NHS continuing healthcare
Most people have to pay something towards the care they receive. But some people with ongoing significant health needs can get their care paid for through NHS continuing healthcare.
What is NHS continuing healthcare?
NHS continuing healthcare is a package of care for people who are assessed as having a 'primary health need'. It is arranged and funded by the NHS.
- If you receive care in your own home the NHS covers the cost of care and support you need to meet your assessed health and associated care needs, which includes personal care such as help with washing and getting dressed.
- If you receive NHS continuing healthcare in a care home the NHS pays your care home fees.
Can I get NHS continuing healthcare?
Eligibility for NHS continuing healthcare isn’t based on whether you have a specific health condition.
To get NHS continuing healthcare you must:
- have ongoing significant physical and/or mental health needs,
- and having taken account of all your needs, it can be said that the main aspects or majority part of the care you need is focused on addressing and/or preventing health needs.
How does the assessment for NHS continuing healthcare work?
There is a process staff must follow and tools they must use to decide your eligibility for NHS continuing healthcare.
1. If your ongoing needs are clear and you have significant health needs, there are times when NHS staff or a member of the social work team should consider whether you may be eligible for NHS continuing healthcare.
These situations include:
- before staff who are planning your discharge from hospital alert social services that you appear to have needs for care and support
- if staff believe, after a period of rehabilitation following a hospital stay, that your condition is unlikely to improve and you have significant health needs
- before deciding you need NHS-funded nursing care in a nursing home
- when your health or social care needs are being reviewed as part of a community care assessment
- if your physical or mental health deteriorates significantly and your current level of care seems inadequate
- when your nursing needs are being reviewed; this should happen annually if you live in a nursing home
- if you have a rapidly deteriorating condition and may be approaching the end of your life.
Important things to know about all stages of the assessment process:
- You should be fully involved and your views should be considered.
- You can ask a relative or carer to help and support you.
2. The assessment process usually starts with the completion of the Checklist tool by a nurse or a social worker trained to complete it. This identifies whether you need to have a full NHS continuing healthcare assessment.
In some situations listed above, it will be clear to health and social care staff that your needs do not indicate NHS continuing healthcare at this time. If health and care staff agree, they should record this in your notes, with their reasons. If there is any doubt between staff, they should complete the Checklist.
If your condition is deteriorating rapidly and you may be approaching the end of life, staff may decide to submit a proposal for you to be Fast Tracked for NHS continuing healthcare, which follows a quicker process.
3. If you’re referred for a full assessment, evidence will be collected from all relevant health and social care professionals about your physical, mental health and social care needs.
4. A team of health and social care professionals will meet to look at this evidence, complete a Decision Support Tool, and make their recommendation as to whether or not you’re eligible. You and/or your representative can attend and participate at this meeting.
5. Their recommendation is given to the Clinical Commissioning Group (CCG) responsible for agreeing and funding your care package. Except in exceptional circumstances, the CCG confirms their recommendation.
6. The CCG should write to you with their decision and explain the reasons for it.
What happens if I’m eligible for NHS continuing healthcare?
If you’re found to be eligible for NHS continuing healthcare:
- The CCG will discuss with you what care and support you need - this could relate to care at home or in a care home.
- You have the right to ask for a Personal Health Budget, which can give you more choice over the services and care you receive. However, this can't be used to pay care home fees.
- The package of care and support that's agreed upon will be reviewed after three months and then at least every year. The primary purpose of the review should be to make sure your care plan is still suitable and meet your needs. It is expected that in the majority of cases there will be no need to reassess eligibility.
- If your care needs change in the future, your funding arrangements may also change. You have a right to challenge this decision.
What happens if I’m not eligible for NHS continuing healthcare?
If it's decided you’re not eligible for NHS continuing healthcare, you can:
Appeal the decision
- The CCG letter explaining the decision should tell you how to appeal.
- If you're not happy with a Checklist decision you can ask the CCG to reconsider your case. If you are still dissatisfied, you can use the NHS complaints system to pursue your case.
- If you’re not happy after a full assessment, you can ask the CCG to reconsider its decision. If still dissatisfied, you can ask for an independent review of your case.
Ask for referral to the local authority
- If you decide not to appeal or the decision isn't overturned, you can ask to be referred to your local authority. They will look at whether you’re eligible for care and support and if you are, apply a means test to see how much you should contribute to your care.
Check if you're eligible for NHS-funded nursing care
- If you don’t qualify for NHS continuing healthcare, but have been assessed as needing to live in a nursing home, requiring help from a registered nurse, the NHS pays a flat rate contribution to the home – known as NHS-funded nursing care. This payment is to support provision of nursing care by nurses employed by the home.
- You won’t usually need a separate assessment for NHS-funded nursing care if you had the full assessment for NHS continuing healthcare.
- Your nursing needs should be reviewed no more than 3 months after the initial decision, and then at least once every year.
What should I do next?
Speak to your doctor or social worker if you think you might be eligible for NHS continuing healthcare. They can make a referral to the relevant CCG.
You can also approach your CCG and explain why you believe you should be considered for NHS continuing healthcare. Your CCG is the one your GP practice is aligned to.
See our factsheet NHS continuing healthcare and NHS-funded nursing care (PDF 1MB) for more information.
Please help us be there for older people in need
By donating today, you could help us answer more calls to our advice line, campaign harder for older people’s rights and fair treatment and provide regular friendship calls to people who are desperately lonely.