding that may be available:
- NHS Continuing Healthcare funding: This is available to individuals who present with a “primary health need”. This is a need that goes beyond the scope of what social care can provide. This type of funding is not means tested.
- NHS Nursing Funded Care: This is available to individuals who have a need for nursing care which would be most appropriately managed in a care home with nursing.
An assessment for NHS Continuing Healthcare funding is carried out in two stages.
First stage assessment
The first assessment is called the NHS Continuing Healthcare Checklist and this may be done in a variety of settings, by a variety of health and social care practitioners. However, the Clinical Commissioning Group prefers individuals to be assessed once they have returned to a home environment, whether this be a residential care home or their own home.
The NHS Continuing Healthcare checklist breaks down the eleven care domains, so that these needs may be looked at individually. The care domains consist of: –
- Breathing
- Nutrition
- Continence
- Skin integrity
- Mobility
- Communication
- Psychological and emotional
- Cognition
- Behaviour
- Drug therapies medication symptom control
- Altered states of consciousness
Each care domain is split into three levels: A, representing a high level of need, B, representing a medium level of need, and C, representing a low level of need.
If your loved one scores the following, they will be entitled to proceed to stage two of the assessment – the NHS Continuing Healthcare Funding Decision Support Tool.
- two or more domains in the A column; or
- five or more domains selected in column B or one selected in A and four selected in B; or
- scoring an A in the domains of breathing, behaviour, or drug therapies medication symptom control, combined with a selection of level of needs within the other care domains
Second stage assessment
The second stage of the assessment is completed using the NHS Continuing Healthcare Funding NHS Decision Support Tool (“DST”). This must be completed by a multidisciplinary team who look at how the patient’s needs are managed and the provisions in place to prevent further deterioration. A review of their records surrounding the period which the DST is undertaken should be considered in order that the multidisciplinary team can consider the appropriate level of need in each care domain.
In order for someone to be eligible for NHS Continuing Healthcare Funding, they must score the following:
- Level A in breathing, behaviour, or drug therapies and medication symptom control; or
- Two or more levels of severe needs
However, if a patient presents with one severe level of need combined with a number of other high or moderate levels of need, they may still be entitled to NHS Continuing Healthcare Funding providing that their primary health need is of a nature, intensity, complexity, and unpredictability that is beyond the scope of what can be provided by social care.
NHS care home fee funding appeals
If your loved one is found to be ineligible for NHS Continuing Healthcare Funding, you are entitled to appeal that decision.
At Slee Blackwell, we can undertake a thorough review of your loved one’s records at the time of the decision in order to advise on the prospects of making a successful appeal. If we believe that there are reasonable prospects that the decision will be overturned, we may be able to work on a no win, no fee basis to prepare the appeal documentation and represent you at the appeal meetings.
If following the first stage of appeal, your loved one is still found not to be eligible for NHS continuing Healthcare funding, you are entitled to request an independent review of the decision.
Rapidly deteriorating conditions
If your loved one is suffering from a rapid deterioration of their condition that is entering into a terminal phase, they may be referred by their GP or the care home by way of the Fast Track Pathway Tool for NHS Continuing Healthcare Funding.
Retrospective care home fee refunds
Claims for care home fee refunds can be made even after the patient has passed away. If your loved was a resident of a care home or in receipt of social care for a long period of time, it might be worth exploring this option to see whether they should have been eligible for NHS Continuing Healthcare funding. If they were then care home fees that have previously be paid can be reclaimed.
We will undertake a thorough assessment of your loved one’s records for the period they were in a care home or social care to determine whether a refund is due. If we think there is a valid claim we can work on a no win, no fee basis in order to recover the care home fees that have been paid out over a prolonged period of time.
So, does the NHS pay care home fees?
Yes, the NHS does pay care home fees where specified conditions are met. All patients are entitled to be assessed for their eligibility. However, decisions are often incorrect and can be appealed and reviewed. Retrospective claims for care home fee refunds can also be made in cases where the patient was eligible for NHS funding but passed away. before it could be granted.
Free NHS care home fee funding helpline
So, if you have been wondering, ‘Does the NHS pay care home fees?’ and require specialist legal guidance then give us a call. We can help people who have been unfairly turned down for funding and would like to make an appeal or those who wishing to make a retrospective claim. Contact our helpline for a free assessment on 0333 888 0404 or by email at [email protected]
