Care Crisis: NHS Continuing Healthcare Funding - What is it and are you entitled to it?

With the cost of care becoming prohibitively expensive and the very real issue many thousands of families face regarding how to fund care in our later years, we interview Tim Davies Managing Director of Compass CHC (offices in Tiverton & Barnstale) who specialises in securing NHS Continuing Healthcare, the pot of money available through the NHS to cover 100% of your care fees irrespective of location or financial assets.

What is NHS Continuing Healthcare?

Continuing healthcare funding, also known as CHC funding, is free healthcare provided by the NHS which can be received in any setting outside of hospital including at home, within a hospice or in a care home (either residential or nursing). The package of care is available to people who have significant ongoing healthcare needs, and it covers 100% of care costs.

To be eligible for NHS Continuing healthcare funding, it must be established that your need for care is primarily health related. Additionally, these needs must be assessed as being either complex, intense and unpredictable in their nature or a combination of the same.  It should be noted that a person’s health needs – not their diagnosis - determines whether they are eligible for funding so having a certain diagnosis, for example having been diagnosed with Dementia, Alzheimer’s Disease or Parkinson’s disease, is not in itself an automatic entitlement to free care.

Importantly, it doesn’t matter what your income is or what savings you have, if you meet the criteria, you are entitled to free NHS CHC funding. NHS continuing healthcare funding is not means tested.

Unfortunately, many families find that the process for applying is too complicated to understand and it is currently estimated that of the 150,000-people eligible to the funding, only 60,000 are receiving it.

How do we apply?

A continuing healthcare checklist is the first stage in determining whether an individual is entitled to free care.  To trigger a checklist, you can ask your social worker, GP or other health and social care professional – such as a care home manager - to organise one.

An assessment should be carried out before a patient is discharged from hospital to a nursing home.  This is a crucial point.  If the patient is already in a nursing home or remains in their own home, then the responsibility for conducting an assessment is with the NHS Clinical Commissioning Group for the area.

If the checklist identifies the need to carry out a full assessment, your Clinical Commissioning Group (CCG) will be contacted. The full assessment is carried out by a multi-disciplinary team comprising two or more health or social care professionals familiar with the patient’s needs. In some cases, the multi- disciplinary team will contact the specialists involved with the care to build a better picture of the health needs the individual has.

The information gleaned from your full assessment will be used by the multi- disciplinary team to complete a ‘Decision Support Tool’ (DST). The DST document was developed to ensure assessments are carried out as consistently as possible across the national NHS network

The multi-disciplinary team will allocate a level of need to each care domain to determine if the individual has a ‘primary health need’ and then make a recommendation to the CCG as to whether the individual should be entitled to NHS continuing healthcare.

How long should it take to receive an answer?

Once your continuing healthcare assessment has taken place, the NHS health and social care professionals involved with your care will recommend whether you are eligible for funded care. This recommendation is forwarded to the Clinical Commissioning Group (CCG) responsible for funding in your area. The CCG will decide whether to accept or decline your assessment results and, if upheld, the level of care and support package available to you.

The ‘National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care’ makes clear that the time between the checklist being received by the CCG and a continuing healthcare funding decision being made should not exceed 28 days.

If the need for care is more urgent, where someone is in very poor health and near the end of their life for example, their eligibility should be determined as quickly as possible using the National Framework fast track pathway tool. In these circumstances, a care package should be approved and put into place as quickly as possible.

Unfortunately, at Compass CHC, we experience all too often CCGs and Continuing Healthcare teams flouting the guidelines clearly laid out in the National Framework, particularly when it comes to time scale assessments. Many of our client’s report being told that there is a ‘backlog’ and their case decision would be delayed until the backlog has been dealt with. This delay can make the process so much more trying for families who simply do not have the time to constantly chase the NHS and CCG for information.  We have even encountered instances of the NHS refusing to complete an assessment for up to a year from when it was first requested, with the patient having to meet their full care costs privately at sometimes more than £1000 a week in the interim.  Clearly this is not acceptable.

What problems may I encounter?

To receive NHS continuing healthcare funding the individuals need for funding must be a healthcare NOT a social care need.

However, we have heard from countless individuals, and witnessed first-hand, how NHS continuing healthcare assessors consistently try to downplay and underscore obvious health needs and recategorise them as social care needs. Clients inform us that they have spent many frustrating and upsetting hours in continuing healthcare assessment meetings disputing the difference between health and social care needs with assessors determined to withhold funding. Many clients ultimately receive the news that their relative doesn’t qualify for funding as their need for care isn’t health based despite clear evidence in the form of medical records and care plans to the contrary.

This desire to withhold funding shouldn’t come as a surprise as it allows the NHS to pass responsibility for funding the individuals care to the Local Authority where the person will be means tested and then, if they exceed the funding threshold of having assets over £23,250, told they must fund social care themselves. But, by its very essence, medical services provided by the NHS are free to residents in the UK so if there is a clear healthcare need, care should be provided for free.

Despite what appears to be clear guidance in the National Framework - the Framework establishes that where the primary need for care is a health need, the responsibility for providing funding lies with the NHS - there are several grey areas. These grey areas are the main source of conflict between patients and the NHS with many people having to argue with the NHS assessors regarding how their treatment should be defined.

What can I do if I am refused funding but disagree with the decision?

There are several options available to you:

a. If you don’t get through the initial Checklist, whilst you are unable to appeal the outcome, you can request that another Checklist assessment is undertaken.
b. If you are denied funding at the full Decision Support Tool stage, you can submit an appeal, in writing, to the local NHS Continuing Care Department. You must list all your reasons – with evidence - for disagreeing with the decision to deny Continuing Healthcare funding.
c. Should the Local Dispute Resolution process uphold the ‘ineligible’ decision, the next step is to request an Independent Review Panel to be convened at regional level.
d. If the Independent Review also find you ineligible for funding, you can approach the Health Ombudsman.

It sounds complicated, is there external help?

Yes, there are several experienced companies, like Compass CHC https://www.continuing-healthcare.co.uk/  providing an invaluable service to individuals needing assistance with continuing healthcare.

At Compass CHC, we are contacted daily by individuals from across England and Wales who require assistance with NHS continuing healthcare funding. Whilst some are at the start of their funding journey, many have been battling with the minefield that is continuing healthcare funding for months or, worse still, years and have reached a state of exhaustion with a process so complex that – incredibly - 39% of NHS professionals also reported finding complicated (CHC Alliance, ‘Continuing to Care’ report).

Some clients are so bogged down under the weight of paperwork and confusing terminology that they simply don’t know how to move forward.

At Compass CHC, our team of continuing healthcare experts headed up by myself and comprising lawyers (non-practising) and clinicians (including nurses, tissue viability specialists and pharmacists), review and consider medical evidence from a clinical perspective before drafting reasoned arguments to the NHS which identify an individual’s entitlement to continuing healthcare funding by cross referring the medical evidence to the National Framework for continuing healthcare criteria.

Our advocates are made up of qualified (non-practising) lawyers specialising exclusively in continuing healthcare funding matters, we do not undertake work in any other area which means we have accumulated vast experience attending assessments and appeal hearings at local and NHS England level and we are not distracted by work of other natures.

The key to success when taking on the NHS continuing healthcare professionals is to ensure that you have sufficient expertise in your corner to support you through the process so the correct outcome is reached.

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