Are you eligible for NHS continuing healthcare funding?

In England, Wales and Northern Ireland, if you have a disability or complex medical problem, you might qualify for free NHS continuing healthcare (CHC). Not many people know about it, so it’s important to find out if you’re eligible and get an assessment. In Scotland there are different care arrangements called Hospital Based Complex Clinical Care.

What is NHS continuing healthcare or NHS continuing care?

Where a person’s primary need is a ‘health need’, the NHS is regarded as responsible for providing for and fully funding all their needs in any setting, this could be in:

  • A hospice;
  • A care home, or
  • Your own home, a care home or hospice.

In England, the NHS can arrange care for you or you can choose to receive funding for your care as a direct payment, known as a personal health budget.

A personal health budget gives you more choice and control over how you plan and pay for your healthcare and wellbeing needs.

Personal health budgets are not currently available in Wales, Scotland or Northern Ireland.

Who is eligible?

Top tip

The only sure way to know if you’re eligible is to ask your GP or social worker to arrange an assessment.

There’s no clear-cut list of health conditions or illnesses that qualify for funding.

Most people with long-term care needs don’t qualify for NHS continuing healthcare or NHS continuing care because the assessment is quite strict. Being frail, for example, isn’t enough.

But don’t let that put you off.

Free healthcare could be worth thousands of pounds each year, so it’s important to find out where you stand.

What are eligible health needs?

As a guide, ‘eligible’ health needs might include:

  • Mobility problems
  • Terminal illnesses
  • Rapidly deteriorating health
  • Long-term medical conditions
  • Physical or mental disabilities
  • Behavioural or cognitive disorders
  • Complex medical conditions that need additional care and support

There are plenty of grey areas and you might have other conditions that mean you qualify.

You might know people in similar circumstances who’ve been turned down.

But the only sure way to know if you’re eligible is to ask your GP or social worker to arrange an assessment.

What costs are covered?

NHS continuing healthcare or continuing care covers personal care and healthcare costs, such as paying for specialist therapy or help with bathing or dressing.

It might also include accommodation if your care is provided in a care home, or support for carers if you’re being looked after at home.

If you don’t qualify for NHS continuing care and you need care in a nursing home you might get NHS funded nursing care which is a non-means tested contribution towards your nursing costs.

Funding varies by region, so you’ll need to check with your local Clinical Commissioning Group, Health Board or Health and Social Care Trust to see what’s covered.

Visit this page for more information. .

What happens during the assessment process?

Step 1 – The initial screening

First of all, you’ll have an initial screening to see if you’re eligible for funding.

It’s usually carried out in hospital or at home by a nurse, doctor, social worker or other healthcare professional.

They’ll assess your general health and care needs with a simple checklist that will cover:

  • Mobility
  • Breathing
  • Continence
  • Communication
  • Nutrition (food and drink)
  • Skin (including wounds and ulcers)
  • Psychological and emotional needs
  • Altered states of consciousness
  • Symptom control through drug therapies and medication
  • Cognition (everyday understanding of what’s going on around you)
  • Other significant care needs

If your health, or the health of someone you care for, is getting worse rapidly, ask about a fast track assessment to bypass the initial screening.

Step 2 – The assessment

Don’t be put off

Even though the assessment process can be complex, most people and families who’ve been through it say the benefits are worth it.

If the initial screening shows that you might be able to get free NHS Continuing Care, you’ll need to have another assessment.

It will be carried by a team of two or more health- and social-care professionals who are involved in your care.

The team will use the same checklist above but will go into a lot more detail.

They will mark each of your care needs as low, moderate, high or severe.

Health conditions can also be classed as priority if they relate to behaviour, breathing, drug therapy, symptom control and altered states of consciousness.

If you have at least a priority need in one of the four priority care domains or two severe needs, you should qualify for funding.

If you have one severe need and a number of other high or moderate needs, you might also be eligible.

Find out more about the assessment process in the Department of Health leaflet ‘NHS continuing healthcare and NHS-funded nursing care’ (PDF).

Find out more about the assessment for NHS Continuing Healthcare in Scotland in this ‘Continuing Health Care Assessment Summary’ (PDF).

What to do if you don’t agree with the assessment

Top tip

Circumstances change, so even if you were turned down for funding at first, make sure you have your situation regularly reviewed particularly if your health deteriorates. Your GP or social worker can help you.

Ask your local Clinical Commissioning Group, Health Board or Health and Social Care Trust for a review of their decision.

This must be requested in writing within six months of the notification that you were ineligible.

If their decision was only based on an initial screening, ask for a full assessment.

You should be given an opportunity to contribute to the review and to see all the evidence that was taken into account.

You might be able to appeal if you’ve already been paying for care-home fees and think you should have received NHS funding.

To do this, speak to your social worker or health practitioner, and ask for a retrospective assessment.

If this does resolve the issue for you, again within 6 months you can request an independent review panel to consider your situation. As a last resort you can ask your complaint to be determines by the Parliamentary Health Service Ombudsman.

What if you don’t qualify?

Even if you don’t qualify for NHS Continuing Care, you might still be eligible for other NHS services to support you including:

  • Palliative care;
  • Respite health care;
  • Rehabillitation and recovery, and
  • Community health services specialist support for healthcare needs.

Alternatively, there might be local authority funding to meet some of your care needs.

Detained under Mental Health Act

Section 117 of the Mental Health Act 1983 provides that the NHS and Local Authority jointly provide aftercare services if you have been detained under some provisions of the Mental Health Act for assessment and treatment.

All services provided under this section should be free.

Hospital Based Complex Clinical Care in Scotland

NHS continuing healthcare in Scotland was replaced on June 1 2015 by a scheme called Hospital Based Complex Clinical Care.

This scheme is only available to people in hospital.

If you need long-term complex clinical care, your needs will be assessed based on one question asking whether your care needs can be properly met in a setting other than hospital.

If it is possible to provide care outside hospital, you’ll receive it in the place that’s best for you.

This could be your home, a care home or supported accommodation.

If you already getting NHS continuing healthcare under the old scheme, you’ll continue to receive it for as long as you’re eligible.

Find out more about Hospital Based Complex Clinical Care and how to get other care services in Scotland on the careinfoscotland website.

You can also read more about the changes and what to do if you don’t agree with a care assessment in the Age UK fact sheet Hospital Based Clinical Care and NHS Continuing care in Scotland.

Need more information?

For further free independent help regarding this you can call FirstStop Advice on: 0800 377 7070 (Monday to Friday, 9am – 5pm), or email them on info@firststopadvice.org.uk.

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