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 a scheme called NHS continuing healthcare.
What is NHS continuing healthcare?
NHS continuing healthcare is a package of care arranged and funded solely by the NHS to meet health needs that have arisen because of disability, accident or illness.
The NHS will ultimately decide where this care should be provided but could include settings such as a residential or nursing home, your own home or in a hospice.
Can I get NHS continuing healthcare?
Eligibility for NHS continuing healthcare isn’t based on whether you have a specific health condition. Eligibility is decided via a full assessment where the nature, intensity, complexity or unpredictability of someone's health needs means that their care needs to be actively managed by the NHS.
The Welsh Government has suggested that a health care need is one "related to the treatment, control or prevention of a disease, illness, injury or disability, and the care or aftercare of a person with these needs (whether or not the tasks involved have to be carried out by a health professional)". This is different to a social care need which the Welsh Government described as a need "that is focused on providing assistance with activities of daily living, maintaining independence, social interaction and (in some circumstances) [finding and] accessing a care home or other supported accommodation".
To get NHS continuing healthcare you must have ongoing significant health needs and require care primarily because of the nature of your health needs (as opposed to social care needs).
How does the assessment for NHS continuing healthcare work?
If you have ongoing significant health needs, the Local Health Board must take reasonable steps to ensure an assessment for NHS continuing healthcare is carried out in all cases where it appears to them that there may be a need for such care.
Examples of when the Health board should consider whether to assess might be following discharge from hospital where long term needs are clear, after a period of rehabilitation or when your needs are being reviewed (for example if you are in a nursing home or having a community care assessment).
If it is agreed that you may be eligible for NHS continuing healthcare, the NHS staff will begin the assessment process. Often NHS staff will first complete a "checklist tool" to help identify whether someone should move on to the full assessment or not. The checklist looks at the same areas of need as the full assessment and depending on how high your needs are assessed to be, they will then either decide that you should move to the full assessment or that an assessment is not needed as you are not eligible. If this happens, you could contact the Local Health Board and ask them to reconsider the decision, giving them any extra information you are able to provide.
Using the checklist tool is not mandatory in Wales. Where it is not used, the decision about NHS continuing healthcare should be based on a full multi-disciplinary assessment and completion of a decision support tool kit. If you find a checklist tool was not completed and it has also been decided that you will not be referred for a full assessment, you could make a complaint if you believe you have been ‘screened out’ of the process too early.
If your condition is deteriorating quickly and you may be approaching the end of life, you may have a Fast Track assessment instead, which is a quicker process.
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. This is called a multi disciplinary assessment.
The information from this assessment is then used to complete a Decision Support Tool which records how high your needs are in a variety of areas such as behaviour, continence, breathing etc. If it can reasonably be anticipated that your condition will deteriorate and your needs in certain areas will increase in the near future, this should also be recorded and considered.
The team will then use this tool to recommend to the Local Health Board whether or not you should receive NHS continuing healthcare. Only in exceptional circumstances - and for clearly articulated reasons - should the Local Health Board not accept the recommendation. Examples of when it might be appropriate for the Local Health Board to deviate from the recommendation could be when the Decision Support Tool is incomplete or there is significant inconsistency between the evidence in the assessment, the Decisions Support Tool and the recommendation made.
What happens if I’m eligible for NHS continuing healthcare?
If you’re found to be eligible for NHS continuing healthcare, the Local Health Board should tell you verbally and in writing, explaining how they reached their decision. The Local Health Board must then arrange a provide a care package it thinks is appropriate to meet your assessed health and social care needs.
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 access the review process if you are dissatisfied with the procedure followed in reaching the decision or the application of the criteria for eligibility. To do this you would need to approach the Local Health Board to ask them to review their decision.
The health board will first review the decision using the local review process. The Local Health Board should be able to give details of the process and time scales. If the issue cannot be resolved at the local review stage, it should then be referred to the Independent Review Panel.
The Independent Review Panel process should normally be completed within 4 weeks and the case will be looked at by a panel at a minimum comprising of an independent chair, representative of a Local Health Board and a Local Authority. Occasionally the Local Health Board will decide not to convene an Independent Review Panel however this should only happen where "the patient falls well outside the eligibility criteria". Prior to deciding not to convene a panel, the Local Health Board should seek the advice of the chairman of the review panel and in all cases where the decision not to convene a panel is made, the Health Board should give a full written explanation of its decision.
If after this the original decision is upheld and you still wish to challenge it, you can contact the Public Services Ombudsman for Wales and ask if they will examine your case.
What should I do next?
Speak to your doctor, consultant or social worker if you think you might be eligible for NHS continuing healthcare. They can make a referral the to relevant LHB.
See our factsheet NHS continuing healthcare and NHS-funded nursing care in Wales (PDF 1MB) for more information.
For more information call Age Cymru Advice on 08000 223 444