Introduction

Continuing Healthcare (CHC) is care that is arranged and funded solely by the NHS for adults over the age of 18 with complex health needs.

Your eligibility for NHS CHC is based on evidence of a ‘primary health care need’. A ‘primary health need’ is not about the reason why you require care or support, nor is it based on your condition and diagnosis; it is about your overall actual day-to-day care needs taken in their totality.

The primary health needs should be assessed by looking at all your care needs and relating them to four key characteristics:

  • Nature – the type of condition or treatment required (quality and quantity)
  • Complexity – symptoms that interact, therefore difficult to manage or control
  • Intensity – one or more health needs, so severe they require regular intervention
  • Unpredictability – unexpected changes in condition that are difficult to manage and present a risk to you or others.

NHS Continuing Healthcare can be provided in a variety of settings outside hospital, such as in your own home or in a care home.

NHS Continuing Healthcare is subject to regular review and if your needs change then your eligibility for NHS Continuing Healthcare may change.

The assessment process has two stages

1. NHS continuing healthcare checklist

For most people, there’s an initial checklist assessment, which is used to decide if you need a full assessment of CHC. Before a checklist is completed the process should be discussed with you and you will be asked for your consent. The checklist can be completed by a social worker or NHS health professional, usually involving you or, if you choose, your family, carers or representative.

Depending on the outcome of the checklist, you’ll either be told that you don’t meet the criteria for a full assessment of NHS Continuing Healthcare and are therefore not eligible, or you’ll be referred to the CCG for a full assessment of eligibility.

2. NHS Continuing Healthcare full assessment

As part of the eligibility consideration for NHS Continuing Healthcare, your needs will be considered by a multidisciplinary team (MDT). A MDT is made up of 2 or more professionals, and will usually include both health and social care professionals who are knowledgeable about your health and social care needs, and, where possible, have recently been involved in your assessment, treatment or care.

The assessment will, with your permission, involve contributions from a range of professionals involved in your care such as your GP to build an overall picture of your needs.

The MDT will then use the information from your assessment to complete a ‘Decision Support Tool’ (DST).

The purpose of the DST is to help the MDT assess the nature, complexity, intensity and unpredictability of your needs – and so recommend whether or not you have a ‘primary health need’

You should be fully involved in the assessment process and kept informed, and have your views about your needs and support taken into account.

The MDT will then make a recommendation to the CCG as to whether or not you have a primary health need, which will determine your eligibility for NHS continuing healthcare. The CCG should usually accept this recommendation, except in exceptional circumstances and with clearly articulated reasons for their decision.

A decision about eligibility for NHS Continuing Healthcare should usually be made within 28 days of an initial assessment or request for a full assessment being received by the CCG. Although in some situations it can take longer than 28 days for a decision to be made.

The CCG will inform you in writing, with a copy of the DST as soon as they can, giving clear reasons for their decision on whether or not you are eligible. They will also explain your right to request a review of the decision.

Following a full assessment you have the right to request a review of the decision that you are not eligible for NHS Continuing Healthcare. This needs to be done within six months from the date of your decision letter, which will give you details on how to request a review of the decision.

If your health is rapidly deteriorating and you may be entering the terminal phase, you should be considered for the NHS CHC Fast Track funding, so that an appropriate care and support package can be put in place as soon as possible. In the fast track pathway there is no requirement to complete a checklist or the decision support tool. Instead, an appropriate clinician will complete the fast track tool to establish your eligibility for NHS Continuing Healthcare.

This clinician will send the completed fast track tool directly to your CCG, which should arrange for a care package to be provided for you, normally within 48 hours from receipt of the completed fast track pathway tool.

If you’re eligible for NHS Continuing Healthcare, the next stage is to arrange a care and support package that meets your assessed needs.

Depending on your situation, different options could be suitable, including support in your own home and the option of a Personal Health Budget (PHB).

If it’s agreed that a care home is the best option for you, there could be more than one local care home that’s suitable.

All organisations will work collaboratively with you and consider your views when agreeing your care and support package and the setting where it will be provided. However, they can also take other factors into account, such as the cost and value for money of different options.

From April 2014 anyone eligible for CHC wanting to have their care provided outside of a care home setting, may be able to receive the money they need to meet their healthcare needs as a Personal Health Budget, in the form of a Direct Payment. This gives people a greater choice over how, when and who provides their care and support.

If you’re eligible for NHS Continuing Healthcare, your needs and support package will normally be reviewed within 3 months and thereafter at least annually. This review will consider whether your existing care and support package meets your assessed needs. If your needs have changed, the review will also consider whether you’re still eligible for NHS Continuing Healthcare.

If you’re not eligible for NHS Continuing Healthcare, but you’re assessed as requiring nursing care in a care home (in other words, a care home that’s registered to provide nursing care) you may be eligible for NHS-funded Nursing Care (FNC).

This means that the NHS will pay a contribution towards the cost of your registered nursing care which is paid directly to the care home. NHS-funded Nursing Care is available irrespective of who is funding the rest of the care home fees.

Following a full assessment you have the right to appeal a decision that you are not eligible for NHS Continuing Healthcare. More information about local resolution is available.

If you think you or your loved one might be eligible for NHS Continuing Healthcare funding, speak to your social worker, GP or other health or social care professional. You can also contact the Continuing Healthcare team.

Continuing Healthcare
Sanger House
5220 Valiant Court
Delta Way
Gloucester Business Park
Brockworth
Gloucester
GL3 4FE

Tel: 0300 421 0302
Email: GLCCG.CHC-SPA-Team@nhs.net

Office hours are 9.00am to 5.00pm Monday to Friday.

Alternatively you can speak to your GP, health or social care professional.