The assessment for eligibility for continuing healthcare (CHC) funding is complex. Unfortunately, there are no strict or simple definitions of what does or does not amount to a primary health need.

In order to be eligible for NHS continuing healthcare, there are two stages of assessment you must go through.

What are the two stages of the NHS continuing healthcare assessment?

1. The CHC checklist assessment stage

A continuing healthcare checklist is the first stage in determining whether an individual is entitled to free care. At the checklist stage, it is the scores that are important and the following domains will be considered:

1. Breathing
2. Nutrition
3. Continence
4. Skin (including tissue viability)
5. Mobility
6. Communication
7. Psychological and emotional needs
8. Cognition
9. Behaviour
10. Drug therapies and medication: symptom control
11. Altered states of consciousness

The checklist stage is the screening stage and the threshold for eligibility is kept low. Keeping a low threshold helps to ensure that anyone who might meet the criteria for CHC funding does not slip through the net and is screened to pass on to the next stage of assessment.

2. The decision support tool stage

The decision support tool (DST) is the final stage of the assessment process where a funding decision is made. This is completed using a DST. Relevant representatives and all family members should be invited to attend a multidisciplinary team meeting (MDT). A representative from Health Services and Social Services must also attend, as well as any other relevant persons, such as care staff, occupational therapist, and community mental health team to give examples.

The MDT will make a recommendation for eligibility, whether that is positive or negative. This recommendation will then be sent to the clinical commission group (CCG) panel, or otherwise ratified by the CCG, who will then advise the personal representative of whether they are eligible or not eligible for CHC funding.

If the decision is negative, the CHC team should then provide information about the next steps in the appeals process.

What is the time frame from the checklist assessment to completion of the DST and an eligibility decision?

National Framework timescale is 28 days from receipt of the checklist. However, there are no meaningful shortcuts unless the individual circumstances are such that a fast-track application should be submitted (see below).

Complaining to the CCG about the timescale does not warrant merit as the response, if any, will be a lack of resources. This time should be used wisely to gather evidence to support the claim.

However, if you have run out of funds and the care package is insufficient then it will be important to put the responsibility back to the NHS and/or Social Services to interim fund until a CHC funding decision is made.

What happens if I am eligible for continuing healthcare funding?

You will be provided with further details on the date from which the person is eligible. It is always important to consider whether funds should be backdated to the date that the NHS checklist was completed and also to consider whether a retrospective application for previous care may be possible.

What happens if I am not eligible for continuing healthcare funding?

You will have six months to get back to the CCG to appeal the process. It is at this time that legal advice and assistance can make all the difference when challenging an incorrect decision. It will be important to consider the factual evidence looking for errors, misunderstandings and assumptions that may have influenced the decision by the MDT or CCG panel. Often, insufficient evidence has been made available. If it is possible to go back to put additional evidence, this will assist in overturning an incorrect decision.

If the local dispute resolution or review procedures have been used but an individual or their representative remains unhappy with the outcome, the case can still be referred to the Board’s independent review panel (RIP) and then to the Parliamentary and Health Service Ombudsman, if required.

What can I do if I am ineligible for continuing healthcare funding?

At this stage, you are likely to be referred to the local authority to determine whether you qualify for local authority funding due to your financial resources. You should also consider whether you are entitled to funded nursing care. If resources are available, you may be self-funding the cost of your care. Be aware that you cannot deliberately avoid paying for care home fees. Your legal advisor will be able to advise you of your options.

Local authority funding

The threshold for local authority funding in England is currently £23,250 (2019/20). If you remain living in your property this will be formally disregarded. The local authority will take your income into consideration and top up the difference to meet your care fees at an agreed rate.

Funded nursing care

If you have nursing needs and are resident in a nursing home or a care home registered to provide nursing, you will be entitled to funded nursing care (FNC).

Often funding is missed by those receiving FNC who do not realise that more funding is available to pay for accommodation, if care needs dictate eligibility.

Self-funding

If you have savings/assets over the threshold of £23,250, you will be self-funding and there is no need to disclose your personal financial affairs to the local authority, even if they request you to do so.

They will still be obliged to ensure that your care needs are correctly assessed and, if an intermediate package of care is required, arrange for this to be put in place. Often families feel abandoned when a relative has the means to pay for care above the threshold but no one is interested in assisting them with care and support providers.

What is the fast track pathway tool?

If you need urgent care, you may still be eligible for funding with the NHS continuing healthcare fast track pathway tool.

The CHC fast track pathway tool is when an individual requires immediate access to an urgent package of continuing healthcare due to a rapidly deteriorating condition that may be entering a terminal phase and has an increased level of dependency. This tool is often used in hospital where someone who previously did not require a package of care has been admitted.

The process requires a simple document that is sufficient on its own to determine eligibility. This makes it much quicker than the continuing healthcare assessment process. The primary aim is to get an appropriate funded care package in place very quickly where urgent assistance is required. If appropriate, end of life care arrangements can be made.

Do you need help and advice with the NHS continuing healthcare funding assessment?

For more advice about the continuing healthcare assessment and to find out whether you may be eligible for funding, contact our Funding Care Team who will be happy to help.