NHS Continuing Healthcare Funding (“CHC”) has hit the headlines recently, with a surge in stories about families receiving inadequate care or having their funding withdrawn unlawfully.
Perhaps most recently publicised was the case of television presenter, Kate Garraway, who has opened up about how care fees for her late husband Derek Draper placed a huge strain on her and her family, eventually leaving her tackling a debt of around £800,000.
Garraway went on the record to detail that her husband’s care cost £4,000 a week, totalling £192,000 a year, which is nearly five times the average UK wage. And despite her admittedly well-paid position as a breakfast TV stalwart, she raised a valid point that £16,000 a month is an unachievable sum for most households.
Whilst Mr Draper’s care needs were undoubtedly extensive, if his needs were assessed to be primary health needs, then he should have been entitled to CHC, and his care costs should have been met by the NHS in full, irrespective of his financial position.
The average cost of a care home in the UK is in the region of £1,000 per week in many areas of the UK, placing financial pressure on families already coping with emotional stress of having a loved on in care.
CHC is designed to help those with long-term complex health needs, but unfortunately, it is not available to all, and many are wrongfully denied funding, despite meeting eligibility criteria. Here we assess how CHC is awarded, and what you need to be aware of if you are seeking to secure CHC funding for a relative.
What is NHS Continuing Healthcare Funding?
In the absence of CHC, individuals with assets exceeding £23,250 are required to cover the full cost of their care, whether it’s provided at home by carers or in a care home. Even if their assets fall below £23,250, they must still contribute to care costs until their assets dip below £14,250. Beyond this point, they are expected to contribute from their income.
The cost of care without CHC can be prohibitively high. An award of CHC usually ensures that an individual does not need to use any of their own assets or income to pay for their care.
CHC is a fully funded package of care paid for by the NHS for people who are assessed as having a “primary health need”. Whilst there is at present no clear definition as to what a “primary health need” actually is, it is generally accepted that it refers to those needs which are over and above social care needs which can be met by the Local Authority because they are complex, intense and unpredictable and not of a nature typically provided for by social services.
CHC covers the full costs of a person’s care including functions which may ordinarily be considered as social care.
For individuals who do not meet the eligibility criteria for CHC funding but require care by a registered nurse in a care home or a nursing home, they may be entitled to NHS-funded nursing care, which is a fixed contribution towards the nursing elements of their care. The NHS must firstly consider eligibility for CHC before considering that they qualify only for funded nursing care. A person cannot be awarded funded nursing care without first having gone through the assessment process for CHC.
Distinct from the standard process of applying for CHC, the fast-track pathway is also available for people who have a rapidly deteriorating condition who may be entering a terminal phase. This is interpreted widely and does not mean that their death has to be imminent.
Who is eligible for NHS Continuing Healthcare Funding?
The difficulty for most is that the threshold for accessing CHC funding is set high. This is demonstrated by the fact that the most recent NHS statistics show that only 33,200 adults in England are eligible for standard CHC, against over 430,000 people living in care homes and estimated 1.5m adults who require some level of care.
It is a common misconception that CHC funding is only for those who are “terminally ill”, and a claim should not be dismissed on the basis of simply believing that someone “won’t be eligible” -a proper assessment undertaken by health and social care professionals as to a person’s eligibility is a necessity.
Eligibility is determined by a 2-stage process:
- Stage 1 – Checklist: This is the initial ‘screening-in’ process to see if the individual can be put forward for a full assessment for CHC funding.
The ‘screening-in’ process uses a checklist to score a person’s needs in various domains (generic areas of need) including, breathing, nutrition, continence, skin, mobility, communication, psychological and emotional needs, cognition, behaviour, drug therapies, altered states of consciousness.
These professionals consider the individual’s specific needs in these areas and apportion a score from A-C. A person will be ‘screened-in’ if they score 2 or more A’s, or 1 A and 4 B’s, or five or more B’s, or one score in a domain marked A*.
The checklist threshold is deliberately low to ensure that nobody is excluded from a full assessment of eligibility. The process itself is normally done after discharge from hospital by a nurse/doctor/social worker or qualified healthcare professional.
If an individual is ‘screened in’, this does not automatically mean they are eligible. It simply means that a full assessment will need to take place. If they do not ‘screen in’, they will not be entitled to a full assessment of eligibility (however, this can be challenged).
- Stage 2 – Decision Support Tool (DST): completed by a multi-disciplinary team – usually a social worker and NHS clinician but could be other professionals.
Once a person screens in, CHC, a more detailed assessment will follow. This is conducted by a multidisciplinary team using a Decision Support Tool. A person’s representative/family member should be invited to attend to give their views and although not a legal process, you may choose to have a solicitor and/or independent social worker present to assist and advise on the process. The same care domains are considered as at the checklist stage, but a different scoring system applies.
Each of the care needs will be marked as either ‘no need’, ‘low’, ‘moderate’, ‘high’, ‘severe’ or ‘priority’.
This score will help assessors to apply the primary health needs test in practice to get a full picture of a person’s specific needs.
They are likely to be eligible if they have any priority need, two or more severe needs, one severe plus needs in several other domains, and a number of high and moderate needs. However, they are unlikely to be eligible if most or all domains are no needs or low need.
The team will also take into consideration the four key characteristics of Nature, Intensity, Complexity and Unpredictability to determine whether a person has a primary health need. It’s important to understand that eligibility is not determined by a person’s diagnosis, but the primary health need arising from that diagnosis.
Appealing an NHS Continuing Healthcare Funding decision?
If you disagree with an NHS CHC funding eligibility decision, it is possible request a review from the Clinical Commissioning Group (or equivalent) within six months of notification, preferably in writing.
During the review, the individual’s representative/family member should be allowed to contribute and view all evidence. If care home fees have already been paid, but there is a belief that the patient should have been eligible for NHS funding, it may be possible to request a retrospective assessment.
The exact process for an appeal varies between different health boards. If the matter remains unresolved after the correct processes have been followed, you may be able to request an independent review from NHS England or escalate matters to the Parliamentary Health Service Ombudsman. Occasionally, court proceedings by way of a judicial review may be appropriate.
Accessing NHS CHC funding is particularly complex and can be somewhat of a postcode lottery. However, at Buckles, our specialists can provide advice and assistance in respect of eligibility and the assessment process involved.
We can attend at Decision Support Tool (DST) meetings as an advocate, or assist with challenging eligibility decisions, whilst also advising on retrospective claims after a person’s death.
Should you require support or advice regarding any of these matters, please do not hesitate to contact us for an impartial, confidential consultation.
