NHS Continuing Healthcare: when the NHS pays the whole fee

Care in England is split. Health care is free from the NHS. Social care, which includes help with washing, dressing, eating and the cost of living in a care home, is means tested by the council. Continuing Healthcare is what happens when someone’s needs are so heavily medical that the whole package is treated as health care and the NHS takes it on.

It is not about a diagnosis. Two people with the same condition can get different answers. It is about the nature, intensity, complexity and unpredictability of what you need, day to day.

The assessment scores you across twelve areas of need, called domains: breathing, nutrition, continence, skin, mobility, communication, psychological needs, cognition, behaviour, drug therapies and medication, altered states of consciousness, and other significant needs. Each is rated from no need up to priority.

As a rule of thumb, you are likely to have a primary health need if you have:

• one priority need in any domain, or
• two or more severe needs, or
• one severe need together with several high or moderate needs

The scores are not the decision. The team then looks at the four characteristics of your needs as a whole: how they interact, how much skill they take to manage, how often they change and how hard they are to predict. That judgement is where most arguments happen.

Well-managed needs still count. If a need only looks small because it is being skilfully controlled, the assessment must score the underlying need.

1. 01
   Ask for the checklist

   Any nurse, doctor, social worker or care home manager can complete it. You can ask your GP or the council to arrange one. It is a screening tool: it is meant to let more people through than will finally qualify.
2. 02
   Multidisciplinary team assessment

   If the checklist is positive, a team of at least two professionals from health and social care completes the decision support tool with you and whoever you want present. It should take a few weeks, not months, and you should be given a copy.
3. 03
   Recommendation and decision

   The team recommends whether you have a primary health need. The integrated care board normally accepts that recommendation. You get the decision in writing with the reasons.
4. 04
   Care planning and review

   If eligible, the NHS arranges and pays for your care, and reviews it after three months and then yearly. Eligibility can be withdrawn at a review if your needs have changed.

If someone has a rapidly worsening condition and may be entering a terminal phase, a doctor or nurse can complete a fast track form instead of the checklist. Funding should then be in place within 48 hours. There is no scoring; the clinician’s judgement is enough. Fast track funding is reviewed, but it should not be withdrawn simply because the person has lived longer than expected.

In a care home, Continuing Healthcare covers the full fee for a standard room and the care you need. In your own home it pays for the care package, which can include live-in care. It does not pay for things that are not care, such as a bigger room, and it does not normally pay a top-up for a dearer home than the NHS thinks you need.

If you were paying fees yourself before the decision, ask about a refund back to the date you became eligible. If the council was paying, it will stop and the NHS takes over.

You can ask the integrated care board to look again at either the process or the outcome. You have six months from the decision letter. If that does not resolve it, you can ask NHS England for an independent review, and after that the Parliamentary and Health Service Ombudsman.

Appeals succeed most often where the decision support tool understated a need, ignored how needs interacted, or where the team did not follow the national framework. Get a copy of the tool, go through it line by line against the care records, and put your points in writing. Organisations such as Beacon and Age UK offer free advice on Continuing Healthcare appeals.

While an appeal runs, the fees still have to be paid. If you are in a nursing home you will at least receive funded nursing care, and the council means test applies to the rest.