Five things you need to know about eligibility for NHS continuing healthcare

Posted on: June 6th, 2016 by Jane

Thousands of people across the UK need to receive ongoing care due to disability, accident or illness. For those that are eligible, the NHS funds the full cost of this care.
Sound simple? It’s not. The eligibility criteria are complex and nuanced, and their interpretation is open to disagreement. We help hundreds of people each week to understand NHS continuing healthcare eligibility, and to challenge funding decisions when appropriate.
Here we’ve put together five important facts about NHS continuing healthcare eligibility that you should bear in mind when preparing for your own, or your loved-one’s, assessment or considering challenging a decision.
You can ask us about these points, or anything else to do with NHS continuing healthcare – for free – by calling our Information and Advice Line on 0345 548 0300.

1. Diagnosis doesn’t guarantee eligibility
Eligibility for continuing healthcare is not judged on a person’s diagnosis. So, even if a person has been diagnosed with Alzheimer’s disease, Parkinson’s disease or another degenerative condition, they may be assessed as not having a primary health need.
Instead, eligibility is determined by the assessment of the person’s day-to-day care needs and how those needs should be met.

2. Be wary of promises
Unless a professional has spent time working within the dedicated field of NHS continuing healthcare, it’s worth treating assurances of a person’s eligibility for funding with scepticism.
We frequently hear of false promises being made to people about their chances of eligibility by health and social care professionals. While this offers hope and reassurance at the time, it can be a cruel blow if continuing healthcare is then refused.
Eligibility is based upon the presence of a primary health need which is established through an in-depth assessment process involving a multidisciplinary team. Until this process has taken place nobody can unilaterally decide that an individual will or will not be eligible, even your GP.

3. Money shouldn’t matter
If the assessment concludes that you have a primary health need then the NHS must, by law, pay the full cost of your health and social care and accommodation.
NHS continuing healthcare is not means tested and financial considerations must not be taken into account. Coordinating assessors should not ask you questions about your financial situation and if they do, you do not have to answer them. Likewise a person’s continuing healthcare status should be established before means tested social care is considered.
The National Framework is absolutely clear that decisions regarding eligibility are free from budgetary and commissioner influences. However, we’ve dealt with cases in the past where commissioner influence on decision-making panels had clearly occurred. In each case our challenge to this procedural failure was upheld and the assessment process started again.

4. Not just for nursing home residents
NHS continuing healthcare is not restricted to any particular setting and can be received anywhere, including in a care home without nursing, or in your own home.
Assessments must be based on the individual’s assessed care needs, regardless of where that care is delivered or whether the setting is appropriate. However, our experience has shown that some assessment teams still struggle to apply this important principle.
If you think you’re missing out because of the setting in which you or your loved one is cared for, talk to us.
NHS continuing healthcare in your own home will not cover your rent, mortgage, food or usual utility bills. In certain situations it may be appropriate for the NHS to pay a contribution toward your utility bills if, for example, you need to run specialised equipment in order to meet your care needs.

5. Eligibility is not for life
NHS continuing healthcare is based on an assessment of care needs and how those needs should be met, and it is common for these needs to change over time. Once eligible, expect your care needs to be reviewed three months from the original decision, and each year after.
Sadly this means that individuals can lose their right to NHS funding at a later stage, despite having similar needs.
For example, if someone with dementia who is mobile and presents with challenging behaviour, is then immobilised by a fall or stroke. Although the diagnosis of dementia has not changed – and in fact the person’s health has worsened – the management of their needs has become less intense because they are no longer mobile, and the person is assessed as no longer having a primary health need.
This type of scenario is extremely upsetting for people, and there is a campaign amongst charities and patient groups that people with degenerative conditions should not be made to have their eligibility status reviewed. However, since eligibility has to be based solely on assessed care needs, and not a diagnosis, it is extremely unlikely that this principle will be changed.
If eligibility for continuing healthcare is being withdrawn from you or your loved one, you should request a thorough explanation of the change in writing from your Clinical Commissioning Group. If you disagree with their explanation, you can challenge that decision. Our free Toolkit will help to show you how.

For more information about eligibility for care funding, appealing decisions, and help to navigate the maze of continuing healthcare, download our free Toolkit or talk to us about your situation.

A version of this blog also appears on UK Care Guide

About Beacon
Beacon CHC is a leading UK-wide social enterprise with profits donated to charity to fund vital older peoples’ services.
Our specialist caseworkers provide a comprehensive and ethical advocacy and support service for individuals trying to navigate the maze of NHS continuing healthcare funding.
We also run an independent support service – funded by the NHS – for people in England who need free information and advice in relation to NHS continuing healthcare.