To receive NHS Continuing Healthcare, a person must be assessed as meeting the eligibility criteria defined in the Department of Health National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care (November 2012 revised version). People who meet the criteria will always have intense, complex and unpredictable health needs. NHS Continuing Healthcare is not awarded on a condition, it is the health needs that arise as a result of the condition which are called ‘Primary Health Needs’.
Where is it provided?
People may receive NHS Funded Continuing Healthcare in suitable and appropriate registered nursing care home, a specialist unit or in their own home.
How are needs assessed?
The decision that someone is eligible for NHS Continuing Healthcare will be made following assessments by professionals (eg. doctors, nurses, social workers, occupational therapists). The patient and their carer/representative will be involved in the assessments in a way that is appropriate to their circumstances.
Following completion of the assessments, the Health and Social Care professionals will hold a Multi-Disciplinary Team (MDT) meeting, to which the patient, carer/ representative will be invited to attend. The MDT will complete a Decision Support Tool (DST) and apply the Primary Health Needs Test, looking at the nature, intensity, complexity and unpredictability of the individual’s needs and will identify if the individual has a Primary Health Need and therefore meets the eligibility criteria for NHS Continuing Healthcare.
The recommendation of the MDT will be considered by Cambridgeshire and Peterborough Clinical Commissioning Group, who will also check the correct process has been followed by the MDT. Funding, if eligible, will be from the date the decision was made. If eligibility is not agreed, then the assessment findings will be shared with Social Services for funding consideration if the patient requires financial assistance.
How often will the need be assessed?
Everyone who receives NHS Continuing Healthcare will be reviewed initially after three months and then either after six months or at least once a year and possibly more frequently if health needs change. It must be noted that as a person’s needs change, their eligibility for NHS Continuing Healthcare might also change. This does not mean that the person has ‘got better’, but that their needs have become less complex or more predictable.
If this is the case funding may then be met by Social Services, or depending on the financial means of a individual being above the limit that Social care will fund they may have to pay the total cost of care fees. If in a nursing home, the patient may be eligible to a contribution from the NHS for the weekly NHS-funded Nursing Care payment.
Who do I talk to if I am not clear on any of this?
If you need clarification on any aspect of NHS Continuing Healthcare or NHS-funded Nursing Care please contact the Complex Case Management Team at the address below:
Complex Case Management Team
NHS Cambridgeshire and Peterborough CCG
Tel: 01223 725429
Fax: 01223 725591
I am not happy with the decision, how can I contest it?
If you have the legal responsibility to act on behalf of a patient who is unhappy with any NHS Continuing Healthcare decision and cannot obtain a solution which you see as satisfactory, you should contact: the Lead for NHS Continuing Healthcare at the above address.
This enables the Commissioners to review how the NHS Continuing Healthcare criteria has been applied to you or to your relative.
What will happen if I request a review?
If you request a review, you will be advised of the process to be followed and be given help to try and reach an agreement between you and the relevant people in the local health services.
If this is unsuccessful, arrangements will be made for your case to be considered by a Continuing Healthcare Review Panel, consisting of an independent chairperson and a group of qualified professionals, to which you will be invited to attend. The results of this review will be reported to the Complex Case Management Team and will then be sent, in writing to the person who requested the review.
What can I do if I am still not happy following a review?
If you are dissatisfied with the outcome of the consideration of your case by the Continuing Healthcare Review Panel, you can request an NHS England Independent Review. This can be requested by writing to the Head of Complex Case Management at the address above.
For further information and advice, you can speak to the Patient Experience Team on 0800 279 2535.