If your relative needs to be assessed for NHS Continuing Healthcare funding, you may be wondering what the different stages of NHS Continuing Care assessment and appeal are.
If you have health needs/nursing care needs and you need full time care, you need an assessment for NHS Continuing Healthcare funding. If you’ve already had an assessment and been turned down for funding, you can appeal.
We’ve outlined here the various stages of NHS Continuing Care assessment and appeal – and who you need to contact in each case…
- Initial assessment: This is the ‘Checklist’ assessment and it looks at 11 aspects of health. You can ask a care home manager, social worker, GP or other health and social care professional to organise this – or you can contact the Continuing Healthcare team at the local NHS Clinical Commissioning Group (CCG). A Checklist can be carried out by one person – but that person must understand the process and be familiar with your relative’s care needs. The Checklist does not determine eligibility; it simply indicates whether you should have a full assessment. See point 2 below.
- If you don’t get through the Checklist, and you disagree with that decision, you can request another Checklist assessment. Contact the local NHS Continuing Healthcare team in writing and say you would like the Checklist to be repeated. Outline why you disagree.
- If you do get through the Checklist stage, you then go on to have a full assessment. At this point a form called the ‘Decision Support Tool’ (DST) is completed by a Multidisciplinary Team (MDT) – not just by one person. A social worker or other local authority representative must be involved.
- If you’re found eligible for NHS Continuing Healthcare after the full assessment, you are said to have a Primary Health Need, i.e. your primary care need is a health need. Funding will be awarded to you by the NHS to cover your care costs, including your social care costs, such as accommodation in a care home. Funding is backdated to day 29 after the original Checklist was received by the NHS. A further funding review then takes place in 3 months, and after that it should be reviewed annually.
- If you’re ineligible at the DST stage, you can submit a Continuing Care appeal via the local NHS. You may be offered a Local Dispute Resolution Meeting first, but in many people’s experience this meeting is unlikely to change the decision. It seems to be simply an opportunity for the NHS to justify the existing funding decision. Write to the local NHS Continuing Care Dept and say that you disagree with the outcome of the MDT assessment and you would like to appeal formally. The NHS must adhere to Dept of Health’s Continuing Care review timescales in dealing with your request. You then need to put together in writing all your reasons for disagreeing with the decision to deny Continuing Care funding.
- If this Local Dispute Resolution process results in the decision of ‘ineligible’ being upheld, let the local NHS know that you would like an Independent Review Panel to be convened at regional level. You can also approach the NHS National Commissioning Board or NHS England directly and ask for an Independent Review. Write to the NHS Continuing Care Review Panel Administrator at your regional office of NHS England, state that you disagree with the decisions made by the local NHS Clinical Commissioning Group. Outline which assessments have been carried out so far, and ask for a date for an Independent Review Panel hearing (IRP). Note: of you don’t go through the motions of any Local Dispute Resolution process first, you may find that NHS will send your case back to the local CCG for this to be completed before you can receive a date for an Independent Review.
- Alternatively, if your relative has clearly deteriorated through this whole process, you can ask the local NHS for a further DST assessment. Also, if your relative is in ‘terminal decline’ or in a period of rapid deterioration, you can ask for a Fast Track assessment.
- If you’re found eligible for funding at the Independent Review, NHS Continuing Care funding will be awarded, backdated to shortly after the Checklist.
- If you’re found ineligible for funding at the Independent Review, you can approach the Health Ombudsman.
- Failing that you may have to go on to judicial review/legal action.