We understand that discussions regarding continuing healthcare happen during a stressful time, often when you have to decide how a loved one will be cared for after illness or injury.
The information on this page is a guide for people who may need ongoing health and social support as a result of disability, accident, or illness. It will navigate you through the process for deciding whether someone is eligible for care funded entirely by the NHS.
What is Continuing Healthcare
NHS continuing healthcare (CHC) is the name given to a package of care which is arranged and funded solely by the NHS for people aged 18 and above who have been assessed by the service as having a primary health need. NHS Continuing Healthcare is not awarded due to disease or diagnosis, nor is it awarded based on who provides the care or where it is provided.
Funding can apply to any setting, including your own home or a care home. It is free, unlike support provided by local authorities, for which you may have to pay, depending on your income and savings.
Funding arrangements are subject to regular reviews and may change in response to peoples changing needs.
The Department of Health provides a summary of the continuing healthcare process, visit the website for more information.
Who is eligible?
Eligibility is determined by a detailed assessment which looks at all of aspects of care needs:
- Nature: the individual's needs and the interventions required to meet those needs
- Complexity: the level of skill/knowledge required to address an individual need or the range of needs and the interface between two or more needs.
- Intensity: one or more health needs, so severe they require regular intervention
- Unpredictability: unexpected changes in condition that are difficult to manage and present a risk to you or to others.
The assessment process guidelines are set down by the Department of Health in the “National Framework for Continuing Healthcare and NHS-funded nursing care”.
What is the process?
Referral: I think I need an assessment
If someone needs to be assessed for NHS continuing healthcare, a referral should be made to the team. The referral form can be obtained from the:
Continuing Healthcare Team,
NHS East Berkshire Clinical Commissioning Groups,
King Edward VII Hospital,
St. Leonards Rd,
Windsor, SL4 3DP
Checklist: Am I eligible for an assessment?
In order to identify whether an individual requires a full CHC assessment, a CHC checklist is undertaken. The checklist will be completed by a health or social care professional trained as part of their role. Trained professionals will identify which statement describes the level of need and individual has across 11 care domains. To see the form, instructions and read more about the checklist, visit the Department of Health’s website.
The checklist will be sent to the CCG for consideration and approval. Where the CCG identifies a full NHS continuing healthcare assessment is required, and the individual is the responsibility of one of the 3 east Berkshire CCGs (Slough CCG, Bracknell and Ascot CCG or Windsor, Ascot and Maidenhead CCG), our CHC Team will arrange the assessment.
When an individual is not eligible for a CHC assessment, the CCG will confirm you of this in writing. You have the right to ask the CHC team to review their decision if you believe they are wrong.
CHC Assessment: The assessment
The holistic continuing healthcare assessment involves the patient, people caring for them, professionals and their family and/or representative. Friends, relatives and official advocates may also be present. The assessment takes place in two sections:
Part 1 - Care Needs Portrayal
The CHC nurse assessor will assess the person’s needs. This will typically be recorded in a document called a Care Needs Portrayal. This document should accurately reflect an individual’s current needs. It will usually be shared with the patient and/or representative for review and comments before the assessment. In some cases this may not be appropriate or necessary.
Part 2 - Decision Support Tool
The CHC assessment will usually take 2-3 hours.
The meeting will usually include the patient and/or their representative, professionals involved in providing care, a CHC assessor and a social worker. The CHC assessor will facilitate a discussion of the patient’s needs with a multi-disciplinary team (MDT). The MDT will be skilled and knowledgeable in the National Framework. Using their professional judgement, and guided by information from all those present, the assessor and social worker (or identified representative) will complete the Decision Support Tool, and make a recommendation as to whether the patients’ care should be funded by the NHS.
The Decision Support Tool can be found on the Department of Health's website.
At the end of the assessment the MDT will make a recommendation as to whether or not the individual being assessed has a “primary health need”. In making a recommendation the MDT carefully consider all the individual’s care needs, relating them to four key indicators:
When the Care Needs Portrayal and Decision Support Tool are complete, you will be asked to check if you believe the recorded care needs of the care person being assessed are accurate. If there are any amendments required, you should let the service know.
Fast Track Tool
If you need urgent care due to a rapidly deteriorating condition which means a person is coming to the end of their life, the Fast Track Tool may be used instead of the Decision Support Tool. The Fast Track Tool can be downloaded from the Department of Health’s website.
An appropriate clinician will complete the Fast Track Tool and send it to the CHC Team. The CHC Team will arrange care and support as quickly as possible.
Determination: Decision Making
Quality Assurance is undertaken by the east Berkshire CHC Team. This is to ensure the assessment and recommended outcome are compliant with the National Framework and can therefore be ratified. The CCG should usually accept the recommendation of an MDT except in exceptional circumstances. Once a decision is made, the CCG will write to the individual that was assessed and/or their representative(s) to confirm the outcome and the reasons for any decisions. If you are not happy with the outcome you can appeal the decision.
Appeal: Your right to recourse
If you are not happy with the CCG’s decision, or are concerned about the process followed by the CCG, you have the right to appeal and request a review of the CCG’s decision. There are 3 stages to this process. You can also seek independent advice from Beacon CHC.
Local resolution – The CHC team will arrange a local review of the assessment to carefully consider your grounds for appeal. We will agree with the appellant the best way to resolve their concerns, which may include another assessment or consideration of the case by an Appeal Panel.
After local resolution if the appellant remains unhappy with the CCG’s decision, they will be advised of their right to request an Independent Review of the decision.
Independent Review – Requests for an Independent Review can be made in writing to: Eileen Roberts, Continuing Healthcare Manager (South Region), NHS England, South West House, Blackbrook Park Avenue, Taunton, TA1 2PX. NHS England has produced a helpful leaflet which describes the Independent Review process.
Requests must be made within 6 months of local resolution being completed. The appellant will need to tell NHS England why they believe the CCGs’ decision should be reviewed and why they believe the decision or process they followed was wrong. If the request for a review is accepted, the appellant will be invited to a meeting to put forward their case. The Independent Panel will consider the evidence and decide whether or not the CCGs’ process and decision were robust. In all but exceptional cases, this decision will be accepted by the CCGs.
Ombudsman - If the appellant remains dissatisfied with the decision, you can write to: The Parliamentary and Health Service Ombudsman (PHSO), Millbank Tower, Millbank, London, SW1P 4QP. You can visit the Ombudsman website or call them on 0345 015 4033. The PHSO will review the case and make recommendations as appropriate.
Complaints – Individuals have the right to complain to the CCG if they are unhappy with the way in which their assessment has been handled. Complaints can be sent to the Complaints Manager, East Berkshire CCGs, King Edward VII Hospital, St Leonard’s Rd, Windsor, SL4 3DP or email .
Commissioning of Care: Planning your care
Individuals eligible for NHS funding, will be contacted by the CHC Team. We will work with you to identify the type of care that best meets your needs from organisations that are registered with the Care Quality Commission, and are able to demonstrate their ability to deliver satisfactory care standards. Your wishes and expectations of how and where the care is delivered should be documented and taken into account. If you wish, you can ask for a Personal Health Budget by contacting the team.
Review: Monitoring and review
Once you are eligible for Continuing Healthcare, we will review your eligibility at least once within the first three months and annually thereafter, or sooner if your needs change. The NHS and local authority should not stop your care or funding without a joint review and reassessment of your needs. They should also consult one another and you about any proposed changes and ensure that alternative funding or services are in place.
What is the Decision Support Tool?
This is a 57 page document which looks at the individual’s care needs across 12 care domains. The professionals will describe the actual needs of the individual, providing evidence to inform the rationale for which level of need should be selected; no need, low need, moderate, high, severe or priority. Please note not all domains have a Severe or Priority weighting. Visit the Department of Health website to view the Decision Support Tool.
Where is NHS continuing healthcare provided?
If you are eligible for NHS CHC, it can be provided in any setting including a care home, or in your own home. Decisions regarding available provision require approval by the CCG.
If you are assessed as eligible for care in your own home, the NHS will pay for healthcare (service such as community nursing or specialist therapy) and associated social care needs (such as personal care and domestic tasks, help with bathing, dressing, food preparation and shopping. In a care home, the NHS also pays your fees, including board and accommodation).
What happens if I am not eligible for NHS continuing healthcare?
When a person is not eligible, they can be referred to their local authority, which can identify whether they are eligible for support from them. There may be a charge for social care provision.
If you are not eligible for NHS continuing healthcare, but need a registered nurse while living in a registered nursing home, you may be eligible for NHS-funded nursing care.
What is funded NHS-funded nursing care?
When an individual is not eligible for a continuing healthcare assessment (following a checklist) or has been assessed as not eligible for NHS continuing healthcare (following an assessment) the CCG will consider whether they are entitled for Funded Nursing Care (FNC). Funded Nursing Care is available for individuals who:
- have been assessed by the CHC Team as eligible for funded nursing
- live in a Registered Nursing home and
- require the services of a Registered Nurse
When an individual is assessed as eligible for Funded Nursing Care they will be notified in writing. The CHC Team will make a fixed rate contribution to the care home. This contribution will cover support including: direct nursing tasks, care planning, supervision and monitoring of nursing and healthcare tasks.