Apply for NHS Continuing Healthcare Funding if your relative has a ‘primary health need’…

Apply for NHS Continuing Healthcare Funding if your relative has a ‘primary health need’…

Applying For FundingThere are two types of care – healthcare and social care.

Why is the distinction so important?

Understanding the difference between healthcare needs and social care needs is vital, as it can dictate which ‘pot’ of funds are used to pay for your relative’s care:

  • Healthcare is provided by the NHS and is free to everyone to the point of use i.e. when you need it. The funded care package is known as NHS Continuing Healthcare Funding (or CHC for short).
  • Social care is provided by the Local Authority (through Social Services) and is ‘means tested’ – which means your relative may have to pay for some or all of their social care needs.
  • If your relative does not fit either category above, they will be required to pay for their care from private funds – which can be very expensive and erode life savings, and in some cases can even result in selling assets (eg their home) to pay for care.

Therefore, getting NHS CHC Funding can save you or your relative many, many thousands of pounds in care fees!

As there is no legal definition of what is a ‘healthcare’ need or a ‘social’ need, this distinction can often be the cause of much confusion and debate.  So, you need to be clear where the dividing line is drawn between these competing needs. The issue can become somewhat blurred where some of these needs combine or overlap.

The technical bit…

The National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care (revised 2018) defines NHS Continuing Healthcare as “a package of ongoing care that is arranged and funded solely by the National Health Service (NHS) where the individual has been assessed and found to have a ‘primary health need’.  Such care is provided to an individual aged 18 or over, to meet health and associated social care needs that have arisen as a result of disability, accident or illness……”.

The concept of a ‘primary health need’ first came to light in the Coughlan case. Following the Coughlan judgment, the test for a Primary Health need was introduced into the National Framework for NHS Continuing Healthcare (see paragraph 58).

In short, a primary health need is where the individual nursing or health needs are more than incidental or ancillary to the provision of accommodation which Local Authority Social Services are under duty to provide, and are of a nature beyond which the Local Authority whose primary responsibility is to provide social services could be expected to provide.

Paragraphs 49 to 51 of the revised National Framework for NHS Continuing Healthcare and NHS-funded nursing care (October 2018) provides some better guidance as to what constitutes a primary health need and what is a social need, and now incorporates the Care Act 2014:

  1. “..in general terms it can be said that a healthcare need is one related to the treatment, control, management or prevention of a disease, illness, injury or disability, and the care or aftercare of a person with these needs (whether or not the tasks involved have to be carried out by a health professional)”
  2. Social needs ”arise from (or relate to) a physical or mental impairment or illness which results in them being unable to achieve two or more of the following outcomes which is, or is likely to have, a significant impact on their wellbeing: • managing and maintaining nutrition • maintaining personal hygiene • managing toilet needs  • being appropriately clothed  • being able to make use of the home safely  • maintaining a habitable home environment • developing and maintaining family or other personal relationships  • accessing and engaging in work, training, education or volunteering • making use of necessary facilities or services in the local community, including public transport and recreational facilities or services, and • carrying out any caring responsibilities the adult has for a child..”.

To summarise:

Think of it this way: put simply, social care needs are often thought of as describing activities of daily living requiring routine care. For example, needing help when out and about, with mobility, feeding, washing, dressing and toileting; whereas primary healthcare needs are more akin to someone requiring frequent monitoring, input, intervention and review by healthcare professionals ie nursing care over and above routine care.  And just because an individual has been diagnosed with medical condition eg dementia, does not mean that they will automatically qualify for CHC Funding. The condition itself is not the key factor here, nor is the setting where the care is provided; it is the interaction between the nature, intensity, complexity and unpredictability of those needs, and whether they over and above what social services could be expected to provide.

Now this is critical…

To establish whether your relative has a primary health need for healthcare, an assessment of their needs has to be carried out. The Checklist assessment and full assessment processes are set out in the National Framework for NHS Continuing Healthcare and NHS-funded nursing care (revised 2018) – including a Fast Track Pathway where an urgent assessment is needed for immediate care needs.

Remember: If your relative has a primary health need, it is the responsibility of the NHS to provide a fully funded care package – FREE OF CHARGE – that meets ALL their assessed health needs and associated social care needs, including any accommodation (if that is part of the overall need). You shouldn’t have to pay a penny more – so beware of unlawful ‘top-up’ fees being charged.

Our top tips:

  1. When undergoing an initial assessment by the Clinical Commissioning Group, their assessors should not ask whether your relative has funds to pay for their own care. This line of financial questioning is fundamentally wrong. The assessment process is to determine if your relative has a primary health need and is eligible for NHS CHC. Remember: it is a matter of health, not wealth. Finances should not be discussed; and if finances are discussed, you must register your objection immediately and complain. It could be good grounds for an appeal if your relative is rejected for CHC Funding.
  2. Alternatively, to save funds, the Clinical Commissioning Group may state at the outset that your relative doesn’t have a primary health need or won’t qualify for CHC. They may try to palm your relative away, and instead suggest that if they have means to consider paying privately for their care; or else approach the Local Authority for social services funding. This ‘financial gatekeeping’ is not permitted and you must object strongly.
  3. Whilst independent financial advisors can be invaluable if consulted at the right time, many will never have heard of NHS Continuing Healthcare Funding, and will therefore not be aware that there is a process in place to assess eligibility for free funded care from the NHS. So, before you part with any money and take out any investment policies to fund long term care, do consider whether your relative has a primary health need and ought first to be assessed for CHC Funding.

12 Comments

  1. Jacquie Lyndley 3 months ago

    We recently had a reassessment meeting for my mum with the CHC and a senior nurse in her care home. My sister was recording the meeting but the nurse said she had to turn it off as it breached her (the Nurse’s) data protection. Is this correct? I understood we should always record the meetings as sometimes things said are changed afterwards
    Many thanks

  2. Siobhain 4 months ago

    My dad was receiving FNC whilst self funding. The Local Authority now pay part of my dad’s care and he pays the rest. FNC was withdrawn 3 months before this happened. Subsequently my dad had a significant fall and a bleed to the brain rendering him bedridden, unable to feed himself and has to be moved in his bed every 4 hours. He has also lost the majority of his speech. Can I apply for CHC checklist to be done and if so how do I do this? Many Thanks

  3. sam smeaton 4 months ago

    My mum went into hospital for a knee replacement in April 2018, she fell in the hospital and broke her pelvis both side so remained in a community hospital for rehab but then had a massive stroke in the May. Since then mum lost use of her right side, she has no sitting balance and is two person hoisted. Mum has limited communication and cognitive ability. Mum is catheterised and incontinent. Mum was managing to feed herself with her left hand but relied on carers to predict and meet all her needs. Mum was not entitled to CHC but we managed to get a 24/7 at home care package which at discharge in October initially involved two carers at night for repositioning but this was reduced as was not needed. The care was going great until 4 weeks ago when mum had a seizure. Mum aspirated and had pneumonia, and after an internal bleed was discovered she was found to have a fractured shoulder and pelvis caused by the seizure. Mum has been in hospital since she is ready for discharge but the LA have not yet agreed the increased care package as she needs two carers at night as cannot help with repositioning. LA have suggested a nursing home or respite but we do not believe it is in mums best interest and will have a detrimental impact on her wellbeing. Hospital plan is to discharge Friday, we have no decision on care package and will be challenging if care is declined which could result in a best interest decision. CHC checklist has been done and we had been advised it would be completed after discharge in 3-4 weeks. All change now as it is being done tomorrow on the ward before a decision is made about the care package (nothing to do with cost of package…yeah right). I feel really unprepared for the meeting. Mums presentation has changed since the seizure and we are unsure what she understands as she is not engaging with us. One part of me wonders if the seizure has caused more damage. Another believes it is behavioural and due to mood and the current situation as she is laying in a hospital bed cannot move, cannot feed herself or hold a drink, cannot communicate with others on the ward or tell anyone want she wants or needs and is staring at the four wall continually. Mum clearly had one severe and multiple high and medium needs last time but didn’t qualify and we were left feeling the domains and boxes were pointless as it was all down to the assessors interpretation. The social worker just sat and agreed and left it to us to challenge. Mum is at risk of aspiration so needs close supervision after feeding/drinks and upright position for at least 15 minutes afterwards, risk of seizures, has unmanaged pain, two person hoisted, catheter care (kinks, back flow), incontinence care no routine so washed/changed (severe constipation and pain some days), has pressure sores since being in hospital, has no mobility so needs repositioned 3 hourly for skin integrity and repositioned when in pain (unpredictable). Carers need to be able to predict her needs and interpret her pain as she does not cry out (family and carers just no) so pain is unpredictable. We were struggling with medication before hospital admission as in she was given them and would chew them, refuse them, hide them and it would often take a very long time to get her to take the medication and she would laugh. I just feel going through the whole process is going to be a pointless exercise to cross t’s and dot i’s but not get the needed outcome. I feel CHC assessment could be the difference between mum going home and the LA making a best interest decision and placing her in a nursing home.

    Any advice would be really appreciated.

    • Care to be Different 4 months ago

      Hi Sam – it sounds as though your mother has some pretty intense and complex needs. We would be happy to chat this through with you if you would like to get in touch via enquiries@caretobedifferent.co.uk Kind regards

  4. Sally 4 months ago

    Hi. My mum has severe dementia and high blood pressure as well as arthritis and low sodium level issues. She owns her own home but have been assessed by a psychiatrist who advised she needs full time nursing care. Will she have to pay for this care and sell the family home or could we apply for NHS continuous health care?

  5. Diane Andrews 5 months ago

    Can I ask the question, if your relative needs nursing care and has not had a checklist assessment because the relative professionals refused to advise the relatives about how to contact the CCG a checklist assessment can we apply for a retrospective claim? D. andrews

    • Care to be Different 5 months ago

      Hi Diane – you can request a Checklist assessment at any time. Contact us if you would like to chat it through. Kind regards

  6. Joanne Morris 8 months ago

    Hi my mother is currently in a Care home , she has frontal lobe dementia, we have been paying for her care, using her savings , how ever as her prognosis is not good , and she rapidly getting worse I was considering applying for CHc , she had severe mental impairment, do you think I should try and apply

    • Care to be Different 8 months ago

      Hi Joanne – Many thanks for reaching out. You should certainly apply. Ask for a Checklist assessment to be carried out but if your Mother has a rapidly deteriorating condition and is not expected to live very long then consider asking for a Fast Track assessment. Contact us direct if we can help further enquiries@caretobedifferent.co.uk Kind regards

  7. Suzanne Morrison 9 months ago

    our son was deemed not to be eligible for CHC last year after meeting the criteria for CHC for 26 years, I used a company to look at the paperwork but be aware as you could be parting with up to £10,000 to bring an appeal against a flawed DST using them without a guarantee of successes.
    The appeal states he has a primary health need and that he meets the criteria for CHC funding in full. I now have to work out what i can do without paying more money up to get back something we all know he meets.
    What is the next step I can take. We have just had a new MDT and the nurse assessor has phone a physiotherapist up we have been forced to employ since 2009 and asked where the money to pay for his physiotherapy comes from and where do the invoices go, this is wrong surely

  8. Veronica Gale 9 months ago

    I was told my Mum needed a nursing care bed in January 2016 but none were available so she had to stay in the care home unit. She ended up in hospital in September 2016 and passed away in January 2017. She had vascular dementia as well as long time mental health issues and scoliosis which deteriorated while in the care home. She got 1 severe and 4 highs plus moderates. I’ve finally had a response to a panel meeting for retrospective funding after they’d failed to follow procedure so had to go through the process again. They have said that she would have got nursing funding if she had moved to the nursing unit but that she didn’t get funding while in the care unit. Where do I stand as I’d like to take this further as I’m seriously annoyed with the time they have taken and this decision. I’m not asking for all the fees back to when she first went into the home just the last 9 months that she was deemed nursing care.

    • Care to be Different 9 months ago

      Hi Veronica – it is worth considering appealing this if you are still within the 6 month time frame for doing so. Contact us if you would like to discuss it enquiries@caretobedifferent.co.uk Kind regards

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