NHS continuing healthcare
The NHS can fund physical or mental healthcare needs as a result of disability, accident or illness for people aged 18 years and over.
This is called NHS continuing healthcare (CHC). Some people will have care packages that are funded jointly by the NHS and a local authority.
Continuing healthcare funds care provision in any setting, and like all other NHS services it is not subject to means testing. This means that, in contrast to services arranged by the local authority, a person cannot be asked to contribute towards their care.
Personal health budgets, including direct payments for healthcare, are available for people receiving support through Continuing Healthcare funding. From September 2014, a 'right to have' a personal health budget has been in place for CHC:
To decide whether the NHS or the local authority is responsible for arranging someone’s care, the government developed the concept of ‘primary health-related needs’.
If someone’s needs are primarily health-related then all of their care will be paid for by the NHS.
Needs and assessment
A primary healthcare need arises if a person’s care needs are in excess of what social services can reasonably be expected to provide. This is established through an assessment process which looks at the quality and quantity of the person’s needs.
The assessment for continuing healthcare funding has to be transparent, person-centred, involve the person concerned and take into account their wishes and the views of their carers. The assessment is carried out by the clinical commissioning group (CCG). A person can be referred for an assessment by their GP, social worker or hospital consultant, or they can self-refer by contacting their CCG.
The assessment has two stages: initial screening, and a comprehensive assessment carried out by a multi-disciplinary team.
There is a fast-track process available for people with rapidly deteriorating conditions who are entering a terminal phase. Social services are usually involved in the assessment process and in some cases social services and CCGs will undertake joint assessments.
The assessing team will look at the evidence and summarise it in a document called a 'decision support tool', then they will make their recommendation to the CCG as to whether the person's needs are primarily health-related.
There are sections in the decision support tool that allow the person concerned and their carers to say what they think their needs are and whether or not they agree with the result of the assessment.
Clinical commissioning group panels should follow the recommendations made by the multi-disciplinary team and can only depart from them in exceptional circumstances. CCGs have to inform the person concerned of their decision within 28 days from the date of referral.
If funding is not approved it is possible to request the CCG to reconsider their decision.
Reasons to refuse continuing healthcare funding must not be based on the diagnosis, care setting, the need for ‘specialist’ staff in care delivery or the fact that the need is well managed.
If the funding is agreed, a care plan will be developed and implemented. Although the care planning process should be person-centred and follow the principle of continuity of care, those who receive CHC funding generally have less choice - compared with social care provision - over who will be providing their care.
People who currently receive direct payments from a local authority might lose this option as a result of being assessed as being eligible for continuing healthcare, as direct payments are not generally available for this.
However, several CCGs are currently participating in a pilot scheme where they are able to make direct payments for continuing healthcare.
The receipt of continuing healthcare funding will affect welfare benefits. A person is treated as being in a hospital for all of the time they are receiving the funding. This is a change of circumstances and needs to be reported to the Department for Work and Pensions.
The law requires social services and the NHS to work together to ensure there is no breakdown in services. If, after a review or reassessment, the CCG decides to stop funding they have to make arrangements to ensure a person’s needs are met by social services before the funding is withdrawn.
If social services have recognised a person’s needs as being eligible for their support, but are trying to obtain continuing healthcare funding to meet these needs, they remain responsible for meeting the needs until the funding is approved.
First published: Thursday 24 May 2012
Updated: Monday 29 June 2015