Do I qualify for NHS continuing healthcare funding?

What is NHS continuing healthcare?

If your primary need is a ‘health need’, the NHS is responsible for providing and funding all your needs, even if you’re not in hospital. For example, you could be in:

  • a hospice
  • a care home
  • your own home.

Not many people know about NHS continuing care. So it’s important to find out if you qualify, and get an assessment.

Who qualifies?

There’s no clear-cut list of health conditions or illnesses that qualify for funding.

The assessment is made on whether your health needs are intensecomplicated or unpredictable.

For example, you might qualify for continuing healthcare if you have difficulty:

  • breathing
  • eating and drinking
  • taking medicines
  • moving about
  • with your memory and thinking.

Intensity

This describes how much – for example, how often – and how severe your needs are. It also describes the support needed to help you, including the need for ongoing care.

Complexity

This is about how your needs affect each other. It also describes the level of skill needed to check your symptoms, treat the condition and/or manage your care.

Unpredictability

This is about how much and how often your needs can change, and what the challenges are for the people who give you care and support. It should also explain the risk to your health if the right care isn’t given at the right time. Someone with an unpredictable health need is likely to have an unstable and changeable health condition.

Most people with long-term care needs don’t qualify for NHS continuing healthcare. This is because the assessment is quite strict.

It’s definitely worth being assessed though, as having your full care package funded by the NHS could be worth thousands of pounds each year.

For more details on whether your health problems mean you might qualify, watch the video on the NHS website

What costs are covered?

Normal NHS healthcare – for example, from your GP, health visitor or in hospital – is free.

But NHS continuing healthcare covers extra costs, such as help with washing or dressing, or paying for specialist therapy.

It might also include accommodation if your care is provided in a care home, or support for carers if you’re being looked after at home.

If you don’t qualify for NHS continuing care and you need care in a nursing home, you might get NHS-funded nursing care. This is a non means-tested contribution towards your nursing costs.

Funding varies by region. So you’ll need to check with your local Clinical Commissioning Group, Health Board or Health and Social Care Trust to see what’s covered:

How do I apply for NHS continuing healthcare

To apply, ask your GP or social worker to arrange an NHS continuing healthcare assessment.

What happens during the assessment process?

Step 1 – The initial screening

First, you’ll have an initial screening to see if you qualify for funding.

It’s usually carried out in hospital or at home by a nurse, doctor, social worker or other healthcare professional.

They’ll assess your general health and care needs with a simple checklist. It will cover:

  • mobility
  • breathing
  • continence
  • communication
  • nutrition – food and drink
  • skin – including wounds and ulcers
  • psychological and emotional needs
  • altered states of consciousness
  • symptom control through drug therapies and medication
  • cognition – everyday understanding of what’s going on around you
  • other significant care needs.

If your health, or the health of someone you care for, is getting worse quickly – ask about a fast track assessment to bypass the initial screening.

Step 2 – The assessment

If the initial screening shows you might be able to get free NHS continuing healthcare, you’ll need to have another assessment.

It will be carried out by a team of two or more health and social-care professionals who are involved in your care.

The team will use a Decision Support Tool which is more detailed than the checklist above. They will assess the possibility of ultimate eligibility and will decide if you should be referred to the next stage.

They’ll mark each of your care needs as no need, low, moderate, high, severe or priority.

Find out more about the assessment process by downloading the Department of Health & Social Care’s leaflet ‘NHS continuing healthcare and NHS-funded nursing care’ (PDF)

I qualify for NHS continuing healthcare – what happens next?

If you qualify, the next stage is to arrange a care and support package that meets your assessed needs. Your local NHS authority (a Clinical Commissioning Group or Local Health Board) will organise this.

They might work with your local council to arrange it.

Depending on your situation, different options could be suitable. This could include support in your own home and the option of a personal health budget.

What is a personal health budget?

In England, the NHS can arrange care for you, or you can choose to receive funding for your care as direct payments. This is known as a personal health budget.

A personal health budget gives you more choice and control over how to plan and pay for your healthcare and wellbeing needs.

Find out more about personal health budgets on the NHS website

Personal health budgets aren’t available in Wales or Northern Ireland.

In Scotland, there are different arrangements called Hospital Based Complex Clinical Care.

There’s also useful information on the Scottish Government website

What if I don’t agree with the assessment?

If you don’t agree with the result of the assessment, ask your local Clinical Commissioning Group, Health Board or Health and Social Care Trust for a review of their decision.

You must ask for this in writing within six months of being told you didn’t qualify.

If their decision was only based on an initial screening, ask for a full assessment.

You should have an opportunity to contribute to the review and to see all the evidence that’s taken into account.

If you’ve already been paying for care home fees and think you should have received NHS funding, you might be able to appeal.

To do this, speak to your social worker or health practitioner, and ask for a retrospective assessment.

If this doesn’t resolve the issue for you, you can ask for an independent review panel to consider your situation within six months.

As a last resort, you can ask for your complaint to be determined by the Parliamentary Health Service Ombudsman.

What if I don’t qualify?

Even if you don’t qualify for NHS continuing healthcare, you might still qualify for other NHS services to support you. This might include:

  • palliative care
  • carer’s breaks and respite health care
  • rehabilitation and recovery
  • community health services specialist support for healthcare needs.

Or, there might be local council funding to meet some of your care needs.

If you have been assessed as needing care from a registered nurse and are a resident in a nursing home, you might be eligible for NHS Funded Nursing Care.

In England for 2020/2021 is £183.92 per week. The rate in Wales is £179.97 per week. The rate for Northern Ireland is £100 per week.

Detained under the Mental Health Act

By law, the NHS and your local council must jointly provide aftercare services if you’ve been detained under some provisions of the Mental Health Act for assessment and treatment.

All services provided under this section should be free.

Hospital Based Complex Clinical Care in Scotland

NHS continuing healthcare in Scotland was replaced in 2015 by a scheme called Hospital Based Complex Clinical Care.

If you need long-term complex clinical care, your needs will be assessed based on one question – can your care needs be properly met in a setting other than hospital?

If the answer is no, the NHS will fully fund your care but only in a hospital.

If the answer is yes, the NHS won’t fund the non-healthcare aspects of your care. But you might qualify for help from your local council instead.

If it’s possible to provide you with care outside hospital, you’ll get it in the place that’s best for you. This could be your home, a care home or supported accommodation.

If you’ve been getting NHS continuing healthcare under the old scheme since before June 2015, you’ll continue to receive it for as long as you qualify.

Find out more about Hospital Based Complex Clinical Care and how to get other care services in Scotland on the Care Information Scotland website

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