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Nursing Care Fee Recovery – FAQS

From Continuing Healthcare in Wales and England, learn everything you need to know about “what is NHS continuing healthcare”, what qualifies you for it, and more.

In this section:

What is CHC funding?

Continuing Healthcare (CHC) funding in Wales and Englandis a health care package fully funded by the NHS to help people financially who have a persistent health need due to an accident, disability, or illness. It covers both the cost of the individual’s day-to-day care and residential accommodation, as well as other needs such as help with daily activities and any ongoing therapies being administered.

What is a CHC assessment?

Most people interested in “What is NHS Continuing Healthcare” are also curious about what a CHC assessment is, and rightly so.

A CHC assessment, also known as the CHC Full Assessment, is a detailed appraisal to determine a person’s care needs. It uses a form called the DST (Decision Support Tool) which helps assessors determine whether you are eligible to receive CHC funding in England or Wales S.

What conditions qualify for Continuing Healthcare?

There are multiple conditions that qualify for NHS Continuing Care in England and Wales, and other parts of the UK. These include:

  • Learning abilities
  • Mental health needs
  • Breathing
  • Mobility
  • Continence
  • Behaviour
  • Communication
  • Cognitive/behavioural disorders
  • Mental illness
  • Terminal illnesses
  • Complex medical conditions

How do I apply for Continuing Healthcare?

Many people are confused or unaware of how to apply for NHS Continuing Healthcare. However, once they know the correct channels, applying for Continuing Healthcare in England or Wales, for example, is fairly straightforward:

  • Speak with a healthcare provider, social worker, or your GP
  • Contact your local ICB (Integrated Care Board)
  • Ask for a screening checklist to be arranged
  • Once you qualify, you’ll go through the Full Assessment to determine your health needs

How to qualify for Continuing Healthcare?

“How do you qualify for Continuing Healthcare” is a question that has kept many people up at night. But if you understand the process, you shouldn’t have to deal with any undue stress whatsoever.

To qualify for Continuing Healthcare, you need to have what’s called a “primary health need”. So, your care needs should primarily be for healthcare, and not centre around social or personal care, for example.

To move forward with the eligibility process, you need to go through a Continuing Healthcare Checklist in Wales or wherever your place of residence is. A social care or health professional will help you complete a screening checklist although you can ask your GP to do the same as well.

If your needs are found to be significant enough, you will proceed to the Full Assessment stage. Once you qualify, you will receive CHC funding.

What is a CHC Checklist?

The Continuing Healthcare Checklist in England and Wales is a tool which assessors use to establish a person’s eligibility for NHS CHC funding. The checklist:

  • Evaluates your care needs.
  • Determines whether you need to go through the Full Assessment.
  • Helps distinguish between people who are eligible and not eligible for the funding.

There are different kinds of professionals who can complete a Continuing Healthcare Checklist for you, such as a nurse, GP/doctor, social worker, district nurse, care home nurse, etc.

What happens once you go through the CHC Checklist in Wales or England?

If you pass the Checklist, you’ll be referred to the Full Assessment. If your care is deemed ‘urgent’, you may be able to have your assessment fast-tracked.

What is CHC Fast Track funding?

CHC fast track is a way to quickly gain funding eligibility if you have a rapidly deteriorating health condition.

So, Fast Track CHC funding ensures that affected individuals receive prompt care instead of having to wait for the lengthier standard assessment process.

How long does a CHC assessment take?

The NHS CHC assessment usually takes anywhere from a few weeks to a maximum of 28 days to complete. However, this timescale is not etched in stone as it is often not met.

What factors affect the CHC assessment process?

The following factors can affect the CHC assessment process:

Inaccurate checklists – At times, CHC Checklists may not be completed with 100% accuracy. This can result in people being unfairly refused Full Assessments.

System pressures – The NHS’s internal system for CHC funding can be under pressure, which means delays in funding, even if an individual has met the eligibility criteria for Continuing Healthcare in Leicestershire or Continuing Healthcare in Hampshire, for instance.

Urgent checklists – Urgent cases, that is, those where significant or irreversible loss in function is likely to occur, are typically processed a lot faster.

What can I do if CHC funding is denied?

If you believe you have been unfairly denied funding, you can challenge the decision, citing ‘inaccurate checklist assessment’ as a reason or other reasonable grounds you may have to pursue an appeal.

You can also work with a solicitor to better understand the appeals process and how to establish the necessary grounds to win the appeal.

You can request a Free no-obligation assessment here.

What does CHC funding cover?

Here’s what Continuing Healthcare funding inEngland and Wales:

Nursing care – The NHS fully covers the standard cost of care administered by a registered nurse in the affected person’s care home or private residence.

Care home fees – The NHS also takes care of the care home fees (paid directly to the care home), including board and accommodation fee.

Personal care – This does not refer to normal day-to-day care but special help or assistance needed with dressing, laundry, washing, and other personal care needs arising due to an accident, illness, or disability.

Medication – The NHS is responsible for handling medication fees, which includes the cost of any drug-specific therapies being administered.

Therapies – The NHS will pay for therapies (both mental and physical as well as psychological), including all complex health needs which may require therapy.

Can everyone qualify for CHC funding?

According to the criteria, the following individuals qualify for CHC funding:

  • Those who have been identified to have significant long term healthcare needs. This is also referred to as ‘primary health needs’.
  • Those who have been identified to have intense, complex, or unpredictable healthcare needs which have arisen due to an accident, illness, or disability.

Is CHC funding means-tested?

No, NHS Continuing Healthcare is not ‘means tested’. This means that the funding does not depend on how much money you currently have in your personal bank account.

What is the criteria for Continuing Healthcare?

In order to be eligible for NHS Continuing Care funding, you need to have a primary health need and your care requirements must primarily be focused on healthcare (and not social and/or personal care).

In addition, the current NHS Continuing Healthcare eligibility criteria states that:

  • You need to have significant/major physical and/or mental health needs to qualify.
  • The majority of your care must be focused on only addressing and/or preventing specific health needs (as opposed to needs arising due to a developing or newly discovered condition, such as cancer).
  • The eligibility of funding must be based on both the extent and nature of your underlying health care needs, and not your health diagnosis.

Do I have to pay for Continuing Healthcare funding in Wales, Derbyshire, or other parts of the UK?

No, if you’re found to be eligible, CHC funding is extended fully by the NHS, no matter where you are in the UK. This includes care home fees or the carer’s fees, if you are being cared for in your own home.

What is the age in the UK for NHS Continuing Healthcare?

You must be 18 years or older in order to be eligible for Continuing Healthcare Warwickshire, Oxfordshire, Lancashire, or wherever your care home or private residence is in the UK.

What if I no longer require CHC funding?

Although rare, if you ever feel the need to have funding removed, you can do so by undergoing a full Multidisciplinary Reassessment. A multidisciplinary team (MDT) comprising different kinds of health and social care professionals will conduct the reassessment to identify if you no longer have a primary health need and, therefore, do not require funding anymore.

Is CHC NHS in England or otherwise awarded for life?

No, the ICB (Integrated Care Board) regularly reviews your eligibility for Continuing Healthcare in Oxfordshire, Derbyshire, Hampshire or wherever you reside. The first review is typically done after three months of funding. In addition, you will also undergo annual reviews.

The CCGs may decide to withdraw your funding for Continuing Healthcare in Leicestershire or anywhere else if they believe that your health needs have reduced– in which case, they become primary social care needs and not healthcare needs – something CHC funding does not cover.

However, if you want to appeal the ICBs decision to withdraw funding, you can always ask a solicitor to assist you with the appeals process.

Am I eligible for NHS Continuing Healthcare in England or Walesonly while living in a Nursing Home?

No, contrary to popular belief, this is not correct. Eligibility for NHS CHC does not depend on where you are receiving care. Therefore, you will still receive your care package whether you are residing in a nursing home, care home, or your own home, as long as you meet the criteria for Continuing Healthcare funding in England orWales.

Does Continuing Healthcare in Wales and other parts of the UK cover the full cost of the care home?

Well, not in every case. Just like Social Services in the UK, the NHS imposes a limit on the total amount they will pay for your care. So, on the one hand, you don’t pay anything out of your own pocket but, on the other, CHC funding is not unlimited.

It’s worth noting that under the NHS’s current funding rules, you cannot legally choose your care home and then ask for CHC funding – as some individuals tend to move to a more expensive care home, expecting the NHS to cover all the costs via a CHC care package. In fact, the NHS might ask you to move to a more ‘economical’ care home, in some cases, before funding can be provided. However, they should negotiate with the care provider a reasonable contract rate.

Are conditions like Dementia and Alzheimer’s covered under CHC NHS England and Wales?

Eligibility for the NHS’s Continuing Healthcare funding in Wales or otherwise is not based on your diagnosis. It is actually based on assessing your health needs; that is, those needs are primarily of a healthcare and not social care nature.

With that said, some individuals do qualify for NHS CHC in England and Walesif they have Dementia or Alzheimer’s, but then again, hundreds of thousands don’t. A situation like this is often referred to by solicitors and other legal experts as “The Dementia Tax” – people with long-term health conditions like these end up using all of their savings and even the value of their home to take care of the associated social care costs.

Can children benefit from CHC funding?

Unfortunately, no – Continuing NHS Healthcare is for adults which means only adults 18 years or older may qualify.

However, Continuing Care can be made available to children and young people but the criteria it is based on is very different from CHC for adults. It is also arranged in a different way – for instance, the way in which a child receives their education must be included.

Is NHS-funded nursing care (FNC) the same as Continuing Healthcare (CHC)?

No, the main distinction lies in the fact that NHS-funded nursing care is only provided to patients living in care homes which are registered and licensed to provide nursing care – and to patients who have not qualified for NHS CHC but still require day-to-day care from a registered nurse.

If I have an existing local authority support package which works well but I am now eligible for CHC – will that change my existing support package in any way?

If you have concerns about how your care package might change due to making a move to the NHS’s CHC, your ICB (Integrated Care Board) should talk to you about how it can extend as much choice and control to you as possible. This is referred to as a personal health budget (PHB), where one of the options being offered is a direct payment for healthcare.

What if I refuse a CHC assessment? After a refusal, can I avail the care services afforded to me by my local authority?

Since an assessment for Continuing Healthcare cannot be done without your explicit consent, you can refuse it, should you choose.

However, upon refusal, there is no guarantee that you will still get the desired services from your local authority even if you are eligible for an assessment with the same.

When you refuse an NHS CHC Assessment, the ICB will find out your reasons for refusing, addressing your concerns as best as possible.

Can I pay “top-up” fees for CHC?

No, this is not possible with NHS CHC even though it is with local authority health care packages.

The only way to have CHC care packages topped up is to do it privately and that’s if you pay for ‘additional private services’ on top of the standard NHS CHC services you are getting. These private services are to be provided by a staff and in a setting distinct from your current CHC care package.

If I don’t agree with the decision following a CHC Assessment, what are the next steps?

If you don’t agree with the decision the NHS made at the initial checklist stage to not move to the Full Assessment stage, you or your representative (such as a solicitor) can get in touch with the ICB, asking for the decision to be reconsidered. This must be done in writing.

Now, if you disagree with a decision which was made following the result of the Full Assessment, you or your representative may get in touch with the ICB to file an appeal against the decision. This appeal must be filed within 6 months of having the decision received in writing. Details such as these, along with others, are also mentioned in the Decision Letter.

Once the ICB receives your appeal in writing, they have a maximum of 3 months to revisit their decision and satisfy your request (called a ‘local resolution’). However, if they do not reconsider, you can file another appeal with NHS England, which again, has a maximum of 3 months to address it.

How do I actually prepare an appeal?

There’s quite a lot involved in preparing a successful appeal. It’s very important to include all the relevant information about your healthcare needs, and while keeping the NHS’s CHC eligibility criteria in view.

This means that you need to be up to speed with the various stages of CHC assessment and appeal, as well as the National Framework assessment guidelines and CHC funding eligibility criteria. This requires a fair amount of research, reading, and preparation.

Furthermore, in terms of actually wording the appeal, you must pull together notes on everything you can think of – that is, everything you believe has been done incorrectly during the assessment process and especially how the eligibility criteria may have been wrongfully applied, in your case. This means establishing grounds for an appeal.

Unless you feel completely confident doing this on your own, it is highly recommended to seek the advice and guidance of a solicitor who specialises in CHC appeals. This can save you weeks of preparation time, stress, and anxiety, not to mention the fact that your chances for success can increase tenfold.

Getting the appeal wording or any other aspect wrong can potentially cost you hundreds to thousands of pounds a month in the form of unnecessary care fees.

What exactly is assessed as part of the CHC Assessment?

The CHC Assessment assesses your care needs across 12 care domains, which are unique aspects of health and care, such as skin integrity, mobility, continence, cognition, behaviour, drugs, and breathing.

The assessment has an initial stage where 11 domains are looked at. Once successful, you are put through the second stage – Full Assessment – which looks at 12 domains.

Is there anything I need to do to prepare for a Continuing Healthcare UK Assessment?

You need to familiar with how the NHS’s National Framework works. This guidance will help you understand how the assessment process unfolds.

In addition, you need to prepare adequately for the MDT (Multidisciplinary Team) Assessment, once you clear the initial assessment.

Furthermore, the DST (Decision Support Tool) form should not be seen as merely a “check this, check that” exercise.

The expert advice of a solicitor specialising in CHC Assessments is always recommended.

What is a primary health need? How is it different from a social care need?

Social care needs are those related to daily living activities. So, this means routine care with activities that involve feeding, washing, mobility, and toileting.

Primary healthcare needs are those which require frequent monitoring and input intervention as well as review by qualified professionals – such as a doctor, nurse, social worker, or healthcare worker – done on a ‘day in and day out’ basis.

It is important to note that a specific health condition itself does not qualify as a ‘primary health need’. It is, in fact, the interaction between the intensity, complexity, nature, and unpredictability of a specific health need which determines eligibility.

I’ve been told that I won’t qualify for CHC funding – should I still go through with the assessment?

Absolutely, yes!

The criteria to determine CHC finding eligibility is extremely subjective. It is crucial that a proper needs assessment is carried out. In fact, solicitors specialising in CHC assessment and funding regularly attend assessments or assist with them in some form or the other. This helps to ensure that all factors are fully and fairly considered before approving or denying funding.

However, despite an individual’s best efforts, CHC funding applications do get rejected. This is where an appeal comes in. Anybody requiring funding for health needs is entitled to an assessment because eligibility cannot be established clearly until a detailed assessment is done.

Follow this link to begin a free assessment. 

The CHC assessor did not allow me to put my views or perspective forward during the assessment meeting? Is this okay?

Under no circumstances, is this okay. The National Framework – a document which explains all the respective procedures pertaining to NHS CHC funding – states that families should be fully involved during the assessment process and that their input should be fully considered.

Furthermore, individuals along with their families are also entitled to have a solicitor represent them during the assessment meeting.

What is an MDT and how does it affect funding for Continuing Healthcare in Warwickshire or other regions?

The Multidisciplinary Team (MDT) is a team of health and social care professionals who are responsible for providing day-to-day care for you. When we talk about CHC assessments in particular, the minimum NHS requirement is that two professionals from varying healthcare backgrounds must be part of the MDT – a GP and care home nurse, for example.

The MDT is responsible for providing the necessary information to complete the DST (Decision Support Tool), so naturally, they need to be individuals who are familiar with your health needs. The same MDT is also tasked with making a recommendation on your eligibility for CHC funding.

My doctor, GP, or nurse has already told me that I will be eligible for Continuing Healthcare funding in Wales and other parts of the UK – is that a guarantee that I will receive it?

No, that’s quite unlikely, and here’s why:

Most health and social care professionals (this includes GPs) as well as health consultants are not 100% up to speed with the criteria for Continuing Healthcare. Not only that, but in most cases, such professionals have likely not spent time working in the dedicated field of NHS CHC in England and– and, therefore, do not understand it.

Furthermore, eligibility for CHC is based on the presence of a primary health need. This can be established only via a thorough assessment process which an MDT conducts, in order to determine that the health needs are primarily “health” based and not “social”. Until and unless this assessment has been conducted by the MDT, no health professional can unilaterally come to the decision that you may or may not be eligible.

My friend or relative is suffering from dementia – will they automatically be eligible for a Continuing Healthcare Assessment in England or Wales?

The short answer is ‘no’ because eligibility for CHC does not depend on a health diagnosis.

Eligibility for CHC is established by assessing an individual’s day-to-day care needs (and how those needs must be met), rather than the fact that the individual is suffering from a health condition like dementia.

But there is a bit of a catch here: depending on how much your friend’s or loved one’s dementia or Parkinson’s, for example, or any other disability has progressed – that in itself can present multiple health and social care needs. Some of these needs may be complex, intense, or unpredictable, or all of these.

So, if any specific health need or a combination of needs due to the illness progressing is assessed as being of a complexity, intensity, and/or unpredictability that points to their primary need as ‘health’ and not ‘social’ or ‘personal’ – then that person may be eligible for Continuing Healthcare funding.

If this sounds overly complicated or confusing, our solicitors are always available to provide tailored advice according to your personal circumstances, or those of your loved one.

I already have existing benefits with my Local Authority. Will CHC funding affect these benefits?

Some benefits granted to you by the Local Authority may change as you become eligible for CHC. For example, if you receive AA (Attendance Allowance) or DLA (Disability Living Allowance) benefits in a care home which includes nursing, these will usually stop 28 days after your Continuing Healthcare care package has gone into effect.

The only exception to this is that DLA will not usually stop if you haven’t been receiving care from a registered nurse or you’ve been receiving care at your own residence (either by a family member or a registered nurse). It’s also worth noting that if either AA or DLA benefits stop, the rest of your disability-focused premiums may also get affected.

Either way, if you are currently receiving AA or DLA benefits, and you become eligible for NHS CHC, it is best to contact the DWPto inform them that your CHC funding is now in effect.

My relative or loved one was denied CHC funding. What are my options?

If your relative or loved one was denied NHS Continuing Healthcare in Nottinghamshire (or any other region within the UK) after an MDT (Multidisciplinary Team) assessment, you can file an appeal with the ICB (Integrated Care Board) within 6 months of receiving the Decision Letter from them. The appeal needs to have solid grounds although it can be based upon several factors. In any case, the professional guidance of a solicitor is highly recommended.

Many of our clients have personally informed us that they tried to go through the appeals process on their own initially but found it very cumbersome, complex, and stressful. Helping families with the appeals process through tailored guidance is all part and parcel of our day-to-day responsibilities as solicitors specialising in NHS Continuing Healthcare in England and Wales. Speak to us now to learn more about the appeals process.

I’ve never heard of Continuing Healthcare NHS in England or Wales. Why is it not advertised?

According to a survey conducted by the Continuing Healthcare Alliance, a disturbing 60% of the participants did not know about the existence of CHC funding until fairly late into their dealings with the  health and social care system.

The process of applying for NHS CHC can often be a distressing one for both patients and their families, apparently, due to a lack of clear, helpful, and transparent information. Not only that, but inadequate support from their health and/or social care teams means affected individuals tend to slip into a void of confusion and uncertainty where no one is providing them with the tailored guidance they need.

This is why many people have now become smarter and hire a solicitor from day one. In the same Continuing Healthcare Alliance survey, an unbelievably low number of participants (3%) were aware of the possibility of CHC funding through their GP. This obvious lack of signposting from health and social care services means that countless patients may be wrongfully paying exorbitant care fees and facing a worrying financial future, as these costs start to pile up fast.

In the same survey, it was also highlighted that 39% of NHS workers (such as doctors, nurses, GPs, and social workers) found the CHC assessment process to be highly confusing or complicated. If a system is too complex for even NHS professionals to decipher, then it takes little effort to understand why patients are also not receiving the assistance or information that they so direly need in a prompt manner.

Seeking the advice of a solicitor is an excellent way to start off on the right foot, ensuring that you and your family don’t pay from your own pocket, as the health care needs can be clearly taken care of by the NHS’s CHC care package.

Following a Continuing Healthcare Assessment, how long do I need to wait for a decision?

The NHS has provided clear guidelines to all ICBs (Integrated Care Boards) and local authorities on specific timescales which need to be followed. The time between the checklist received following an assessment and a CHC funding decision should not, under any circumstances, exceed 28 days.

If, for some reason, you have not received a decision within 28 days, the funding needs to be met by the NHS on an urgent basis, no matter what the cost. However, we have witnessed significant delays where individuals have been paying for their care in full from their own pocket while awaiting a decision.

While this is not acceptable, you can work with a solicitor to recover nursing care fee due to delays in the decision.

What is CHC nursing fee recovery? How does it work?

In some instances, you may be paying for care out of your own pocket. This may be due to delays in the funding being released or the ICB not providing a Decision Letter to you within 28 days.

In other instances, you may simply not be aware of what CHC funding is or whether you are eligible for it. If you have been paying for your health needs or those of a loved one out of your own pocket, you can make a Nursing Care Fee Recovery claim in either of these two scenarios. Our solicitors have one of the best track records across the nation, helping clients recover thousands of pounds in care fees.

What is the difference between a CHC Checklist Assessment and a CHC Full Assessment?

Initially, a Checklist Assessment is conducted to decide if an individual qualifies for the Full Assessment of eligibility.

The Full Assessment is only triggered once the Checklist indicates that:

  • The individual has secured an ‘A’ in two or more care domains.
  • The individual has secured an ‘A’ in one domain, a ‘B’ in four domains, and a ‘B’ in more than four domains.
  • The individual has secured in ‘A’ in the following care domains – Altered states of consciousness, Breathing, Behaviour, and Drug therapies and medication.

Only if you meet the above criteria, you are eligible for a full assessment. With that said, the ICB can at their discretion green light funding even if you don’t meet the criteria.

How many care domains are there as part of the CHC Checklist in Wales and England? What do they mean?

The CHC Assessment is completed at a meeting conducting by an MDT (Multidisciplinary Team), where the complexity, severity, and unpredictability of an individual’s health needs are discussed across 12 unique domains. These are:

  • Altered states of consciousness
  • Behaviour
  • Breathing
  • Cognition
  • Communication
  • Continence
  • Drug therapies and medication
  • Mobility skin
  • Nutrition
  • Psychological and emotional needs
  • Skin
  • Other significant needs

The MDT uses evidence to assign a ‘need level’ to each domain with an ‘A’, ‘B’, or ‘C’. An ‘A’ is assigned to areas which require a high level of care needs; a ‘B’ is assigned to areas requiring a moderate level of care needs, and; a ‘C’ is assigned to those areas which require a low or no needs.

This assessment of needs is then integrated into a DST (Decision Support Tool) form, and once the due process is complete, the designated assessor will ask you to review it, in case you want to add your own views under the relevant section in the form.

After this phase of the process has been concluded, the MDT makes a recommendation to the ICB as to whether you meet the eligibility criteria or not. The MDT need not involve you in this final phase of the process.

How much am I expected to be involved in the CHC Assessment?

Anyone being assessed ought to be involved at every stage (minus the decision which is announced by the ICB afterward) of the CHC Assessment. It is the designated assessor’s responsibility to invite you to add your views to the assessment during the meeting with the MDT. This is why most people have a solicitor present at the meeting as their representative. It ensures that the affected individual is not left out or brushed aside during any phase of the assessment.

What is the NHS National Framework? Do I need to be aware of it as an affected individual?

While it’s not a requirement for those seeking CHC funding to be explicitly aware of what the NHS National Framework is, it is, nevertheless, good to be armed with some information beforehand.

The National Framework for Continuing Healthcare (CHC) and NHS-funding Nursing Care (FNC) applies in England only. It has:

  • The eligibility criteria NHS staff must follow when determining eligibility of an affected individual;
  • The tools the NHS staff must integrate and complete in order to arrive upon a decision – such as the Checklist Tool, the Decision Support Tool, and the Fast Track Tool;
  • Common paperwork and documentation needed for recording evidence to support decision-making;
  • The formal process for challenging decisions around eligibility;
  • Clarification around the interaction between NHS CHC and NHS FNC assessments.

What is the NHS CHC Fast Track Tool?

The Fast Track Tool is a quick turnaround process used to assess CHC funding eligibility for someone who is suffering from a rapidly deteriorating condition or approaching the end of their life.

Again, this only applies to someone whose health condition is rapidly deteriorating or they are entering a terminal phase. Funding can often be granted in as little as 2-3 days.

How is eligibility for CHC NHS in England and Wales checked?

From July 1, 2022, the ICS (Integrated Care Systems) became statutory bodies. These are a partnership between NHS bodies and local authorities (LAs) who work with other designated organisations to deliver health and care services. Each ICS works with an ICB (Integrated Care Board), where the latter commissions specific health services, including CHC (Continuing Healthcare) and FNC (Funded Nursing Care).

Once the long-term health needs of the affected individual are clear, eligibility for CHC NHS is checked through the following steps:

  • The NHS staff considers the type and level of your needs, and whether that would trigger the Checklist. This can either lead to a positive or negative In some cases, however, the staff may determine that you should be put through a Full Assessment without having to go through the initial Checklist first.
  • When you go through the initial Checklist, a ‘positive’ Checklist means that you must now go through the Full Assessment of your needs.
  • An MDT (Multidisciplinary Team) will conduct the assessment to establish specific needs information on the affected individual after which a DST (Decision Support Tool) must be completed. This informs the staff whether the individual is eligible for Continuing Healthcare and then recommends them to the ICB.
  • The final eligibility decision rests with the ICB, although they typically follow the MDT’s recommendation unless exceptional or extraordinary circumstances apply.

If your Checklist is ‘negative’, you can challenge the ICB’s decision to deny your eligibility for CHC. The final decision only comes after a Full Assessment. One exception to this is when there is a rapidly deteriorating condition or where you may be reaching the end of your life (terminal illness); in that case, you can take advantage of the Fast Track Tool to access CHC without delay.

What is a Positive Checklist and a Negative Checklist? What do I need to know about it?

A ‘positive’ Checklist means that you have cleared the initial assessment and now require a Full Assessment, where you will be referred to the ICB for the final eligibility decision. This doesn’t, however, guarantee eligibility as the ICB will decide on eligibility even if the MDT has made a recommendation for you to be eligible.

The ICB has a maximum of 28 days from the date they receive a positive Checklist, to reach an eligibility decision. If there’s a chance that it’s going to take longer than that, then the ICB must inform you and your legal representative.

If you are paying for your care while awaiting decision and are found to be eligible, and if the ICB takes longer than 28 days to grant funding, you can recover nursing care fee in both instances. A solicitor can guide you further on how to do this.

A ‘negative’ Checklist means that you do not require a Full Assessment and are, therefore, not eligible to receive NHS Continuing Healthcare in England and  Wales. In this case, the ICB must send you a written explanation of the decision to not grant CHC, explaining how you can make an appeal in order for the decision to be reconsidered.

Should the ICB be asked to reconsider their decision, they must acknowledge any additional information you and your legal representative provide. You will receive a written response which will explain your right to use the standard NHS complaints procedure in order to move forward with the appeals process.

What is an MDT Assessment?

The current NHS Framework states that a Multidisciplinary Team (MDT) must be appointed to conduct the Checklist Assessment. The MDT must, at the very least, comprise:

  • Two professionals from different health backgrounds, or;
  • One professional from a healthcare background and one professional who can assess the individual for community care services – the latter is typically a carer or nurse who has been working with the affected individual or familiar with his/her care needs.

While the minimum for an MDT should be two professionals from varying healthcare backgrounds, the team must comprise at least one health professional and one social care professional – both must be knowledgeable on your health and social care needs. In addition, these individuals must have been involved in a recent Assessment you were put through, along with your treatment or care.

Do I have an active role at the MDT meeting? What about my representative or solicitor?

The case coordinator, who may or may not be an MDT member, should clearly explain the meeting format and make it clear that you and your legal representative should be fully involved throughout.

If either you or your solicitor cannot attend the meeting, the coordinator must obtain evidence and views from you. According to para. 145 of the NHS Framework:

“It is important the individual’s view of their needs, including supporting evidence, is given appropriate weight alongside professional views.”

It’s important to know that the ICB may use any number of approaches to arrange the MDT assessment, which may include a face-to-face meeting or one arranged via video conferencing. However, the decision should be made while keeping person-centred principles in mind in order to encourage active participation from all MDT members, including you and your solicitor.

In addition, the ICB must give due notice of the date of the meeting, so that your solicitor can make the necessary arrangements if they wish to participate. Most solicitors participate to ensure that you are involved at each stage of the process, with the exception of the final decision stage which the ICB undertakes on its own.

What is a DST? Do I need to complete it myself?

As an affected individual, it is important to familiarise yourself with what a DST (Decision Support Tool) is. It contains the same 11 care domains as the initial Checklist, with the addition of a 12th domain (Other significant care needs), which the NHS staff must consider when completing it:

  • Altered states of consciousness
  • Behaviour
  • Breathing
  • Cognition
  • Communication
  • Continence
  • Drug therapies and medication
  • Mobility skin
  • Nutrition
  • Psychological and emotional needs
  • Skin
  • Other significant needs

Each domain is rated with descriptions between 4 and 6 levels of need. These are:

  • No need
  • Low
  • Moderate
  • High
  • Severe
  • Priority

The different levels also indicate specific aspects of the need. For example, the intensity, nature, complexity, and unpredictability of a need. The MDT will take all these aspects into account when determining the level of need across each one of the care domains.

It should be noted that the DST itself is not an assessment. It is merely a tool for recording the affected individual’s needs across each one of the 12 care domains.

You do not need to complete the DST; only the MDT will and when they do, they should:

  • Ensure that all domains are completed using specific information about your care needs.
  • Use both evidence acquired during the assessment and their own professional judgment to accurately determine the level which most closely describes your needs.
  • Choose a higher level where appropriate, and record any evidence or disagreements should they be unable to decide or agree to the level for a specific care domain.
  • Consider the various interactions between needs and not marginalise those needs based on the fact that they are being successfully managed; well-managed needs are still ‘needs’, after all, and should be recorded appropriately as per the current NHS Framework.

Once completed, the DST tool ought to provide a comprehensive picture of the individual’s needs, capturing their intensity, nature, complexity, and unpredictability, as well as the quality and quantity of care needed to manage them.

The DST also has space to record both your views, as well as that of your legal representative, on your care needs and if you consider the assessment and respective domain levels to accurately reflect them. This ensures that the ICB is aware of your views when reaching a final decision.

How does the MDT make a recommendation to the ICB?

It is the MDT’s responsibility to make a recommendation on whether you have a primary health need or not, as that determines your eligibility for CHC NHS in England or otherwise.

When making this recommendation, the MDT must take into account the complete range and level of your care needs. So, this includes:

  • The intensity, nature, complexity, and unpredictability of needs.
  • Evidence acquired from risk assessments.
  • If and how needs in a specific domain may interrelate with another one to create additional intensity, complexity, or unpredictability.

Furthermore, the recommendation for Continuing Healthcare funding in Wales, England, or Scotland, for example, must refer to all the key characteristics which indicate a primary health need. However, any characteristic can also, on its own, or in combination with others, be considered sufficient enough to indicate a primary health need.

A clear recommendation of eligibility is expected if you have one of the following:

  • A need in any domain which is classed as ‘priority’, or;
  • Two or more ‘severe’ needs across all the respective care domains.

A primary health need can also be indicated if one of the following is true:

  • One care domain is classed or recorded as ‘severe’, along with needs in several other domains, or;
  • If multiple domains are classed or recorded as ‘high’ or ‘moderate’.

Ultimately, whatever recommendation the MDT forwards to the ICB for consideration, it needs to be supported by clear and evidence-based reasons only.

How long does the ICB typically take to respond to a recommendation forwarded by the MDT?

The ICB is expected to respond to the MDT’s recommendation within 2 working days. They can only go beyond 2 working days under exceptional circumstances, such as when there are issues to be addressed. For example, the ICB may need to refer back to the MDT if it sees any gaps in the supporting evidence, or an indefinite mismatch between the evidence presented and the recommendation.

Even though the ICB may share their decision with you verbally, they are obliged to confirm this decision in writing as well, providing clear reasons for the decision (whether funding has been granted or denied), and a copy of the completed DST.

It should also mention in writing who you can contact in case you require clarification and how to request a review of the final decision for eligibility – that is, if funding has been denied.

Furthermore, the individual appointed to act as your representative, such as your solicitor, is entitled to receive a copy of the DST.

What if I’m unhappy with the care package being offered by Continuing NHS Healthcare for adults in Wales or other parts of the UK? What can I do?

If you’re unhappy with certain aspects of the care package, such as the location, type, or content being offered, the ICB will explain the right to complain using the existing NHS complaints process.

Making an effective complaint involves:

  • Being clear about what the actual complaint is. So, this means clearly stating what you believe is wrong with your care package and how it is affecting your care needs.
  • Being clear about what kind of goal or outcome you have in mind by forwarding a complaint. This means explaining the changes you’d like to see in the care package and why.
  • Stating that you wish to make a formal complaint. This should make it clear to the ICB that you are expecting them to respond, and in a way which is in line with the current complaints policies and procedures as per the NHS Framework.
  • Staying on point – so, avoiding unnecessary details that may detract from the key issues. Overall, try to be as polite as possible, while sticking to the relevant details only.

How is eligibility for NHS FNC (Funded Nursing Care) decided?

If the NHS staff proposes that your best option is to avail the care package in a nursing home, they must first consider your eligibility for NHS CHC (Continuing Healthcare) and agree that you are not eligible for it. Only then can they consider you for NHS FNC.

If you did not qualify at the Checklist stage and, as a result, did not take the Full Assessment, you must undergo a nursing needs assessment. This will determine your daily nursing care and support needs.

Therefore, you become eligible for NHS FNC if you are assessed as having such nursing care and support needs, where the staff decides that your overall care needs would be best met in a nursing home.

If your question is not covered on this page, please get in touch with us now. We would be happy to address any questions, concerns, or queries around Continuing Healthcare in Wales or England.

Author bio

Lisa Morgan

Partner

Lisa Morgan is a Partner and Head of the Nursing Care department. She is regarded as an experienced and specialist solicitor leading in the niche area of continuing healthcare.

She has been instrumental in developing a niche legal department in Hugh James, which comprises of 25 fee earners who solely act for the elderly and families in recovering wrongly paid nursing fees.

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