Who Qualifies for NHS Continuing Healthcare?

Many families are unaware that the NHS may be responsible for paying the full cost of care where a person’s primary need for care is related to health needs rather than social care needs.

This funding is known as NHS Continuing Healthcare (CHC) and can cover the full cost of care provided in a nursing home, care home or the person’s own home.

Unlike local authority funding, eligibility for NHS Continuing Healthcare is not based on savings, income or property. Instead, eligibility is determined by the nature and complexity of a person’s health needs.

Understanding whether someone may qualify for NHS Continuing Healthcare funding can be difficult, particularly as the assessment process is detailed and often unfamiliar to families.

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What Is NHS Continuing Healthcare

NHS Continuing Healthcare is a package of care arranged and funded entirely by the NHS for individuals who have ongoing healthcare needs.

Where a person is found eligible for NHS Continuing Healthcare, the NHS becomes responsible for the full cost of care, regardless of the person’s financial circumstances.

Care funded through NHS Continuing Healthcare may be provided in:

• a nursing home

• a residential care home

• the person’s own home

• a specialist care setting

Because NHS Continuing Healthcare covers the entire cost of care, eligibility decisions can have a significant financial impact on families.

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How Eligibility for CHC Funding Is Assessed

Eligibility for NHS Continuing Healthcare is determined through a detailed assessment process carried out by a multidisciplinary team (MDT) of health and care professionals.

The outcome of this assessment is recorded within a document known as the Decision Support Tool (DST).

The Decision Support Tool considers a number of care domains which reflect different aspects of a person’s health needs. These domains are assessed in the following order:

• Breathing

• Nutrition / Food and Drink

• Continence

• Skin (including tissue viability)

• Mobility

• Communication

• Psychological and Emotional Needs

• Cognition

• Behaviour

• Drug Therapies and Medication

• Altered States of Consciousness

• Other Significant Care Needs

Each domain is assigned a level of need based on the available evidence.

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The Primary Health Need Test

The Decision Support Tool scores are not used in isolation when determining eligibility.

Instead, the multidisciplinary team must consider whether the person’s overall needs demonstrate what is known as a Primary Health Need.

This decision is based on four key characteristics outlined within the National Framework for NHS Continuing Healthcare:

Nature
The type and quality of care required to meet the individual’s needs.

Intensity
The severity and quantity of care needed to manage the person’s condition.

Complexity
How different health needs interact with each other and increase the difficulty of care.

Unpredictability
The degree to which needs fluctuate or create risks that require skilled monitoring.

Where these characteristics indicate that the primary reason for care is health related, the person may be eligible for NHS Continuing Healthcare funding.

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Conditions That May Require an Assessment for NHS Continuing Healthcare

Eligibility for NHS Continuing Healthcare is not determined by diagnosis alone. However, individuals with significant ongoing health needs may be considered for an assessment.

Examples of situations where an assessment may be appropriate include individuals living with:

• advanced dementia

• complex neurological conditions

• severe physical disabilities

• progressive illnesses

• significant behavioural or cognitive difficulties

• complex nursing needs

Each case must be considered individually based on the nature and complexity of the person’s health needs.

What Happens If NHS Continuing Healthcare Funding Is Refused

Many families only become aware of NHS Continuing Healthcare after they have already started paying for care privately.

Where an assessment concludes that the person is not eligible for CHC funding, families have the right to request a review of the decision.

If you believe that the assessment outcome does not accurately reflect your relative’s needs, it may be possible to challenge the decision through the NHS Continuing Healthcare appeal process.

Speak With Us About NHS Continuing Healthcare Eligibility

If your relative requires ongoing care due to health needs and you are unsure whether NHS Continuing Healthcare funding may apply, you can speak to one of our NHS CHC funding specialists today.

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