Continuing Healthcare

There is no legal definition of what constitutes a ‘primary health need’. However, a key court judgement, the Coughlan case, set a precedent for when someone’s healthcare needs are beyond the responsibilities of local authorities and should be paid for by the NHS.

If someone is assessed as eligible for CHC, the ICB funds the full package of health and social care. For example, if a patient is eligible for CHC in their own home, the ICB will pay for health care costs (such as services from a community nurse or specialist therapist) and associated social care costs (such as personal care and help with bathing). In a care home, the ICB also pays for people’s care home fees, including board and accommodation.
 

There is a national framework which states that eligibility should be based on someone’s healthcare needs and not their diagnosis. It’s not linked to savings or income.

Many people who are assessed for CHC are reaching the end of their lives or face a long-term condition, because of a disability, accident or illness.  They can have a wide range of healthcare conditions and may receive funding for just a few weeks or many years.

People who may be assessed as eligible for CHC include:

• People near the end of their lives. 

They may have conditions like advanced cancer or heart disease or be a frail elderly person with a rapidly deteriorating condition and entering a terminal phase of their lives. Typically, people near the end of their lives will receive care for weeks or a few months.

• Frail elderly people with complex physical or psychological needs

This could include frail elderly people with conditions such as dementia, weight loss, lack of mobility or Parkinson’s disease. Care can often be provided for several years.

• People, aged 18 and over, with long term healthcare needs

This could include people who have had an accident that has left them with long-term health care needs, such as spinal injury. It may also include people with long-term conditions such as multiple sclerosis. People will often receive care for many years and their eligibility for CHC may change as their needs change.
 

Completing the CHC checklist does not indicate that someone may be eligible for CHC and less than one in three of those who pass the initial screening will be assessed eligible. To find out more about NHS CHC please visit NHS England

NHS CHC can be provided by the NHS in any setting, including a care home or at home.

If CHC is provided in a care home, it will cover the care home fees, including the cost of accommodation, personal care and healthcare costs.

If CHC is provided in the person’s home, it will cover personal care and healthcare costs.

Those in receipt of NHS CHC continue to be entitled to access to the full range of health services e.g. GP, hospital, outpatients, district nursing.
 

If you are assessed as eligible for NHS CHC please be aware that it is subject to review and if your care needs change the funding arrangement may also change. 

Your eligibility for NHS CHC will be reviewed regularly. If you are not eligible at assessment, you may become eligible if your needs change over time. 
 

If you have a rapidly deteriorating condition that may be entering a terminal phase, the National Framework has a ‘fast-track tool’. This can be completed by an ‘appropriate clinician’ as defined by the Framework, who may recommend you move quickly onto NHS Continuing Healthcare. This recommendation should be acted on immediately by the ICB, ideally within 48 hours.

Due to the nature of your care needs it may not always be possible to accommodate your first choice of care home.
 

For most people, the assessment process involves an initial screening and then a full assessment. After the full assessment, a recommendation will be made to the ICB about whether the patient is eligible.

The initial screening is usually carried out by a health or social care professional who knows the person and uses a checklist to decide whether people need a full assessment. The person who completes the checklist will send it to the CHC team.

The full assessment is usually undertaken by a group of health and social care professionals who have been involved in the patient’s care. They are known as a multidisciplinary team (MDT).

The MDT will then make a recommendation to the ICB about whether the person is eligible, and the ICB will make the final decision. However, we also work with local authorities to make sure that they are able to contribute to the assessment process should the applicant wish.
 

CHC assessments can take place at home or in a care or nursing home. In some instances assessments may be conducted in hospital, however, hospital is not usually the best place for the assessment to be completed. Once you are medically fit for discharge we will arrange for you to be allocated to a ‘Discharge to Assess’ bed, within a care home. The ‘Discharge to Assess’ location aims to provide a calmer environment than an acute ward.

If your preferred destination is home (either your own or a family member’s) we will provide a short-term package of care before undertaking your CHC assessment. This will reduce the amount of time you spend in hospital. The assessment will be undertaken within seven days of your move from hospital.

Black Country ICB actively promotes and supports discharging patients back to their own (or a relative’s) home with a package of care providing quality and safe care. Leaving hospital to return home depends on the complexity of your care needs and the availability of domiciliary care providers suited to meeting your needs at home.
 

Financial issues are not part of the decision about an individual’s eligibility for CHC. ICBs can, however, take account of comparative costs and value for money when arranging care and should ensure the services provided reflect the person’s preference as far as possible.

Health and social care professionals must use their professional judgement at both the screening and full assessment stages. They will consider the person’s combined healthcare needs across 11 domains (areas of need) to complete an initial checklist and across 12 domains to undertake the full assessment.

People will be assessed three months after their successful assessment and then annually.  This is to ensure the care provided is still relevant and providing the right support, as well as ensuring that CHC is still needed.

If you are not eligible for NHS CHC, you may appeal. To find out more about the appeals process, please refer to the CHC Appeals section
 

Either you or your representative will be contacted to arrange a mutually suitable date and time for the assessment. You will receive written confirmation of the agreed arrangements.

You will be visited by one or two qualified nurses. Depending on your individual needs this may be a Registered General Nurse (RGN), Mental Health Nurse (RMN), Learning Disability Nurse (RNLD) or a Paediatric Nurse. 

A Social Worker will also be invited to attend, and you can have family/friends present to support you.

First, the nurse leading the assessment will gain consent from you to undertake the assessment. The nurse will then put you at ease by explaining the process and documents used. During the assessment the nurse will take into account evidence provided by you and your representative(s).

After the assessment the nurse will advise you of the recommendation regarding your eligibility for CHC or Funded Nursing Care. The nurse will also explain what happens once the recommendation is submitted to the ICB.

You will receive a letter confirming your eligibility within five working days of a decision being made by the ICB.

If you are not eligible for Continuing Healthcare you will be provided with a route to appeal the decision.
 

We will:

• Ensure you know who everyone at the meeting is
• Treat you as an individual
• Involve you in every decision about your care – if professionals use jargon or words you don’t understand please ask them to explain
• Be respectful and value your privacy and dignity
• Be polite and helpful
• Keep your personal information secure (with your consent, we may need to share some information with other professionals involved in your care)
• Show you our ID badge. If we forget, it’s OK to ask.
   

If a patient or their carer is unhappy with the outcome of their CHC assessment they can ask the ICB to review their case. There are three stages to this process:

1. The patient or their representative should contact their local CHC team in the first instance for a local review: 

Once the local review stage has been completed, the ICB should provide you with information about how to refer your case for an Independent Review (IRP).

2. You should write a short letter to the regional NHS England CHC team requesting an IRP to review a continuing healthcare decision, explaining that you have completed the local review process and briefly outlining your reasons for appeal.

The regional team will send you a formal IRP request form. This will ask you to explain your reasons for requesting an IRP in more detail and will encourage you to specify any complaints you have about the assessment process.

The Regional CHC Team can be contacted by email: England.irpwestmids.nhse@nhs.net or by calling 0113 825 3232.

3. If a patient is unhappy with the outcome of the independent review, they can complain to the Parliamentary and Health Service Ombudsman. The Ombudsman’s role is to decide whether decisions made by the NHS are in line with the national framework; it does not generally make judgements about whether the NHS has made the right decision.​​​​​​

NHS England has taken on board feedback from the ombudsman, for example by refreshing its CHC redress guidance in 2015.

This is an amount of money to support the health and wellbeing needs of you or someone you care for. They are designed to improve yours or your child’s healthcare by offering more choice and control over the support and services you get.

In the Black Country we are offering PHBs to people aged 18 years and over who are registered with a local GP, living in their own homes and are eligible for fully funded NHS Continuing Healthcare. We are also offering them to children who receive Continuing Care. Since 2 December 2019 NHS England has extended the right to have a PHB to individuals entitled to Section 117 Aftercare under the Mental Health Act (1983) for wellbeing needs and Personal Wheelchair Budgets (PWB). PWBs aim to help people access a wheelchair that meets their health and wellbeing needs and goals, as well as any specific wheelchair requirements that they have.

PHBs work in a similar way to the personal budgets or individual budgets for care and support from social services. If you already get this benefit, and your care coordinator agrees, you can combine this with a PHB too as an integrated care arrangement. You can also use ‘direct payment’ to manage these budgets (see next section).
 

A personal Health Budget can be managed in any of these three ways, or a combination of them:

• Direct Payments – You get the money to buy the services you and your care coordinator agrees you need. Your care coordinator is the person who works with you most often on your care plan to show what you have spent it on, but you buy and manage the services yourself and/or with support from an independent Direct Payment service.
• Notional Budget – No money changes hands. The NHS arranges your care and pays for it. This will usually be the budget used for domiciliary care packages. The personal health budget holder from the outset knows how much money is available for their assessed needs and decides together with the NHS team how to spend that money. 
• Third Party – This is where the money is paid to an organisation who holds and manages the money on your behalf. They pay and arrange support agreed in your personalised care plan.
   

If you would like a PHB for yourself or someone you care for, talk to the local NHS worker who helps you most often with organising care for you or your child. They will discuss PHBs with you.

If you’re eligible for CHC or your child is eligible for continuing care, and you would like to consider a personal health budget, then you can work together with your care coordinator to develop a Personalised Support plan (PSP). The support plan, the proposed amount of money and how the budget will be managed, then has to be agreed by the ICB.

If your child gets continuing care, they will have an education, health and care plan (an EHC plan) – or will be transferring to one very soon. For children, PHBs can contribute to some or all of the social, health or educational elements of this plan. In your area there will be a ‘local offer’ and you can usually find out more about this on your local council website.

Even if a PHB is not right for you, you can talk to your care coordinator about other ways to make sure you get the healthcare and support that works best for you and your family.
 

There are three key steps to meeting health and wellbeing needs under the personal health budgets system:

• Step 1 – assessment of needs

Your care coordinator will ask you questions to find out what you need for your health and wellbeing.

• Step 2 – budget allocation

Your assessment of needs is used to calculate an ‘indicative budget’. This is an estimated amount of the money needed to meet your health and wellbeing needs.

•  Step 3 – support planning and using the budget

Your care coordinator will then work with you, and those who support you, to decide how best to use the personal health budget to meet your needs. They will work with you to complete your personalised support plan. This will include your choice of how care is delivered. 

While it can take some time to set up your health budget, we will make sure that this doesn’t cause a delay in being discharged from hospital and an interim care package may be offered in these circumstances.
 

This is a document completed with the NHS team by you (if you want) with help from family and friends as agreed by your care coordinator. It is a personalised approach, to establish the things that matter to you most in supporting with you or your child’s personal health and wellbeing needs, the health outcomes you want to achieve, the amount of money in the budget and how you are going to spend it.

You can use a personal health budget to pay for a wide range of items and services, including therapies, personal care and equipment. You don’t have to change any healthcare or support that is working well for you just because you get a PHB, but if something isn’t working, you can change it.

Your care coordinator will advise you and can recommend a range of organisations that can offer local support.

There are some things you can’t use the budget for, such as alcohol, tobacco, gambling or debt repayment, or anything that is illegal.

You also can’t use a personal health budget to buy emergency care – for example if someone who has a PHB had an accident, they would go to A&E like everyone else. You also can’t use it for primary care services like dental treatment, but other services recommended by a GP, like physiotherapy, could be included.

PHBs are given to meet health and wellbeing needs and cannot be spent for any other reason. The ICB has a duty to ensure that payments are being used for what has been agreed with your CHC care coordinator and documented in your personalised support plan. The ICB is entitled to recover any money that is not spent appropriately.

Whatever form of PHB is used, the assessment and review process for continuing healthcare remains as it is now.

Your NHS team will be able to help you with more details about what you can use your budget for.
 

You can get lots of information on the NHS website.