NHS Wakefield acknowledges its responsibility to clearly identify our statutory powers and duties in relation to the commissioning of NHS Continuing Healthcare for patients, and demonstrate adherence with these responsibilities.
What is NHS Continuing Healthcare?
“Continuing care” means care provided over an extended period of time, to a person aged 18 or over, to meet physical or mental health needs that have arisen as a result of disability, accident or illness.
“NHS Continuing Healthcare” (“CHC”) means a package of continuing care that is arranged and funded solely by the NHS as part of the duty to provide healthcare services currently under section 3(1)(e) of the National Health Service Act 2006. It applies where the individual is assessed as having a primary health need.
Where an individual qualifies for CHC the NHS funds and delivers both health and social care services to the patient.
Revised National Framework
The National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care – November 2012 (revised) (“Framework”) was implemented on 1 April 2013. The Framework now incorporates the following guidance:
- NHS Continuing Healthcare Practice Guidance
- NHS Continuing Healthcare Frequently Asked Questions
- NHS Continuing Healthcare Refunds Guidance
In addition, the Framework is supported by:
A public information leaflet is available here.
Easy Read Guide
This book is about money from the NHS to pay for help and care. This is called NHS Continuing Healthcare.
- What is NHS Continuing Healthcare?
- Who can get NHS Continuing Healthcare?
- Who will help you find out about NHS Continuing Healthcare?
Primary health need
To be eligible for CHC the individual must be assessed as having a ‘primary health need’. The eligibility criteria used to determine a ‘primary health need’ considers the nature, complexity, intensity and unpredictability of the care needs. However, complex, social care needs only will not amount to a primary healthcare need.
Case law has confirmed that it is unlikely that an individual will have a primary health need unless their needs predominantly require the provision of services which can properly be described as “healthcare services” as opposed to social services.
The emphasis is “need” rather than “condition” focused. It does not necessarily follow that the mere presence of a healthcare need means that the individual is entitled to CHC. The healthcare need must be a primary need balanced against the need for social care.
Use of the Decision Support Tool (DST)
The decision making process to be followed is set out in the Directions (which it is a legal requirement to follow); however the Framework and DST provide additional guidance. The Continuing Care Team will arrange for an assessment by a multi-disciplinary team, and the DST will be completed and used to inform the decision about whether the individual has a primary healthcare need.
Where possible the individual and/or their representative should be present when the DST is completed. Where there is a disagreement about which score to recommend, the higher should be recommended and the disagreement should be noted on the DST.
The DST states that there should be a clear recommendation for eligibility for CHC where:
A level of priority need is shown (where this applies), or
The need in two or more care domains is assessed to be severe
The DST states that there can be an indication of eligibility for CHC where:
One domain is recorded as severe with needs in a number of other domains, or
There are a number of domains with high or moderate needs
It is important to bear in mind that although the DST supports the process of determining eligibility, it cannot directly determine eligibility and the exercise of professional judgment is necessary in all cases.
Fast track pathway tool
If an “appropriate clinician” is of the opinion that a person has a primary health need arising from a rapidly deteriorating condition that is entering a terminal phase, the Fast Track Pathway Tool will require the CCG to determine that the individual is eligible for CHC until a full assessment is completed using the DST.
Packages of care
There is a large amount of discretion in terms of how CHC services can lawfully be provided. Difficult judgments have to be made as to how a limited budget can be best allocated to the maximum advantage of the greatest number of people.
It is perfectly legal to take resources based rationing decisions as to what services can be offered to an individual. There is no legal requirement that every healthcare or social need of an individual must be fulfilled.
Sometimes patients feel that they would have been eligible for CHC funding in the past but did not receive an assessment. For the period 01/04/2004-31/03/2012, the deadlines for submitting a retrospective application have passed.
For the period 01/04/2012 to the present time, patients can write to NHS Wakefield CCG Continuing Care Team, advising re the period of possible eligibility, providing an account of the reasons for eligibility, and the team will consider the application on the basis of the guidance available at the time of application. Anyone applying on behalf of someone else will need to have ‘Lasting Power of Attorney’ registered with the Court of Protection and provide the CHC team with the original document: this will be photocopied and returned to you.
Claims and Redress
NHS England has now published the refreshed NHS Continuing Healthcare Redress Guidance for clinical commissioning groups (CCGs), to be used when considering NHS Continuing Healthcare redress payments for individuals.
The document has been updated to reflect the ‘Principles for Remedy’ from the Parliamentary and Health Service Ombudsman for all public bodies. It maintains the principles of fairness to ensure that individuals are returned to the financial position that they should have been had they later been found eligible for continuing healthcare, whilst ensuring nobody makes financial gain from the public purse. CCGs will continue to consider the specific circumstances of each individual case when determining the appropriate level of redress.
You can find more information and the new guidance from NHS England here.
Children’s Continuing Care
Continuing Healthcare relates to individuals over the age of 18 only, however, arrangements to prepare the child for adulthood in relation to their eligibility for NHS Continuing Healthcare will need to begin before the 18th birthday. Continuing care for children is available but is based on different criteria than CHC for adults and arranged in a different way. (For example, the way in which the child receives their education has to be included).
Personal health budgets
As of 1 April 2014, all service users in receipt of domiciliary care (delivery of personal care and support services to individuals in their own homes) who receive NHS continuing healthcare in Wakefield will be eligible to ask for a personal health budget.
Find out more:
What are the contact details for CHC applications or to talk to someone about eligibility for NHS Continuing Healthcare?
Continuing Healthcare Team
NHS Wakefield CCG
White Rose House
Tel: 01924 213050