The cost of care can be a significant burden for many families, but financial assistance is available through NHS Continuing Healthcare (CHC), a program designed to cover care expenses for individuals with substantial health needs. Eligibility for CHC is determined by the nature and extent of a person's health requirements, not their income or savings.
James Urquhart-Burton, head of continuing healthcare claims at Winston Solicitors, explained that if an individual's primary need is health-related, the NHS is responsible for funding their care in full. However, accessing this funding can be challenging.
Understanding NHS CHC Eligibility
NHS CHC is not means-tested, and entitlement is not based on a specific diagnosis. Instead, assessments focus on whether a person has a 'primary health need,' evaluated across various criteria. Families often mistakenly concentrate on the condition itself, but the decision hinges on how these needs are presented within a structured framework. Eligibility can be assessed regardless of whether care needs have just begun or have been present for a long time.
Integrated Care Boards (ICBs) are responsible for assessing eligibility. Individuals have the right to request an assessment, and it is crucial to be proactive, as the ICB may not always be aware of an individual's substantial care needs. Urquhart-Burton emphasized the importance of knowing one's right to an assessment, how to request it, and how to maximize the chances of being found eligible.
CHC funding can be granted for care provided at home, in a residential care home, or in a nursing home, with the location not affecting eligibility. For those incurring significant care costs, regularly checking eligibility is vital to avoid unnecessary expenses.
The application process typically begins with an initial checklist screening. If this screening is passed, a more detailed assessment follows, leading to a recommendation to the ICB, which makes the final decision. However, the threshold for eligibility is high, and outcomes often depend on how evidence is recorded and interpreted. Common issues include understated needs, an overemphasis on how needs are managed, and inconsistent application of national guidance.
The Application Process
To apply for an assessment, individuals can ask a health or social care professional to initiate the process or contact their local ICB directly. It is recommended to make the request in writing, noting the date and keeping a copy. For those who believe they should have been assessed previously, a 'retrospective assessment of eligibility' can be requested.
Before the assessment, it is advisable to familiarize oneself with the 'NHS Checklist,' a screening tool used to determine if a full assessment is necessary. Working through the checklist in advance, either alone or with a relative or professional, can help prepare for the discussion. During the assessment meeting, it is important to articulate all needs across various care domains, such as communication, mobility, and nutrition.
If an individual is unhappy with the outcome of the Checklist or believes they were wrongly denied a full assessment, they can lodge a complaint in writing with the ICB, usually within a 12-month deadline. Summarizing understated care domains and any failures to consider relevant information can strengthen the complaint.
If referred for a full assessment, familiarization with the 'Decision Support Tool' (DST) is recommended. The DST is a more detailed assessment tool. As with the Checklist, reviewing the DST in advance and considering professional support, such as an advocate, can be beneficial. During this assessment, it is important to articulate views on the levels of need and to challenge assessors if they do not follow correct procedures or disregard individual perspectives.
Post-Assessment and Appeals
Following the full assessment, all decisions should be confirmed in writing, and a copy of the DST should be obtained. If eligible for NHS CHC, the ICB will fund care until the next review. If deemed ineligible, an appeal can be considered, typically within six months of the decision letter. Appeals should be made in writing, supported by evidence, and should focus on whether needs were under-assessed or if the ICB failed to follow the National Framework process.
Practical tips for success include ensuring care provider records accurately reflect daily realities, avoiding downplaying difficulties, keeping detailed records of incidents, and understanding the National Framework guidance. It is also important to remember that individuals are entitled to have someone present during assessments for support and to help ensure all relevant points are fully explored and accurately represented.
Engaging a specialist adviser or solicitor can be beneficial, particularly for complex cases or when significant fees are already being incurred. These professionals can help ensure important aspects of need are fully addressed, challenge interpretations, and keep the discussion focused on key issues within the National Framework.