Unfortunately, most people have never heard of NHS Continuing Healthcare Funding, or if they have, have failed to get it for their spouse or relative, without a lengthy and frustrating struggle.
Even when CHC is granted, families are still at risk that their relative may be reassessed and have funding improperly withdrawn or reduced, leaving them to pay any shortfall from their savings whilst battling with an appeal.
Many doctors and consultants we speak to don’t really know what NHS Continuing Healthcare Funding is all about either, or how to advise their patients about requesting an assessment as to their legal entitlement to this free funding.
However, whether you are new to CHC, awaiting an assessment, looking to appeal a decision where funding has been refused, or just generally looking for some guidance on hot topics such as unlawful ‘top-up’ fees, countering the ‘well-managed’ needs argument, your right to advocacy support, or just want to learn from other peoples’ experiences who have already been through the same situation – you can find this and much more free information on our website.
Here’s a quick guide to the basic essentials you need to know at the start of the process …
Don’t pay a penny for care fees until you’ve read this!
What is NHS Continuing Healthcare Funding (CHC)?
NHS Continuing Healthcare Funding is FREE funding available to an individual to meet the cost of their care and accommodation, whether living in a care/nursing home or in their own home.
Note: The place/setting where care is provided is not relevant.
NHS Continuing Healthcare Funding is not means-tested.
You need to grasp the fact that CHC is all about health.
An individual’s wealth is never a consideration – nor should your relative ever be asked if you can afford to self-fund their own care.
Remember: CHC is only about health, not wealth.
It is the level of healthcare needs that determine whether an individual is eligible for this FREE funded package of care. You either qualify for CHC or you don’t.
Clinical Commissioning Group (CCG)
There are about 200 CCGs in England and Wales, which are NHS organisations responsible for “planning and commissioning healthcare services” in a designated locality.
CCGs perform the NHS’s responsibilities for assessing, decision-making, implementing and carrying out the NHS Continuing Healthcare packages.
So, to start the ball rolling and see if your relative is eligible for CHC Funding, you need to ask your local CCG to carry out a CHC assessment.
Here’s a link to all CCGs in England and Wales to help you find their contact details.
National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care (revised 2018)
The NHS National Framework, as it’s known, is the guidance governing the whole CHC assessment and appeals process.
You need to familiarise yourself with the National Framework, as it contains the governing rules the NHS use to assess eligibility for CHC Funding. But don’t expect a fair fight! The assessment process is subjective, prone to inconsistencies throughout the country, and therefore open to abuse.
Know the NHS National Framework so you can point out any abuse of the assessment process.
The National Framework also sets out a short cut process for Fast Track assessments, which should be used if your relative has a rapidly deteriorating condition and may be entering into a terminal phase of their life. If successful, the CCG should implement a package of care within 48 hours.
Do you have authority to act?
If acting for an elderly relative, or someone who has lost mental capacity to look after their own health or finances, you will usually need to have in place a Lasting Power of Attorney (LPA).
There are two types of LPA – one for Property and Financial Affairs, and the other for Health and Welfare.
An LPA can only be made if an individual is 18 years or older, and has mental capacity to make decisions themselves. Under an LPA an individual can appoint a designated Attorney(s) to act in their best interests and make decisions on their behalf – either before, or once they have lost mental capacity.
If your relative has mental capacity, but does not yet have an LPA in place, then you ought to consider setting one up as soon as possible to protect their best interests and avoid delays or a third party making decisions on their behalf instead.
For further reading:
What is a Primary Health Need?
To get CHC funding, your relative must have a ‘primary health need’.
In simple terms, there is a dividing ‘line’ between care that the NHS must pay for and care that is the responsibility of a Local Authority.
When a person’s care is the responsibility of the NHS, that care is free of charge, and is not-means-tested.
When it is the responsibility of a Local Authority, the person may be means-tested.
In short, a ‘primary health need’ is simply a way of describing that a person’s care is on the NHS side of that line – ie health needs over and above what a Local Authority are legally obliged to provide.
If coming out of hospital
If your relative is coming out of hospital and going into a care home for the first time, the NHS should put in place an interim package of care for their ongoing health needs, whilst waiting for an initial Checklist assessment.
If already in a care home – ask the care home manager to contact the CCG to arrange an initial Checklist assessment.
For further information, read: What’s new in 2018 NHS National Framework for CHC? Are you getting an interim care package?
The Initial Checklist
This is the start of the assessment process.
The initial Checklist is a basic screening tool used by CCGs to determine whether an individual should proceed to a full assessment at a Multi-Disciplinary Team (MDT) assessment.
You can access the Checklist here: Link to Checklist
The threshold for proceeding to a full assessment is set quite low, so if you don’t get past this level and move on to a full assessment, you can assume that your relative’s needs are insufficient to qualify for CHC at this stage.
In the event that an individual does not qualify for CHC Funding, they may be entitled to funding from the Local Authority (provided through Social Services) which is means-tested. If your relative has capital or assets of more than £23,250, then they may be asked to contribute, in whole or in part, to their care.
If your relative’s health needs deteriorate over time, you can request another Checklist.
The MDT should take place within 28 days from the CCG receiving the positive Checklist assessment.
For further reading around the subject:
Multi-Disciplinary Team Meeting (MDT)
This is a full assessment of an individual’s health needs carried out by professionals from different disciplines using the Decision Support Tool (DST) – see below.
The purpose of the MDT is to make a recommendation to the CGC as to whether your relative is eligible for CHC Funding or not.
The assessment must be carried out by at least 2 people, one from healthcare and the other from social care, who have been trained in the NHS National Framework and have been involved in your relative’s care.
Ensure that you receive notification of the MDT in good time, so that you can prepare your thoughts in advance.
It is essential that you are present when your relative’s needs are being assessed, so that you can contribute to the process, fill in any gaps in the assessors’ knowledge, correct any misunderstandings they might have, and generally ensure that the whole assessment is carried out thoroughly, fairly and robustly.
Beware, some assessors may come with ‘preconceived’ ideas that your relative simply won’t qualify even before they have met them, or else might try to put you off claiming. Make a note of any improper comments or abuse of process, as they may give grounds for appeal.
Remember: It’s a very good idea to take someone along else with you to the MDT as another pair of eyes and ears, and to take notes of what is being discussed.
You are entitled to have an advocate to represent you.
The MDT assessment is completed using a Decision Support Tool.
For more help with Multi-Disciplinary Team assessments, read our blogs below, and many more on our website:
Decision Support Tool (DST)
The DST sets out the 12 Care Domains, namely: (Behaviour, Cognition, Physical/emotional needs, Communication, Mobility, Nutrition, Continence, Skin integrity, Breathing, Drugs/medication/symptom control and also Altered state of consciousness).
The DST is a scoring ‘tool’ used at the MDT to build a picture of an individual’s health needs across the various Care Domains by reference to a description as to what level of need constitutes a ‘Priority’, ‘Severe’, ‘High’, ‘Moderate’, ‘Low’ or ‘No need’.
You can access the Decision Support Tool here: Link to checklist
The DST is not an assessment in itself, but rather a way of recording your relative’s overall needs in consultation with the four Key Indicators (‘Nature’, ‘Intensity’, ‘Complexity’, and ‘Unpredictability’), and by looking at the totality of their needs when determining whether they have a primary health need.
The assessors will complete the DST and send it to the CCG with their recommendations as to whether the individual is eligible for CHC or not.
Getting the Multi-Disciplinary Team Decision
The CCG should communicate the outcome of their assessment to you in writing within 28 calendar days of the MDT assessment.
If found eligible, the CCG should be put in place a CHC funded package of care to cover ALL your relative’s cost of care and accommodation.
Note: If CHC is awarded, the CCG should carry out a reassessment within 3 months of the eligibility decision being made, and thereafter at 12 monthly intervals.
CHC is not guaranteed for life and can be withdrawn if your relative’s health needs improve. Or more cynically, if a CCG needs to make some costs savings, despite the individual’s needs remaining the same or even deteriorating since the previous assessment!
If the CHC funded package paid by the CCG is not enough to pay for the care home fees in full, then it is unlawful for the care home to ask your relative to top-up the difference. Instead, the care home should approach the CCG to get increased funding to meet any shortfall in the actual cost of care.
If your relative is turned down for CHC Funding, they should be automatically be assessed for NHS-funded Nursing Care (FNC).
FNC is available to individuals living in a care/nursing home, who need some element of nursing care from a registered nurse.
FNC is not means-tested and is tax free. It is currently paid by CCGs to a care home at £158.16 per week.
If rejected for CHC Funding – consider whether you have reasonable grounds for appeal.
These links will help you understand more and keep going:
How to appeal
If your relative is not eligible for CHC following a Multi-Disciplinary Team assessment and you do not agree with the outcome decision – consider appealing to a Local Resolution Panel Meeting. The National Framework sets out the procedure you must follow.
Lodge your intention to appeal in writing within 28 days of the decision.
Tip: Use Recorded Delivery for proof of posting.
But beware! A strict 6 month time limit applies to lodge your formal appeal from the date you received the outcome refusing CHC Funding.
Tier 1 appeal – At a Local Review
A review will be conducted by the CCG through their local resolution procedure. There is a 2 stage process:
Stage 1 (optional) – At an informal review you can raise any concerns in a two-way process designed to encourage dialogue with the CCG, so that they can explain their rationale for the decision to reject funding. However, it is highly unlikely that you will be able to persuade the CCG’s representative to recommend overturning their decision to refuse funding at this encounter.
Stage 2 – If you remain dissatisfied with Stage 1, or else just want to save time and proceed straight to Stage 2, you need to present your appeal to a Local Resolution Panel. For further information, read our blogs:
Tier 2 – Local Resolution Panel (LRP)
This appeal is conducted at local level by the CCG. Think of it as the CCG marking their own exam paper!
You will need to prepare written submissions to the CCG in advance to support your appeal, and at the same time use it as an opportunity to highlight any gaps/inconsistencies in their evidence, and also deal with any arguments that have been raised.
This can be very time consuming, often amounting to many days of careful preparation and detailed consideration of voluminous care home records and other medical records. Attention to fine detail is the key to success.
Note: You are entitled to have an advocate represent you at the appeal, if you wish.
We suggest that you seek professional help to alleviate emotional stress and give yourself the best chance of success. Visit our one-to-one page.
A strict 6 month time limit applies to lodge your formal appeal from the date you received the outcome refusing CHC Funding.
Tier 3 – Independent Review Panel (IRP)
If you still remain dissatisfied with the outcome of the LRP’s Decision, then you can appeal to NHS England who will convene a hearing in front of an Independent Review Panel.
This is your last real chance of appeal.
Again, there is a strict procedure to follow as set out in the NHS National Framework, and there is a 6 month deadline to lodge your written appeal submissions with NHS England.
Careful preparation is paramount. Read: Act Now – Get Help With The CHC Funding Process
You are entitled to have an advocate to represent you.
As this appeal is effectively your last chance to get CHC Funding, and could mean the difference in saving or paying many thousands of pounds in care fees per month, we recommend that you get professional help. To maximise your prospects of success, visit our one-to-one page.
Parliamentary and Health Service Ombudsman (PHSO)
At any stage of the process, if you remain dissatisfied with the assessment or appeal process, you can complain to The Parliamentary and Health Service Ombudsman to investigate any abuse of process. However, they will not overturn any refusal to grant funding merely because you don’t agree with the decision outcome.
For further general reading around the subject: