NHS Continuing Healthcare funding, how do I access it?

NHS continuing healthcare (“CHC”) means a package of care that is arranged and funded solely by the NHS. 

If you are found to be eligible for NHS CHC, your care will be provided free of charge regardless of your own financial circumstances.

NHS CHC is only available if your need for care results from a health condition and only a small proportion of people who require support to meet their needs will be eligible.

How do I access CHC funding?

The assessment process is led by the Clinical Commissioning Group (“CCG”), which is responsible for commissioning NHS services in your local area.

1.    The Checklist

Firstly, a checklist is completed. This looks at your needs across a number of different categories, or “domains”. Your level of need will be scored in each category: A, B or C (where A represents a high level of need and C represents a low level). 

The checklist will determine whether or not a full CHC assessment is required. A full eligibility assessment will be required if you score 2 or more As, 5 or more Bs, 1 A and 4 Bs, or 1 A*. 

The checklist can be completed by a variety of health and social care practitioners, which can include a registered nurse, GP or social worker.

If the checklist determines that you do not fulfil the criteria for a full CHC assessment, you can ask the CCG to reconsider its decision.

We can discuss your needs with you and advise you on the likelihood of you being eligible for CHC funding.

Where a checklist has been completed and found that you are ineligible, we can review this and advise you on your options.

2.    The full assessment: the Decision Support Tool

If the checklist determines that you require a full CHC assessment, a decision support tool (“DST”) document will be completed by a multidisciplinary team (“MDT”) at a meeting, usually led by a CCG Nurse Assessor. You should be prepared to attend the meeting, together with any representative, family member or carer who can support you to provide evidence of your needs.  

The DST breaks down a person’s needs into different domains, similarly to the initial checklist, as follows:

1.  Breathing
2. Nutrition – Food and Drink
3. Continence
4.  Skin integrity
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
12.   Other significant care needs

The MDT will consider the level of your needs within each of the above categories and will give each category a rating, ranging from “no additional needs” to “severe” or “priority” (for certain needs categories). The MDT will also consider the overall nature, complexity, intensity and unpredictability of your needs.

The MDT will make a decision as to whether you are eligible for CHC funding, and this will be submitted to the CCG for ratification. The outcome of your assessment will be communicated to you after the MDT meeting.

Preparing thoroughly for the MDT meeting can help to ensure that CCG has all of the relevant information to make its decision. Thorough preparation at this stage may also help to avoid the need for an appeal against a decision of ineligibility.

We can provide advice ahead of the assessment and help you to prepare thoroughly for the MDT, ensuring that you understand the process and are presenting the most relevant information.

I am ineligible for CHC funding: what are my options?

It is possible to seek a review of the CCG’s decision and you should be informed of the process and the relevant timescales when receiving the outcome of your assessment. There are two stages to this process:

• Stage 1: The CCG will have a local resolution process. Usually, you will be invited to a meeting, where the decision will be explained and you will have the opportunity to provide further information not already considered and to put forward reasons why you are dissatisfied with the CCG’s decision.
• Stage 2: If the CCG upholds its ineligibility decision, you can apply to NHS England for an independent review. An independent review panel will be convened to review the decision and to consider any representations made by you and/or your representative.

Despite the ineligible decision, you may be eligible for NHS funded nursing care, or for a package of care that is funded jointly by the NHS and social services.

Your local authority should also consider whether you have eligible needs that should be met by social services instead. 

If a DST has been completed and a decision has been made that you are ineligible for CHC funding, we can advise you on the prospects of a successful appeal and help you to prepare, and/or represent you throughout the process. 

I am eligible for CHC funding: what happens next?

If the CCG has decided that you are eligible for CHC, it must make arrangements to provide your care. 

Care can be arranged and provided by the CCG directly. Alternatively, you can request a Personal Health Budget. This can enable you to have more control over the care that you receive. There are three different ways that you can receive care via a Personal Health Budget:

1.  A notional budget: the CCG will confirm how much money is available to meet your needs, and you will then decide with the CCG how that money should be spent. The CCG will arrange the care and support for you;
2.   A third party budget: an independent organisation will hold the money for you and will pay and arrange your care and support;
3.  Direct payment: you or your representative will receive the money to pay for your care and support directly. You must show the CCG what your budget has been spent on

We can provide advice on the care planning process and help you to prepare for your discussions with the CCG to ensure that your care plan meets your needs.

If you are unhappy with a decision made by the CCG in respect of the level of support that you require, we can advise you on your options to challenge this.

Will my CHC funding continue indefinitely?

A NHS CHC care package will be subject to regular review (usually at 3 months, and then every 12 months) to consider whether the care arrangements remain appropriate. Although the focus at a review is on whether the care package continues to meet your needs, it is possible for this to lead to a reassessment of your eligibility for CHC funding, if it appears that your needs have changed. 

If your needs improve over time, you may not always be eligible for CHC funding. 

We can help you to prepare for the review of your care package. If your needs are reassessed and the CCG determines that you are no longer eligible for CHC funding, we can advise you on the prospects of a successful appeal and help you to prepare, or represent you throughout the process. 

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