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Continuing Healthcare

Introduction

This website is a guide for individuals who may be in need of on-going care and support from health and social care professionals as a result of disability, accident or illness, and explains the process used to determine whether the individual is eligible for care funded entirely by the NHS.  

What is NHS continuing healthcare?

NHS continuing healthcare is the name given to a package of care which is arranged and funded solely by the NHS for individuals aged 18 or over with complex, intense or unpredictable healthcare needs. 

NHS funded Continuing Healthcare is not awarded based on an individual having a particular disease, diagnosis or condition, nor is it awarded based on who provides the care or where that care is provided. 

NHS continuing healthcare can be received in any setting, including your own home or in a care home.  NHS continuing healthcare is free, unlike support provided by local authorities, for which a financial charge may be made depending on your income and savings.

Once eligible for NHS Continuing Healthcare, care is funded by the NHS.  Any decision is subject to regular reviews and in the event that an individual’s care needs change, the funding arrangements may also change.

Where is NHS continuing healthcare provided?

If you are eligible, you can receive NHS continuing healthcare in your own home or a care home, or in your own home.

If you are found to be eligible for NHS continuing healthcare in your own home, this means that the NHS will pay for healthcare (e.g. services from a community nurse or specialist therapist) and associated social care needs (e.g. personal care and domestic tasks, help with bathing, dressing, food preparation and shopping).  In a care home, the NHS also pays for your care home fees, including board and accommodation.

Who is eligible for NHS continuing healthcare?

In order to receive funding from the NHS, individuals must be assessed for their eligibility.  We follow the guidelines set down by the Department of Health in the “National Framework for Continuing Healthcare and NHS-funded nursing care”.  If you want to know more, you can visit their website

REFERRAL: "I think I need an assessment"

If it is believed that an individual should be assessed for NHS continuing healthcare, a referral should be made to the team.  The referral form can be obtained from the Continuing and Complex Care Commissioning Service - team, NHS Ealing Clinical Commissioning Group, Ealing Council, Perceval House, 14-16 Uxbridge Road, Ealing, W5 2HL Telephone: 020 8280 8091 or email ealccg.chcreferrals@nhs.net

CHECKLIST: "Am I eligible for an assessment?"

In order to identify whether an individual is eligible for a Continuing Healthcare Assessment, a checklist is completed. To see the form and read more about how the checklist is applied, you can visit the Department of Health’s website. If the checklist indicates that the individual should receive a full NHS continuing healthcare assessment, this will be arranged.  If the individual is not eligible for a continuing healthcare assessment, the CCG can be asked to review the decision.

CHC assessment: The Assessment

This person-centred assessment involves people responsible for caring for the individual, their family and/or their representative if they have one.  The team will make sure that the individual plays a full role in the assessment and decision-making process and gets support to do this where needed. This could be by the individual asking a friend or relative to help them explain their views.  It usually takes 2-3 hours to complete. The professionals (multi-disciplinary team) will need to complete a document called a Health Needs Assessment which will help to identify the individual’s care needs. They will also complete a Decision Support Tool. This is a national tool which you can view here.

The Decision Support Tool is a 57 page document which looks at the individual’s care needs across 12 care domains.  The professionals will describe the actual needs of the individual, providing evidence to inform the rationale for which level of need should be selected; no need, low need, moderate, high, severe or priority.

1 - Behaviour: Human behaviour is complex, hard to categorise, and may be difficult to manage. Challenging behaviour in this domain includes but is not limited to: aggression, violence or passive non-aggressive behaviour, severe dis-inhibition, intractable noisiness or restlessness, resistance to necessary care and treatment (this may therefore include non-concordance and non-compliance), severe fluctuations in mental state, extreme frustration associated with communication difficulties, inappropriate interference with others, identified high risk of suicide.  The assessment of needs of an individual with serious behavioural issues should include specific consideration of the risk(s) to themselves, others or property with particular attention to aggression, self-harm and self-neglect and any other behaviour(s), irrespective of their living environment.

2 - Cognition: This may apply to, but is not limited to, individuals with learning disability and/or acquired and degenerative disorders. Where cognitive impairment is identified in the assessment of need, active consideration should be given to referral to an appropriate specialist if one is not already involved.  A key consideration in determining the level of need under this domain is making a professional judgement about the degree of risk to the individual.

3 - Psychological Needs: There should be evidence of considering psychological needs and their impact on the individual’s health and well-being, irrespective of their underlying condition. Use this domain to record the individual’s psychological and emotional needs and how they contribute to the overall care needs, noting the underlying causes. Where the individual is unable to express their psychological/emotional needs (even with appropriate support) due to the nature of their overall needs (which may include cognitive impairment), this should be recorded and a professional judgement made based on the overall evidence and knowledge of the individual.

4 - Communication: This section relates to difficulties with expression and understanding, in particular with regard to communicating needs. An individual’s ability or otherwise to communicate their needs may well have an impact both on the overall assessment and on the provision of care. Consideration should always be given to whether the individual requires assistance with communication, for example through an interpreter, use of pictures, sign language, use of Braille, hearing aids, or other communication technology.

5 - Mobility: This section considers individuals with impaired mobility. Please take other mobility issues such as wandering into account in the behaviour domain where relevant. Where mobility problems are indicated, an up-to-date Moving and Handling and Falls Risk Assessment should exist or have been undertaken as part of the assessment process (in line with section 6.14 of the National Service Framework for Older People, 2001), and the impact and likelihood of any risk factors considered. It is important to note that the use of the word ‘high’ in any particular falls risk assessment tool does not necessarily equate to a high level need in this domain.

6 - Nutrition: Food and Drink - Individuals at risk of malnutrition, dehydration and/or aspiration should either have an existing assessment of these needs or have had one carried out as part of the assessment process with any management and risk factors supported by a management plan. Where an individual has significant weight loss or gain, professional judgement should be used to consider what the trajectory of weight loss or gain is telling us about the individual’s nutritional status

7 - Continence: Where continence problems are identified, a full continence assessment exists or has been undertaken as part of the assessment process, any underlying conditions identified, and the impact and likelihood of any risk factors evaluated.

8 - Skin (including tissue viability): Evidence of wounds should derive from a wound assessment chart or tissue viability assessment completed by an appropriate professional. Here, a skin condition is taken to mean any condition which affects or has the potential to affect the integrity of the skin

9 - Breathing: As with all other domains, the breathing domain should be used to record needs rather than the underlying condition that may give rise to the needs For example, an individual may have Chronic Obstructive Pulmonary Disease (COPD), emphysema or recurrent chest infections or another condition giving rise to breathing difficulties, and it is the needs arising from such conditions which should be recorded.

10 - Drug Therapies and Medication: The individual’s experience of how their symptoms are managed and the intensity of those symptoms is an important factor in determining the level of need in this area. Where this affects other aspects of their life, please refer to the other domains, especially the psychological and emotional domain. The location of care will influence who gives the medication. In determining the level of need, it is the knowledge and skill required to manage the clinical need and the interaction of the medication in relation to the need that is the determining factor. In some situations, an individual or their carer will be managing their own medication and this can require a high level of skill. References below to medication being required to be administered by a registered nurse do not include where such administration is purely a registration or practice requirement of the care setting (such as a care home requiring all medication to be administered by a registered nurse).

11 - Altered States of Consciousness: ASCs can include a range of conditions that affect consciousness including Transient Ischemic Attacks (TIAs), Epilepsy and Vasovagal Syncope

12 - Other significant care needs: There may be circumstances, on a case-by-case basis, where an individual may have particular needs which do not fall into the care domains described above or cannot be adequately reflected in these domains. If the boxes within each domain that give space for explanatory notes are not sufficient to document all needs, it is the responsibility of the assessors to determine and record the extent and type of these needs here. The severity of this need and its impact on the individual need to be weighted, using the professional judgement of the assessors, in a similar way to the other domains. This weighting also needs to be used in the final decision. It is important that the agreed level is consistent with the levels set out in the other domains. The availability of this domain should not be used to inappropriately affect the overall decision on eligibility

During the assessment process, we will agree the levels of need from between 'No needs' and 'Priority'.  The levels of need do not define eligibility, however if all your care needs are measured as 'No need' or 'Low need', it is unlikely that you will be eligible for NHS continuing healthcare.  If your care needs include one 'Priority', or two or more 'Severe' weightings, then you are very likely to be eligible for NHS continuing healthcare.

At the end of the assessment they will need to make a recommendation as to whether the individual has a “primary health need”.  In making a recommendation the multi-disciplinary team carefully consider whether all the individual’s care needs and relating them to four key indicators;

  • Nature – this describes the characteristics and type of the individual’s needs and the overall effect these needs have on the individual, including the type of interventions required to manage those needs.
  • Complexity – this is about how the individual’s needs present and interact and the level of skill required to monitor the symptoms, treat the condition and/or manage the care.
  • Intensity – this is the extent and severity of the individual’s needs and the support needed to meet them, which includes the need for sustained/ongoing care.
  • Unpredictability – this is about how hard it is to predict changes in a individual’s needs that might create challenges in managing them, including the risks to the individual’s health if adequate and timely care is not provided.

When the care needs assessment and Decision Support Tool are complete, you will be asked to check if you agree with what has been written about you/the individual being assessed.  The multi-disciplinary team can give you a copy of all the forms and documents that have been written. 

Fast Track Tool

If you need an urgent package of care due to a rapidly deteriorating condition which may be entering a terminal phase, then the Fast Track Tool may be used instead of the Decision Support Tool.  The Tool can is a word document that can be downloaded from the Department of Health’s websiste here

An appropriate clinician will complete the Fast Track Tool and send it directly to the CCG which will arrange for care to be provided as quickly as possible.  

DETERMINATION: Continuing Healthcare Panel

The role of the panel is to ratify the recommendation of the assessment completed by the multidisciplinary team.  The CCG should usually accept this recommendation except in exceptional circumstances.  The CCG will write to the individual and/or their representative to confirm the outcome and the reasons why.

What if I am not eligible for NHS continuing healthcare?

If you are not eligible for NHS continuing healthcare, the CCG can refer you to your local authority who can discuss with you whether you may be eligible for support from them.   If you are not eligible for NHS continuing healthcare but require the services of a registered nurse and are living in a registered nursing home, then you may be eligible for NHS-funded nursing care.   

NHS-funded nursing care

Registered nursing care may include direct nursing tasks as well as the care planning, supervision and monitoring of nursing and healthcare tasks to meet an individual’s needs.  In order to fund this nursing care, Ealing CCG makes a standard rate contribution towards direct to the nursing home.

APPEAL: Your right to recourse

In the event you are not happy with the eligibility decision, or have concerns about the process followed by the CCG, you have the right to appeal and request a review of the CCG’s decision.  There are 3 stages to this process. 

Local Resolution: CCG will arrange a local review of your appeal.  In this meeting the CCG will carefully consider your grounds for appeal.  In the event that your appeal is not resolved, you can proceed to stage 2.

Independent Review: If after completing local resolution the appellant remains dissatisfied with the CCG’s decision, they can request an Independent Review Panel (IRP) consider the case.  Requests should be made in writing to: Karen Scarsbrook, Continuing Healthcare Manager (London Region), NHS England, Southside, 105 Victoria Street, London, SW1E 6QT. 

Requests of this nature must be made within 6 months of local resolution being completed.  Agreement from NHS England to proceed to an independent review are subject to approval by the Independent Chair appointed to consider the case.    The appellant will need to provide reasons in writing as to why they believe the CCG’s decision should be reviewed, and why they believe the CCG’s decision or process followed was wrong.

If accepted, appellants will be invited to a meeting where they will be given the opportunity to put forward their case.  NHS England will consider the evidence and make a recommendation to the CCG as to whether the process and decision were robust.   In all but exceptional cases, this decision will be accepted by the CCG. 

Ombudsman: If the appellant remains dissatisfied with the outcome, they can write to the Health and Health Investigations Directorate, The Parliamentary and Health Service Ombudsman; Milbank Tower, Milbank, London, SW1P 4QP.  They will complete their own review of the case and make recommendations as appropriate. 

Complaints: Individuals have the right to make a complaint.  Any complaint for NHS Ealing CCG should be put in writing to the: Complaints Manager CWHHE Clinical Commissioning Groups, 15 Marylebone Road, London, NW1 5JD

COMMISSIONING OF CARE

Planning your care provision: If you are assessed to be eligible for NHS funding, we will work with you to identify the most suitable care provision to meet your needs.  We only commission care from providers that are registered with the Care Quality Commission, and are able to demonstrate their ability to deliver satisfactory care standards.   When deciding on how your needs are met, your wishes and expectations of how and where the care is delivered should be documented and taken into account. Any individual eligible for NHS continuing healthcare can request to have a Personal Health Budget.  For more information about Personal Health Budgets, contact us below or email ealccg.phb@nhs.net.

REVIEW: Monitoring and review

If you are eligible for continuing healthcare, we will review your eligibility for NHS continuing healthcare at least once within the first three months and annually thereafter, or sooner if your needs change.  Neither the NHS nor the local authority should withdraw from an existing care or funding arrangement without a joint review and reassessment of your needs, and without first consulting with one another and with you about any proposed changes and ensuring that alternative funding or services are in place. 

For more information

To find out more about NHS Continuing Healthcare in Ealing you can contact the team:

Continuing and Complex Care Commissioning Service

NHS Ealing Clinical Commissioning Group

Ealing Council,

Perceval House,

14-16 Uxbridge Road,

Ealing

W5 2HL

Telephone: 020 8280 8091

Email: ealccg.chcreferrals@nhs.net

Website: www.ealingccg.nhs.uk

For more information, you can read the Department of Health’s public information here