Surrey Heartlands CCG hosts NHS Continuing Healthcare and NHS-funded Nursing Care (FNC) services across Surrey on behalf of the three Surrey CCG’s – North East Hampshire & Farnham CCG [Farnham GP patients only], Surrey Heartlands CCG and Surrey Heath CCG.
What is NHS Continuing Healthcare?
NHS Continuing Healthcare funding is a package of ongoing care that is arranged and paid for by the NHS. This is for individuals who have been assessed and found to have a ‘primary health need’ as set out in the National Framework. Such funding is provided to an individual aged 18 or over, to meet health and associated social care needs that have arisen as a result of disability, accident or illness.
NHS Continuing Healthcare is free (with no financial assessment) unlike support provided by local authorities, for which a financial charge may be made depending on your income and savings.
You can receive NHS Continuing Healthcare funding in a variety of settings, including your own home, or in a care home with nursing. If you choose to receive your care in your own home, the NHS already provides for healthcare, e.g. services from a community/district nurse or specialist therapist. They will fund associated social care needs (e.g. personal care and domestic tasks, help with bathing and dressing). If you choose to receive your care in a care home with nursing, the NHS will also pay for your care home fees, including board and accommodation.
If you are eligible, the Continuing Healthcare Team will be responsible for identifying and funding a package of care that has been discussed and agreed with you and your family or representative. Funding is subject to regular review and if your healthcare needs change the funding arrangements may also change.
A public information film from NHS England provides a guide for individuals and their families to NHS Continuing Healthcare and what to expect throughout the complex assessment process. There is also an easy-read guide ‘What is NHS Continuing Healthcare’ for people with learning disabilities.
The revised 2018 National Framework sets out the principles and processes of NHS Continuing Healthcare and NHS-funded Nursing Care. This guidance, which replaces the previous version of the National Framework published in November 2012, was implemented on 1st October 2018.
NHS England recognises that information and support are vital to all individuals involved in the CHC process and has therefore funded an independent information and advice service through a social enterprise called Beacon. This service is supported by a consortium of leading voluntary sector organisations including Age UK, Parkinson’s UK and the Spinal Injuries Association.
Beacon provide information and advice on their website and individuals are also able to access up to 90 minutes of free advice with a trained NHS continuing healthcare adviser.
The Continuing Healthcare Team support the use of advocacy for any individual to represent their views or speak on their behalf. This could be a family member, friend or peer, a local advocacy service or someone independent who is willing to undertake an advocacy role.
How is eligibility for NHS Continuing Healthcare assessed?
Eligibility is not dependent on a particular diagnosis or disease or determined by where your care is provided. Where a person’s “primary need” is a health need, they are eligible for NHS Continuing Healthcare. Deciding whether this is the case involves looking at all the relevant needs from the assessment process. Where an individual has a primary health need, the NHS is responsible for providing all of their health and social, including accommodation, if that is part of their need.
Consideration of primary health need includes taking into account what those needs are and their impact on the care required to manage them. In particular, to determine whether the quantity or quality of care goes beyond the limits of Local Authority.
Consideration is given to the following areas: -
- Nature and type of need: This describes the particular characteristics of an individual’s needs (which can include physical, mental health or psychological needs) and the type of those needs. This also describes the overall effect of those needs on the individual, including the type (‘quality’) of interventions required to manage them.
- Intensity of need: This relates both to the extent (‘quantity’) and severity (‘degree’) of the needs and to the support required to meet them, including the need for sustained/ongoing care (‘continuity’).
- Complexity of need: This is concerned with how the needs present and interact to increase the skill required to monitor the symptoms, treat the condition(s) and/or manage the care. This may arise with a single condition, or it could include the presence of multiple conditions or the interaction between two or more conditions. It may also include situations where an individual’s response to their own condition has an impact on their overall needs, such as where a physical health need results in the individual developing a mental health need.
- Unpredictability of need: This describes the degree to which needs fluctuate and thereby create challenges in managing them. It also relates to the level of risk to the person’s health if adequate and timely care is not provided. An individual with an unpredictable healthcare need is likely to have either a fluctuating, unstable or rapidly deteriorating condition.
To support consistent decision making, the NHS Continuing Healthcare Decision Support Tool (DST) has been developed for use by practitioners. This enables them to obtain a full picture of needs and to inform the decision regarding the level of need that could constitute a primary health need.
The DST, combined with the practitioners own experiences and professional judgement, will enable them to apply the primary health needs test in practice in a way which is consistent with the limits on what can be legally provided by a Local Authority.
Eligibility for NHS Continuing Healthcare is based on an assessment of an individual’s presenting care needs. An NHS Continuing Healthcare Checklist may be completed initially to decide if a full assessment, known as a DST should be undertaken.
The DST provides the basis for decisions on eligibility for NHS Continuing Healthcare funding. This must be completed by the multi-disciplinary team, which will include as a minimum, two professionals from different health professions or one professional from a healthcare profession and one who is responsible for undertaking community care assessment (a social care professional). Specialist staff and mental health staff could also be involved dependent on the individual’s needs.
What is NHS-funded Nursing Care?
NHS-funded Nursing Care (FNC) is the funding provided by the NHS directly to care homes with nursing to support the provision of nursing care by a registered nurse. Where the individual is living in their own home or a care home without nursing, then the NHS will provide such care via community services, such as district nurses.
How is eligibility for NHS-funded Nursing Care assessed?
In all cases individuals will be considered for eligibility for NHS Continuing Healthcare (CHC) before a decision is reached about the need for NHS-funded Nursing Care.
If a checklist indicates that no referral is necessary for a full assessment, but registered nursing needs are identified, then FNC can be awarded without the need for a further assessment.
If the Decision Support Tool identifies that the patient is not eligible for CHC then it will go on to consider whether they are eligible for FNC.
The registered nursing needs are services provided by a registered nurse and involving either the provision of care or the planning, supervision or delegation of the provision of care, other than any services which, having regard to their nature and the circumstances in which they are provided, do not need to be provided by a registered nurse.
How do I apply for NHS Continuing Healthcare or NHS-funded Nursing Care?
A nurse, doctor or other qualified healthcare professional or social care practitioner can apply the Checklist to refer individuals for a full consideration of eligibility from within the community or hospital setting.
A referral can also be made in the form of a telephone call, email or letter from a patient or their representative. This will usually result in the completion of a Checklist by the CHC Team.
What is a Fast Track
The Fast Track application is there to ensure that individuals who have a “rapidly deteriorating condition and may be entering a terminal phase” have access to NHS Continuing Healthcare funding with minimum delay and without the need to complete a DST.
A completed Fast Track Pathway Tool, which clearly evidences that an individual is both rapidly deteriorating and may be entering terminal phase, is sufficient to establish eligibility.
The Fast Track Tool will be completed by an ‘appropriate clinician’ described in the National Framework as a person who is:
- Responsible for the diagnosis, treatment or care of the individual under the National Health Service Act 2006 in respect of whom a Fast Track Pathway Tool is being completed;
- A registered nurse or a registered medical practitioner.
The ‘appropriate clinician’ will be knowledgeable about the individual’s health needs, diagnosis, treatment or care and be able to provide an assessment of why the individual meets the Fast Track criteria.
If you are involved in supporting those with end of life needs, (including those in wider voluntary and independent sector organisations) you should contact the appropriate clinician who is responsible for the diagnosis, care or treatment of the individual and ask for consideration to be given to completion of the Fast Track Pathway Tool.
How do I appeal an eligibility decision?
Where an individual has been found not eligible for NHS Continuing Healthcare or NHS- funded Nursing Care following completion of a DST, they or their representative can appeal the decision within 6 months of the date of the outcome letter.
Appeals in the first instance should be sent to:
NHS Continuing Healthcare Team
Tel: 0300 561 1444
When an appeal is received it will be acknowledged by way of a telephone call from a clinician, which also allows the opportunity to establish any process issues that the appellant may have in addition to the outcome of the DST. A letter will then be sent to the appellant together with a questionnaire to complete and a request for documentation in relation to their authority to act.
Once this has been returned, evidence will be obtained from all parties involved in the patients care for a period of six weeks either side of the date of completion of the DST being appealed. This evidence will be reviewed by a clinical assessor who was not previously involved in the completion of the DST. The appellant will then be advised in writing of their decision.
If the appeal is not resolved at this point, then the next stage of the local appeal process is the offer of a Local Resolution Meeting (LRM). The individual and/or their representatives will be invited to attend the LRM and to participate in the discussion. The meeting will be chaired by a member of the clinical team who will be accompanied by a Clinical Assessor.
This meeting will review the original DST decision and the outcome of the first appeal. Notes will be made of the meeting discussion and these together with the Clinicians’ decision will be sent to the appellant. We aim to offer a date for the LRM as soon as the request is received and these meetings are currently taking place within two months.
Where it is identified at the Appeal stage that the DST was not conducted as an MDT the team will make every effort to hold the LRM as an MDT. Although Local Authority are not required under the terms of the National Framework to attend the LRM, an invitation is always sent to them, ahead of the meeting affording the opportunity to attend if they wish to do so. Where the DST was not completed as an MDT, and the Local Authority choose not to attend, the LRM will be held using clinicians from different backgrounds wherever possible.
If, following the LRM, the individual or their representative remain unhappy with the CCG’s decision, they can approach NHS England to request an Independent Review Panel (IRP) by writing to:
NHS England South
South West House
Blackbrook Park Avenue
FAO: Continuing Healthcare Administrator
All appropriate steps will have been taken by the CHC Team to resolve the case locally before an IRP is convened.
The IRP can be asked to review either or both of the following:
- a) The procedure followed by a CCG in reaching a decision as to that person’s eligibility for NHS Continuing Healthcare;
- b) The primary health need decision made by a CCG.
The IRP meeting, arranged and hosted by NHS England in accordance with the National Framework, will make a recommendation to the CHC Team in the light of its findings on the above matters.
Following an IRP, if the original decision is upheld, but there is still a challenge, the individual has the right to make a complaint to the Parliamentary and Health Service Ombudsman (PHSO).
The complaint needs to be made in writing, within 12 months of the date of the IRP outcome letter to the PHSO at the following address:
Parliamentary and Health Service Ombudsman
What is a personal health budget and who can have one?
A personal health budget is an amount of money that can be given directly to a person receiving NHS Continuing Healthcare to allow them to manage their healthcare and support such as treatments, equipment and personal care, in a way that suits them. The allocation of this budget is agreed with the individual and is based upon a detailed care and support plan.
NHS England have produced a short video entitled ‘what are personal health budgets?’ which describes what they are and how they are helping people to get care and support that is right for them
If you are registered with a GP in Surrey, are eligible for NHS Continuing Healthcare and are receiving your care at home, you can ask for a personal health budget.
Who do I contact for more information about personal health budgets?
If you want to know more or you have any questions about personal health budgets, you can call and speak to a member of the personal health budget team on 0300 561 1344.
Surrey Independent Living Council work closely with us to help people with their personal health budgets by providing independent advice and support.
How does a personal health budget work?
When NHS Continuing Healthcare funding has been agreed you will receive a letter confirming this. If you are interested in arranging a personal health budget (PHB) please get in touch with the team and they will arrange for a PHB Case Coordinator to contact you.
The case coordinator will work out the amount of money which will be available to you based on your health and wellbeing needs. If you want to go ahead, a personalised care and support plan will be developed by you and the PHB Case Coordinator, which meets your needs and NHS funding rules. You can, if you choose, also be supported throughout this planning process by an Independent Living Advisor from Surrey Independent Living Council.
As soon as your Health Support Plan has been approved, your personal health budget will need to be activated. This can be organised in a number of different ways:
Notional personal health budget – No money changes hands. You find out how much money is available for your assessed needs, and together with your NHS team, you decide on how to spend that money. They will then arrange the agreed care and support for you.
Third party personal health budget – An organisation legally independent of both you and the NHS (for example, an independent user trust or a voluntary organisation) holds the money for you, and also pays for and arranges the care and support agreed in your care plan.
Direct payment – You get the money to buy the care and support you and your NHS team agree you need. You must show what you have spent it on, but you, or your representative, buy and manage services yourself.
You can also choose to receive your budget as a combination of the three options above.
Your PHB Case Coordinator is responsible for making sure the help and support you are receiving is meeting your needs. As your needs change, so might your personal health budget, to make sure it is giving you the most appropriate support.
Can I make a retrospective claim for care already received?
The CHC Team will only consider requests for retrospective reviews where it is satisfied that one or more of the following grounds for the review exist:
- The CHC Team failed to carry out an assessment of the patient’s eligibility for NHS Continuing Healthcare funding when requested to do so.
- The request for a retrospective review is for periods of unassessed care.
- The period to be considered is after 01.04.2013 as the opportunity to claim for periods before that date has now passed.
Requests for a retrospective review, which should detail the period you want to be considered, should be sent to:
NHS Continuing Healthcare Team
If the CHC Team agree to undertake a retrospective review the applicant will be asked to complete a questionnaire and provide documentation in relation to their authority to act.
Once this has been returned, evidence will be obtained from all parties involved in the patients care for the duration of the claim period.
The evidence will be reviewed by a clinical assessor who will complete a Portrayal of Needs (PON) document detailing the individual’s health needs throughout the period of the review. Once completed the PON will be shared with the applicant who will be requested to confirm the details presented and provide any further comments they may have.
The clinical assessor will use the PON, together with any comments made, to produce the retrospective Decision Support Tool(s). The DST(s) will contain a recommendation on the individual’s eligibility for NHS CHC or NHS-funded Nursing Care (FNC) for the period of the review. That recommendation will be submitted to a multi-disciplinary team (MDT) panel, as the Local Authority do not participate in the retrospective process.
Wherever possible, the MDT will comprise two healthcare professionals from different backgrounds from within the CHC Team. The MDT panel will consider the clinical assessor’s recommendation and make the final decision on eligibility.
A letter detailing the outcome of the retrospective review will be sent to the applicant. The outcome will be either:
- The individual was eligible for Continuing Healthcare Funding/NHS-funded Nursing Care throughout the period of the Retrospective Review
- The individual was eligible for Continuing Healthcare Funding/NHS-funded Nursing Care for part of the period of the Retrospective Review
- The individual was not eligible for Continuing Healthcare Funding/NHS-funded Nursing Care for any part of the period of the Retrospective Review
If the CHC Team decide that the individual was eligible for all or part of the period under consideration, arrangements for a reimbursement will be made.
If the applicant is unhappy with the outcome of the Retrospective Review they can notify the Appeals Team within six months of the date of the outcome letter that they wish to appeal the decision further. Any appeal of a retrospective review will follow the appeals process.