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Factsheet 20
NHS Continuing Healthcare and
NHS-funded nursing care
July 2024
About this factsheet
This factsheet explains what NHS Continuing Healthcare is; how the
NHS decides whether you are eligible for it, and what to do if you are
unhappy with an eligibility decision.
It explains NHS-funded nursing care – a weekly payment NHS makes to
nursing homes towards their costs of providing nursing care to residents.
The following factsheets may also be of interest:
6 Finding care at home
10 Paying for permanent residential care
22 Arranging for someone to make decisions on your behalf
37 Hospital discharge and recovery
38 Property and paying for residential care
39 Paying for care in a care home if you have a partner
41 How to get care and support
76 Intermediate care and reablement
The information in this factsheet is applicable in England. If you are in
Northern Ireland, Scotland or Wales, please contact Age NI, Age
Scotland or Age Cymru for advice in these countries. Contact details can
be found at the back of this factsheet.
Contact details for any organisations mentioned in this factsheet can be
found in the Useful organisations section.
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Contents
1 Recent developments 4
2 Continuing care terminology 4
3 NHS Continuing Healthcare 4
3.1 What is NHS Continuing Healthcare? 5
3.2 What is the National Framework? 5
3.3 How is NHS CHC eligibility decided? 6
3.4 Who decides NHS CHC eligibility and funds your care? 8
3.5 Routes to reaching an NHS CHC decision 8
3.6 Getting an assessment 8
4 National Framework principles 9
4.1 Person-centred approach involving you and your carers 9
4.2 Seeking consent to the assessment process 9
4.3 Consent and mental capacity 10
4.4 Confidentiality and sharing information 11
5 Process for reaching an eligibility decision 12
5.1 Apply the Checklist 12
5.2 The multidisciplinary assessment 14
5.3 The Decision Support Tool (DST) 15
5.4 Reaching a decision 16
5.5 Joint package of health and social care 18
6 Care planning when eligible for NHS CHC 18
6.1 Your care package and options 18
6.2 If you lack capacity to consent to a care plan 20
6.3 Personal Health Budgets and NHS CHC 20
6.4 If unhappy with your NHS CHC care package 22
7 The Fast Track Tool 23
8 NHS Continuing Healthcare reviews 24
9 Challenging an eligibility decision 24
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9.1 Submitting a request for a review of the decision 24
9.2 Review process 25
10 Refunds if NHS should have paid for your care 27
11 Retrospective reviews 28
12 Care planning if you have a negative Checklist 28
13 Effect on benefits of NHS CHC funding 29
14 NHS-funded nursing care 29
14.1 How is eligibility for NHS-funded nursing care decided? 30
14.2 NHS-funded nursing care payments 30
14.3 Review of NHS-funded nursing care needs 31
14.4 Admission to hospital or a short stay in a nursing home 32
15 Glossary 32
Useful organisations 34
Age UK 35
Support our work 35
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1 Recent developments
⚫
The NHS-funded nursing care single band rate for the year starting 1
April 2024 is £235.88 a week. If you moved into a nursing home before 1
October 2007 and are on the high band, it is £324.50 a week.
⚫
December 2023 The Department of Health and Social Care published
guidance: Dealing with requests for an assessment of previously
unassessed periods of care from 1 April 2012. This looks at whether
people should have received NHS CHC for past periods of care.
2 Continuing care terminology
Health and social care professionals use these terms to describe support
from the NHS and local authority social services department.
NHS Continuing Healthcare – a complete package of on-going NHS
and social care support, arranged and funded by the NHS.
Continuing NHS and social care - ongoing care package involving free
NHS services and means-tested social care services. It may be called a
‘joint package of care’.
Terminology and abbreviations used in this factsheet
Residential home - a residential care home
Nursing home - a care home registered to provide nursing care.
We use ‘care home’ in this factsheet to refer to both, unless
referring to a nursing home specifically.
NHS CHC - NHS Continuing Healthcare
NHS-FNC - NHS-funded nursing care
DST - Decision Support Tool
ICB - Integrated Care Board
LA - local authority
MDT - multidisciplinary team
PG - practice guidance
3 NHS Continuing Healthcare
If you have significant ongoing care needs, it is not always clear whether
responsibility to meet your needs lies with the NHS or local authority.
The Department of Health and Social Care National Framework for NHS
Continuing Healthcare and NHS-funded nursing care standardises the
process staff in England must follow when deciding this.
NHS services are free at the point of delivery, whereas those arranged
by a local authority social services department are subject to a financial
assessment, meaning you must usually pay a contribution.
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3.1 What is NHS Continuing Healthcare?
NHS CHC is an ongoing package of care that is funded solely by the
NHS, if you are aged 18 or over, and found to have a ‘primary health
need’. It is provided to meet needs arising because of disability, accident,
or illness.
Your package must meet your assessed health and associated social
care needs and include accommodation if that is part of your overall
need. You can receive NHS CHC in any appropriate setting, but it is
usually at home or in a residential setting such as a care home.
Sections 3.2 and 3.5 describe the process staff must follow to reach a
decision. ‘Primary health need’ is explained in section 3.3.
3.2 What is the National Framework?
The National Framework for NHS Continuing Healthcare and NHS-
funded nursing care applies in England. It contains:
⚫
the eligibility criteria, principles and processes staff must follow when
deciding eligibility for NHS Continuing Healthcare. See sections 4, 5, and
7
⚫
the tools staff must use and complete to support decision-making – the
Checklist Tool, Decision Support Tool (DST) and Fast Track Tool. See
sections 5.1, 5.3 and 7
⚫
common paperwork – the tools above must be used for recording
evidence that informs decision-making
⚫
the process for challenging eligibility decisions. See section 9
⚫
clarification of the interaction between assessment for NHS CHC and
NHS-FNC. For information on NHS-FNC, see section 14.
The Framework document also includes numbered Practice Guidance
(PG) in Q&A format, to support staff who assess and deliver NHS CHC.
Standing Rules Regulations and Directions underpin the Framework and
carry the force of law. To view the updated guidance and associated
tools, see www.gov.uk/government/collections/nhs-continuing-
healthcare-and-nhs-funded-nursing-care
Understanding the decision-making process
The organisation Beacon can help you navigate and understand the
decision-making and appeals process. They offer up to 90 minutes free,
independent advice funded by NHS England. It is helpful to be familiar
with the Checklist and DST, especially if you or a family member is to be
present when they are used.
The flowchart on page 7 outlines the overall process of the assessment
for NHS CHC. A public guide to NHS CHC is available at
www.gov.uk/government/publications/nhs-continuing-healthcare-and-
nhs-funded-nursing-care-public-information-leaflet
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3.3 How is NHS CHC eligibility decided?
An NHS CHC eligibility decision is based on your day-to-day needs. It
rests on deciding whether the main aspects, or the majority part, of the
care you need is focused on addressing and/or preventing health needs.
If it does, it means you have a ‘primary health need’.
Having a particular diagnosis does not determine eligibility - people with
the same health condition can have very different needs. There is no
requirement for specialist staff to be providing care. However, staff
contributing to your assessment must have relevant skills, knowledge
about and an understanding of your underlying condition(s).
The term ‘primary health need’ is from a 1999 Court of Appeal case
known as Coughlan Judgment. The judge found there was a limit on
nursing care assistance an LA could legally provide when, taken as a
whole, nursing or other health services you require are:
⚫
no more than incidental or ancillary to the provision of the care and, if
required, accommodation which an LA is, or would be but for your means
(income/capital), under a duty to provide (the ‘quantity test’), and
⚫
not of a nature beyond which an LA, whose primary responsibility is to
provide social services, could be expected to provide (the ‘quality test’).
When considering NHS CHC eligibility, staff look at key characteristics
of your needs in 12 areas in the DST, and their impact on the care you
require. This is to help determine whether the care you require exceeds
the limits of a local authority’s responsibilities. The 12 areas are listed in
section 5.3.
The key characteristics are:
Nature - the type and features of your needs - physical, psychological or
mental - and type of support or treatment needed to manage them.
Intensity - relates to the severity of your needs, how frequently and to
what extent they vary, and the resulting level of support required.
Complexity - how different needs present and interact with each other to
increase the knowledge and skills staff need to a) monitor symptoms
b) treat any multiple conditions; and how this affects management of
your care. Staff also look at your response to your condition and how it
affects your overall physical and mental health.
Unpredictability – how much, how often and how unexpectedly
changes in your condition create challenges because of the timeliness
and skills required to manage needs that arise. It can affect the level of
monitoring required to ensure you and others are safe and the level of
risk to you or others, unless you receive adequate, timely care.
Each of the characteristics may on their own, or in combination,
demonstrate a ‘primary health need’ because the quantity, the quality, or
a combination of the quantity and quality of care required to meet your
needs, exceeds the limits of an LA’s responsibilities.
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Stages in the process to decide eligibility for NHS CHC
Review needs after 3
months then at least
every 12 months.
May need to
reconsider eligibility
Individual possibly eligible for NHS CHC
FAST TRACK
recommendation
by appropriate
clinician
ICB actions
request and care
arranged, ideally
within 48 hrs
Explain process and sources of
support, and provide written
information
Complete CHECKLIST involving
Individual /their representative
Write to individual explaining
checklist outcome.
Not eligible for next stage.
Can ask ICB to reconsider.
Eligible for next stage:
Full needs assessment + DECISION
SUPPORT TOOL (DST)
Appoint NHS Co-ordinator. Identify
assessment information required for
consideration at multidisciplinary
team (MDT) meeting. Invite
individual / their representative to
participate.
MDT assesses needs, completes DST
and makes recommendation
ICB verifies MDT
recommendation
Individual /
representative
sent written explanation of
decision and completed DST .
Where necessary information
on how to appeal decision
Not eligible: care
planning discussion to
agree how to meet
needs. Means test
Eligible: care planning,
discussions to agree
care package to be
fully funded by ICB
Review Needs after 3 months then at
least every 12 months . Ask for
reconsideration of eligibility if needs
change /increase
Has rapidly
deteriorating
condition
Yes
Could individual benefit
from further NHS
Services??
Arrange services then review
progress.
Ask ICB to
reconsider
CHECKLIST
outcome
If still unhappy
can use NHS
complaints
process
Full health and social
care assessment to
identify eligible needs
then care planning /
means test.
No
:
• Local process then
• Independent Review
• Ombudsman
If you want to appeal
then
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3.4 Who decides NHS CHC eligibility and funds your care?
From 1 July 2022, the NHS structure changed. Integrated Care Systems
(ICS) became statutory bodies. These are partnerships of NHS bodies
and local authorities, working with other relevant organisations to deliver
joined up health and care services. Each ICS has an Integrated Care
Board (ICB) which is responsible for the commissioning of services
including NHS CHC and NHS FNC.
3.5 Routes to reaching an NHS CHC decision
In most cases, once long-term needs are clear, staff follow these steps:
⚫
They consider whether the type and level of your needs prompts them to
apply the Checklist, which can lead to a positive or negative decision. In
some cases, staff believe you should go straight to a full assessment.
⚫
A positive Checklist triggers a full assessment of your needs.
⚫
A multi-disciplinary team (MDT) conducts an assessment and then uses
that information to complete a DST that informs their eligibility
recommendation to the ICB.
⚫
The ICB makes the final eligibility decision and they should follow the
MDT recommendation, unless exceptional circumstances apply.
You have a right to challenge the ICB if you receive a negative Checklist
decision, or on receiving a final decision following a full assessment. If
you have a rapidly deteriorating condition and may be reaching the end
of your life, staff can submit the ‘Fast Track Tool’, see section 7.
3.6 Getting an assessment
ICBs should agree, with their LA(s), processes to identify who may be
eligible. Not everyone with on-going health needs is likely to be eligible.
If it is clear to health and care staff that there is no current need for NHS
CHC, there is no need to complete the Checklist. Staff should record
their decision not to complete one, with reasons (Framework para 121).
If there is doubt between practitioners, they should complete the
Checklist. Be sure to ask staff if they have considered NHS CHC when:
⚫
your condition is rapidly deteriorating and you may be approaching the
end of your life. You may be eligible for ‘fast tracking’
⚫
staff are considering your needs following a stay in hospital
⚫
your physical or mental health deteriorates significantly and your current
level of care, at home or in a care home, seems inadequate
⚫
staff propose you move into a nursing home; or if you already live in a
nursing home, when they conduct your annual review of NHS-FNC.
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4 National Framework principles
4.1 Person-centred approach involving you and your carers
Staff should tell you if they think you may be eligible for NHS CHC. They
should ensure you and your representative understand the process and
provide information and advice to maximise your ability to participate in
an informed way. This includes asking about language preferences and
meeting Accessible Information Standard requirements, by for example
addressing hearing or visual difficulties and supporting you to participate.
Staff should take account of how you view your needs, how they affect
you and how they might be managed. You can ask a family member or
representative to support you or ask about access to local advocacy
services. You should have reasonable notice of key events, such as
dates to complete the Checklist or DST, so your representative can
arrange to participate.
If you are eligible for NHS CHC, staff should take account of your wishes
and ways you would prefer to be supported when deciding where and
how to meet your needs, as well as the risks of different care packages
and fairness of access to local NHS resources.
The Framework PG 4 explores key elements of a person-centred
approach to NHS CHC.
Note
A note to para 71 of the Framework states the term ‘representative’
is intended to include any friend, unpaid carer or family member
who is supporting you in the process as well as anyone acting in a
more formal capacity (for example, a welfare deputy, an attorney or
an organisation representing you).
4.2 Seeking consent to the assessment process
Staff must provide relevant information about the assessment so that
you can make an informed decision regarding your participation in the
process, including potential consequences of refusing to participate
(para 75). The ICB can proceed with an assessment without consent.
However, valid consent must be obtained and recorded for any physical
intervention or examination required as part of the assessment process,
and for the sharing of personal information with third parties such as a
family member, friend or advocate. They should record your consent
prominently in your notes or using a consent form.
It is not necessary to seek consent to share personal data with other
health and care professionals, but staff should explain with who and how
your information might be shared as part of the assessment or to
arrange appropriate care and support.
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Refusing or withdrawing consent
At any stage, you can refuse to give or withdraw consent to participate in
any physical examination or to the sharing of personal data with third
parties other than health or care professionals. If you do, staff should try
to find out why and address your concerns.
They must explain that refusing consent may affect the ability to meet
your needs. If you later agree to an LA assessment, the LA cannot take
responsibility for meeting needs found to be an NHS responsibility.
4.3 Consent and mental capacity
From the outset, staff must take all practical steps to help you make
decisions for yourself.
If they have concerns about your mental capacity to give informed
consent to participate or to a physical examination or to the sharing of
personal information, even with support, they should use the two stage
test described in Mental Capacity Act 2005 Code of Practice:
Stage 1 Is there an impairment of, or disturbance in, the functioning of
your mind or brain? If so, see Stage 2.
Stage 2 Is the impairment or disturbance sufficient that you lack the
capacity to make the particular decision required?
You are considered unable to make the decision if the answer to these
questions is ‘yes’ and you cannot do one or more of the following:
⚫
understand information given to you
⚫
retain that information long enough to be able to make the decision
⚫
weigh up the information and make a decision
⚫
communicate your decision – talking, sign language or muscle
movements such as blinking or squeezing a hand are acceptable.
If staff agree you lack mental capacity to do this, they must record their
reasons in your notes. They must check if there is someone appointed to
act on your behalf on health and care matters under a valid and
applicable Lasting Power of Attorney (LPA) or as a court appointed
personal welfare deputy.
To confirm a person has the authority to consent to a physical
examination or information sharing on your behalf, staff should request
sight of a certified copy of the documentation. A partner, family member
or third party can only consent on your behalf, if appointed to do so.
If there is no such individual, the person leading your assessment is
responsible for making a ‘best interests’ decision on your behalf as to
whether to proceed with the assessment and sharing of information.
In doing so, they must consult you and those with a genuine interest in
your welfare, usually including family and friends.
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They should be mindful of the need to respect confidentiality and not
share personal information about you with third parties, unless they
believe it to be in your ‘best interests’ for the purposes of NHS CHC
assessment.
4.4 Confidentiality and sharing information
Staff must share health and care information with an attorney with a valid
and registered LPA (health and care) or a court appointed deputy
(personal welfare). Family members or carers should have information
relevant to their caring role.
Sharing information in the absence of formal authority
When deciding whether to share personal or clinical information with a
family member or someone chosen to represent you, the information
holder must act within the following principles:
⚫
any decision to share information must be in your ‘best interests’
⚫
only share information necessary for them to act in your ‘best interests’.
Subject to these principles, staff should not unreasonably withhold
information.
PG 8.7-8.9 provides the following examples where it is acceptable for a
third party, who assumes responsibility for acting in a person’s ‘best
interests’ but does not have formal authority of a LPA or deputyship on
health and care matters, to legitimately request and receive information:
⚫
someone making care arrangements who requires information about
your needs to arrange appropriate support
⚫
someone with LPA (Finance), deputyship (Finance), or registered
Enduring Power of Attorney seeking to challenge an eligibility decision,
or other person acting in your ‘best interests’ to challenge a decision.
Any information shared must be in their interests, or to enable a third
party to act in the person’s best interests.
With this in mind and with regard to confidentiality, information should not
be unreasonably withheld.
Note
An attorney or deputy for property and financial affairs does not
have the authority to give consent or make health and welfare
decisions. See Framework PG 8.
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5 Process for reaching an eligibility decision
5.1 Apply the Checklist
Once long-term needs are clear, the Checklist helps identify who needs a
full assessment to determine eligibility, with the threshold set deliberately
low, so anyone requiring a full assessment has the opportunity. As per
section 3.6, there is no need to complete a Checklist if staff agree there is
no evidence that you have a need for NHS CHC at that time.
Note
A decision to apply the Checklist does not imply you should or will
be eligible for either a full assessment or NHS CHC. If professionals
disagree about the need for a Checklist, they should complete one.
Who can apply the Checklist?
Health and care professionals trained in its use can complete the
Checklist. This could include, for example, a social worker, GP or
registered nurse. As far as possible, it should be someone who assesses
or reviews care needs as part of their day-to-day work. Staff should give
you reasonable notice of the intention to complete the Checklist, so that
you or your representative have the opportunity to participate if you wish
to. Your ICB is responsible for ensuring that the checklist is completed.
Applying the Checklist as part of hospital discharge
Staff are not required to complete a checklist or DST in an acute setting.
In most cases, screening is likely to take place after a period of recovery
following discharge.
To ensure timely discharge from hospital, consideration should be given
to whether there is a need for further NHS funded services. This might
include therapy, rehabilitation, intermediate care or an interim package of
care, which should continue until an eligibility decision has been made.
ICBs should ensure there are processes in place to identify people who
may require an NHS CHC assessment prior to their discharge, so that
screening can take place at an appropriate time once discharged.
Applying the Checklist if you live in a care home
A care home manager should ensure they contact the ICB CHC team if
they believe you may be eligible for NHS CHC. The ICB may have its
own procedure for identifying and assessing care home residents.
Applying the Checklist if you live in your own home
NHS or social care staff should contact their ICB CHC team to arrange a
Checklist, if they think you may be eligible for NHS CHC. Community
based staff may be trained to complete the Checklist.
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Can you or a family member complete the Checklist?
You or a family member cannot complete and submit a Checklist. If NHS
or social services staff are involved in your care, discuss your
observations on, or changes to, your care needs with them and ask they
contact the ICB for you. Or contact the ICB CHC team to explain why
you think a Checklist is necessary. Find the contact details of your local
ICB at www.nhs.uk/nhs-services/find-your-local-integrated-care-board/
Completing the Checklist Tool
The Checklist Tool and the DST uses 11 ‘domains’ or ‘areas of need’
(see section 5.3 for details of the domains). The Checklist has three
columns for each domain – A, B, C. The description in column A
represents a ‘high’ level of needs; in column B a ‘moderate’ level of
needs; and in column C ‘no and low’ needs.
The assessor completes the Checklist by choosing the description most
closely matching your needs and should take account of well-managed
needs. The Framework discusses well-managed needs in paras 162-166
and PG 23.
Checklist outcome
You require a full assessment if the Checklist shows:
⚫
two or more domains rated as high, or
⚫
five or more domains rated as moderate, or
⚫
one domain rated as high and four rated as moderate, or
⚫
high in one of four DST domains with a priority level of need and any
level of need in other domains.
Staff should share the outcome with you and your representative as
soon as reasonably practical in writing, giving reasons for reaching their
decision.
A positive Checklist
A positive Checklist means you require a full assessment and should be
referred to your ICB, but it does not indicate eligibility. In most cases, it
should take no more than 28 calendar days from the date the ICB
receives a positive Checklist to reaching an eligibility decision. ICB
staff should tell you and your representative if it is likely to take longer.
While awaiting a decision, you should not be left without appropriate
support. You may have to pay for this support unless you are to receive
NHS-funded interim care as part of your discharge from hospital.
If you pay for services while awaiting decision, are later found to be
eligible and the ICB unnecessarily takes longer than 28 days to reach its
decision, you can apply for reimbursement of services paid for beyond
the 28 days. See Annex E of the National Framework for more details.
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A negative Checklist
A negative Checklist indicates you do not need a full assessment and
are not eligible for NHS CHC. The ICB should ensure that you are sent a
written explanation of the decision, explaining your right to ask them to
reconsider it.
When reconsidering, the ICB must take account of additional information
you or your representative provides. You should receive a written
response explaining the right to use the NHS complaints procedure, if
dissatisfied with their final decision.
See factsheet 66, Resolving problems and making a complaint about
NHS care, for more information about making a complaint.
If a review of a negative Checklist does not alter the decision
You should have an assessment of your care needs to identify your
eligibility for social care support and any care from NHS staff, see
section 12 for more information.
5.2 The multidisciplinary assessment
On receiving a positive Checklist, the ICB appoints a case co-ordinator
who is responsible until a decision on funding is made. They should
ensure you and your representative understand the process, participate
as much as you can and want to, and keep you informed at each stage.
The case co-ordinator identifies and secures the involvement of the
multidisciplinary team (MDT) who will complete the DST.
Multidisciplinary team (MDT)
The Framework defines an MDT as comprising of at least:
⚫
two professionals from different health professions, or
⚫
one professional from a healthcare profession and one responsible for
assessing individuals for community care services.
As a minimum, it can be two professionals from different healthcare
professions. It should usually include health and social care
professionals, knowledgeable about your health and social care needs
and where possible, recently involved in your assessment, treatment or
care.
If the ICB consults the local authority, it should provide advice and
assistance and not allow your financial circumstances to affect its
participation.
The Framework does not exclude the case co-ordinator from being an
MDT member, but they should be clear about their two different
functions.
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Your and your representative’s role at MDT meeting
The co-ordinator should explain the meeting format and identify support
you or your representative need to be fully involved. If no one can attend,
the co-ordinator should obtain your evidence and views. The Framework
says, ‘it is important the individual’s view of their needs, including
supporting evidence, is given appropriate weight alongside professional
views.’ (para. 145).
ICB’s may use a number of approaches to arrange an MDT assessment
e.g. face to face or video conferencing. This decision should be made
using person centred principles and to enable active participation of all
MDT members. They should give reasonable notice of the date, so your
representative can arrange to participate if they wish.
The DST has space to record how you contributed, and if you were not
involved, whether you were not invited or declined to participate.
5.3 The Decision Support Tool (DST)
It is helpful to familiarise yourself with the DST. It has the same 11
‘domains’ as the Checklist, with an additional ‘other’ domain or area of
need that staff must consider when completing it:
1 Breathing ►►
2 Nutrition ►
3 Continence
4 Skin integrity ►
5 Mobility ►
6 Communication
7 Psychological and emotional needs
8 Cognition ►
9 Behaviour ►►
10 Drug therapies and medication ►►
11 Altered states of consciousness ►►
12 Other significant care needs to be taken into consideration ►
Each domain has descriptions of between four and six levels of need:
‘No need’ ‘low’ ‘moderate’ ‘high’ ‘severe’ ‘priority’
The different levels also reflect changes in the nature, intensity,
complexity, or unpredictability of the need. See section 3.3 for more
information on how these levels should be assessed.
►► indicates this domain goes up to ‘priority’ level of need
► indicates this domain goes up to ‘severe’ level of need
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Completing the DST
The DST is not an assessment in its own right. It is a tool for recording
your needs in each of the 12 care domains.
When completing the DST, an MDT should:
⚫
complete all domains with information about your care needs
⚫
use assessment evidence and professional judgement to select the level
most closely describing your needs
⚫
choose the higher level and record any evidence or disagreements if
they cannot decide or agree the level
⚫
consider interactions between needs and not marginalise needs because
they are successfully managed. Well-managed needs are still needs,
and should be recorded appropriately (DST para 31-32)
⚫
consider needs recorded in domain 12 - Other significant care needs.
The completed tool should give a comprehensive picture of your needs
that captures their nature, complexity, intensity and unpredictability, and
the quality and quantity of care required to manage them.
The DST has space to record your or your representative’s views on
your care needs and whether you consider the assessment and selected
domain levels accurately reflects them. This is to ensure the ICB is
aware of your views when making its final decision.
5.4 Reaching a decision
MDT recommendation to the ICB
The MDT must make a recommendation as to whether you have a
primary health need and are therefore eligible for NHS CHC. They
should take into account the range and level of your needs, including
their nature, intensity, complexity and unpredictability; evidence from risk
assessments; and if and how needs in one domain interrelate with
another to create additional complexity, intensity or unpredictability.
The recommendation should refer to all key characteristics, but any
characteristic can on its own, or in combination with others, be sufficient
to indicate a primary health need. Clear recommendation of eligibility
is usually expected if you have either:
⚫
priority level of need in any domain with priority level (see page 15), or
⚫
two or more instances of severe needs across all care domains.
A primary health need may also be indicated if there is either:
⚫
one domain recorded as severe, together with needs in a number of
other domains, or
⚫
a number of domains with high or with moderate needs.
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Whatever recommendation the MDT makes, it must be supported by
clear, evidence-based reasons. It is not possible to equate incidences of
one level of need with those of another level, for example two moderates
do not equate to one high.
Dementia
The Alzheimer’s society has a guide about approaching the NHS CHC
assessment specifically for people with dementia. The guide provides
tips and advice about how to prepare for the assessment.
For a copy of the guide, see www.alzheimers.org.uk/get-
support/publications-and-factsheets/booklet-when-does-nhs-pay-care
The ICB’s decision
An ICB is usually expected to respond to MDT’s recommendation
within two working days and only in exceptional circumstances go
against it. In such circumstances, the ICB should refer back to the MDT
to address any issues, for example are there gaps in supporting
evidence, or an obvious mismatch between evidence and
recommendation (see PG 39).
The ICB may share its decision with you verbally but should always
confirm in writing, giving clear reasons for the decision and a copy of the
completed DST. It should tell you who to contact for clarification and how
to request a review of the eligibility decision, if they decide you are not
eligible. Someone appointed to act as your representative is entitled to
receive a copy of the DST provided the correct basis for sharing such
information has been established (see DST para 43).
Note
An eligibility decision is not permanent. It can be overturned if needs
change and they no longer meet the ‘primary health need’ threshold.
Use of a panel
Panels are not a required part of the decision-making process. ICBs can
use them to ensure consistency and quality of decision-making, but they
should not play a financial gate-keeper role. If the ICB and LA disagree
about your eligibility, they may use a panel as part of their local dispute
resolution process.
If a person dies while waiting for an eligibility decision
If you die while waiting for an eligibility decision and were receiving
means-tested services that could have been funded through NHS CHC,
the ICB must complete the decision-making process and where
necessary, arrange appropriate reimbursement. If you were not receiving
such services, there is no need to continue the decision-making process.
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5.5 Joint package of health and social care
The ICB may decide you are not eligible for NHS CHC but because
some of your needs are beyond the powers of an LA to meet on its own,
the ICB is responsible for some of your care. In this case, the LA and
ICB must agree their respective responsibilities for a joint package of
health and social care.
They should tell you who will lead in agreeing, managing and reviewing
your care plan. They must also explain whether the ICB contribution
affects how much you pay towards the social care element of the
package, which is subject to a financial assessment.
6 Care planning when eligible for NHS CHC
If you wish, you can ask family members to help you make your views
known or you can ask about local advocacy services instead.
6.1 Your care package and options
The ICB that decides your eligibility is responsible for providing a care
package appropriate to meet your eligible health and care needs, taking
account of goals or outcomes you want to achieve. These should be
identified in your care plan. The funding must be sufficient, wherever it
agrees you may live. Your ICB or care provider should not ask you to pay
towards meeting your assessed needs.
The ICB should tell you who to contact with any concerns and who is
responsible for monitoring your care and arranging regular reviews.
If the ICB agrees you can live outside its area, it remains responsible for
care associated with meeting your NHS CHC needs. Once in your new
area, you must register with a GP. Arranging NHS services unrelated to
your NHS CHC, is the responsibility of your new GP practice and ICB.
Your care package can be provided in a range of settings:
Own home
If funding your care at home, the ICB must fund and, if asked, arrange a
package to meet your identified health and personal care needs.
Funding does not cover rent, mortgage, food and normal utility bills. If
running specialist equipment adds substantially to utility bills, an NHS
contribution may be appropriate.
If you lived at home before becoming eligible for NHS CHC, you may
have had direct payments from the LA. The ICB should aim to arrange
services to maintain a similar package of care and replicate, as far as
possible, the personalisation and control of direct payments.
You can ask for, and the ICB should offer, a Personal Health Budget
unless there are clinical reasons why it is not suitable. See section 6.3.
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Family member provides care as a part of your care package
If a ICB agrees to a home-based package and a family member or friend
is an integral part of delivering your care plan, the ICB should identify
and meet training needs to help them carry out this role.
In particular, the ICB may need to provide additional support to care for
you whilst carers have a break from caring responsibilities and to assure
them such support is available when required. This could mean you
receive additional services at home or spend a period of time away from
home (for example, in a care home).
If your carer provides, or is about to provide, informal care for you, they
have a right to a separate carer’s assessment from the LA and have
eligible needs met to support them in their caring role. See factsheet 41,
How to get care and support, for more information.
Care home
Your ICB is responsible for meeting the cost of your accommodation and
care needs identified in your care plan. If a care home is the preferred or
best option, you should be offered a reasonable choice of care homes,
wherever possible. Issues to be aware of, include:
⚫
ICB has block contracts with several care homes in an area. There
may be reasons, based on your assessed needs, why an ICB should
consider more expensive homes or accommodation than it usually does.
Examples include a recognised link between feeling confined in a small
room and displaying behaviour that challenges those caring for you.
⚫
Your current care home cannot meet your assessed needs. You
need to discuss your options with the ICB.
⚫
It may be appropriate to move to a home closer to relatives who live
in a different ICB area. You cannot assume reasons you give will be
accepted. If the ICB agrees you can live in a care home in another ICB
area, they remain responsible for your care home fees.
⚫
Your current care home can meet your NHS CHC needs but is more
expensive than the ICB normally pays to meet similar needs. This
can arise if you were a self-funder before being eligible for NHS CHC or
a relative paid a ‘top up’ to meet your preferred home’s costs which were
higher than your local authority would normally pay. Social care
legislation allows for ‘top ups’, whereas NHS legislation does not.
When reviewing your current accommodation, the ICB should explore
why you want to stay there or keep your room and consider if there are
clinical or needs-based or risk-related reasons for doing so. Reasons
might include your frailty, mental health needs, or needs that mean a
move could involve significant risk to your health and wellbeing.
The Framework discusses paying for higher cost services in paras 303-
314.
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Hospice
Staff should take account of your wishes and preferences when deciding
the setting and location of your care. Hospice care may be appropriate if
you are reaching the end of your life.
If you want to move to another ICB area at a later date
If you receive NHS CHC at home and want to move to accommodation
outside your ICB area, raise this with your funding ICB in plenty of time.
It needs careful discussion between your current ICB and the ICB who
would be responsible for providing NHS CHC services after you move.
Both will want to ensure continuity of care, that arrangements represent
your best interests, and associated risks are identified.
Moves in the UK
If you want to receive care in Wales, Scotland, or Northern Ireland,
regardless of setting, there needs to be discussion between your funding
ICB and the relevant health body in your chosen country.
6.2 If you lack capacity to consent to a care plan
An ICB or LA must instruct, or consult, an Independent Mental Capacity
Advocate (IMCA) to act on your behalf if:
⚫
it must make a ‘best interests’ decision involving an accommodation
change, hospital admission over 28 days, or other accommodation for
more than eight weeks, or serious medical treatment, and
⚫
you have no family member or friend willing and able to represent you or
be consulted while reaching such a decision.
An IMCA aims to find out your views, wishes and feelings by talking to
you, people close to you and professionals who know you. Staff must
use an IMCA report to help reach a best interests decision and an IMCA
can challenge a decision if it appears not to be in your best interests. An
IMCA must be involved in these circumstances, even if you are not
eligible for NHS CHC. For more information, see factsheet 22, Arranging
for someone to make decisions on your behalf.
6.3 Personal Health Budgets and NHS CHC
Anyone receiving NHS CHC has the right to have a Personal Health
Budget (PHB) with the expectation it will be provided, unless there are
clear clinical or financial reasons why it should not.
What is a personal health budget?
A PHB is an amount of money you can spend to support your identified
health and wellbeing needs and goals. It is not new money but can mean
spending this money in a way that better suits you. It cannot be used
simply to pay care home fees.
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It is expected someone who chooses to have a care package at home
will have a PHB. If you do not, contact your care manager to find out how
it could work for you and about ways you could spend an allocated
budget. You will never be asked to have more choice and control over
your care or your money than you feel comfortable with.
You (or someone who represents you) and your NHS team discuss and
agree a care and support plan describing how you would like to meet
your goals and spend allocated money. Staff sign it off once satisfied the
goods or services you intend to purchase can meet your health and
wellbeing needs and the budget is sufficient to do this.
You can ask your NHS team to review and update your plan because
your health or care needs have changed, or you feel the current plan is
not working for you.
A care manager keeps your care plan and PHB management under
review.
You can manage a PHB in one of three ways or in combination:
⚫
notional budget – the ICB holds the money, but you are actively
involved in choosing who delivers your care and support
⚫
third party arrangement – an organisation such as a trust holds the
money and manages your care and budget in line with your care plan
⚫
direct payment – money is transferred to you or your nominee or
representative, who contracts for necessary services or expenditure.
Using a direct payment to manage PHB
The PHB direct payments scheme is broadly similar to that offered by a
LA for social care. In some areas, the NHS and LA are working
cooperatively to support the delivery of PHBs.
For more information, see factsheet 24, Personal budgets and direct
payments in social care.
Some practicalities
Speak to your care manager to discuss your options and find out what
support is available if you choose to have a PHB:
⚫
is there a brokerage service to help you manage your care and PHB?
⚫
if you opt for direct payments, is there a representative or suitable
nominee who can take on full responsibility for this?
⚫
would another way of managing your PHB prove to be a better option?
⚫
if you lack capacity to consent to or manage a direct payment, is there
someone who can take on the responsibilities of your direct payment?
If you take the direct payment option, your care manager can explain the
duties placed on you or the nominee or representative acting on your
behalf.
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You may consider employing a personal assistant to help manage your
health, care and wellbeing needs. This means understanding the
responsibilities of being an employer such as:
⚫
how to recruit a personal assistant and arrange necessary training?
⚫
how to pick the right staff and arrange cover for holidays or sickness?
⚫
payroll duties (this can be outsourced to a payroll company)
⚫
do you need to pay into a pension scheme for a personal assistant?
A PHB direct payment must be paid into a bank account specifically set
up for this purpose and held in the name of the person receiving it. You
may need guidance on managing the budget and keeping records on
what you spend money on.
If you are refused a direct payment, are asked to pay back any money,
or the ICB wants to bring the arrangement to an end, you are entitled to
a review of the decision and if unsuccessful, you can use the NHS
complaints procedure to try to resolve the problem.
Note
For more about PHBs see www.nhs.uk/using-the-nhs/help-with-
health-costs/what-is-a-personal-health-budget/
6.4 If unhappy with your NHS CHC care package
If you are unhappy with issues such as the type, location or content of
the care package being offered, the ICB should explain your right to
complain using the NHS complaints process.
Making an effective complaint
Key points to consider:
⚫
Be clear what your complaint is about – explain what you think is wrong
with the current care package and how you are affected by it.
⚫
Be clear about what you want to achieve by making a complaint –
explain what changes you would like to see and why.
⚫
State that you are making a formal complaint – this makes it clear that
you expect them to respond in line with their complaints policies and
procedures.
⚫
Keep to the point- avoid giving details that distract from the main issues.
Try to be polite and keep to relevant details.
For more information, see factsheet 66, Resolving problems and making
a complaint about NHS care.
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7 The Fast Track Tool
As there are various end-of-life care pathways, not everyone at the end
of their life is eligible for, or requires, NHS CHC. However, if you have:
⚫
a rapidly deteriorating condition, and
⚫
may be entering a terminal phase
you may be eligible for fast tracking for prompt provision of NHS CHC,
with no requirement to complete the DST.
Staff caring for you in any setting who believe that your needs are
appropriate for the Fast Track pathway should contact an ‘appropriate
clinician’ and ask them to consider completing the Fast Track Tool.
An ‘appropriate clinician’ is a doctor, nurse or specialist in end of life care
knowledgeable about your health needs, diagnosis, treatment or care
and able to provide an assessment of why you meet Fast Track criteria.
The ICB should accept a Fast Track recommendation and staff should
promptly action it, so that a suitable care package is in place, preferably
within 48 hours. The Tool should be supported by a prognosis, but the
ICB should not impose strict limits basing eligibility on a specified,
expected length of life remaining.
When developing your care package, staff should ask if you have an
advance care plan and take account of your expressed care preferences
and wishes. For example, if you live in a residential home and want to
remain there rather than move to a nursing home, staff should make
every effort to enable this to happen, if it is clinically safe and within the
home’s terms of registration.
Staff should sensitively explain your needs may be subject to a review
and as a result, the funding stream may change.
Exceptionally, there may be circumstances where a ICB does not believe
the form, as completed, meets Fast Track criteria. In this case, the ICB
should urgently ask the relevant clinician to clarify the nature of your
needs and the reason for the use of the Fast Track Pathway Tool.
Review of Fast Track decision
If you are fast tracked, it is important to review your care package to
make sure it continues to meet your needs. In doing so, there may be
situations where it is appropriate to review your NHS CHC eligibility (see
paras 266-267 for when it may not be appropriate).
In such cases, a ICB should not remove Fast Track funding without
reconsidering your eligibility. It should arrange for an MDT to complete a
DST and make their eligibility recommendation.
If the ICB proposes a change in funding responsibility, it should tell you
and give reasons in writing and explain your right to request a review of
the decision. You may wish to contact Beacon for support in this
situation.
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8 NHS Continuing Healthcare reviews
Reviews are a normal part of the NHS CHC process. They should be
proportionate to the situation and primarily focus on whether the care
plan arrangements remain appropriate to meet your needs. In most
cases, it is expected there will not be a need to reassess for eligibility
(para 203).
Reviews should take place within three months of the initial eligibility
decision, but the timing may be affected by the MDT recommendation.
After this, a review should take place at least annually.
When undertaking reviews, staff must ensure they do not misinterpret a
situation where your care needs are being well-managed, as instead
being a reduction in your actual day-to-day care needs.
Eligibility should only be reviewed if the ICB can demonstrate there is
clear evidence that needs have changed significantly since completing
the previous DST. If the ICB believes this, it should arrange for an MDT
to complete a new DST and make their eligibility recommendation.
Staff should consider risks and benefits of a change in location or
support (including funding) before any move or change is confirmed.
During this time, the ICB must ensure your needs continue to be met.
You may want to contact Beacon for support in these circumstances.
Even if the ICB is responsible for all support, it should involve the LA in
the MDT/DST process. The ICB and LA should support a decision to
remove eligibility and if they disagree, use their local disputes procedure
to resolve it.
If they agree you are no longer eligible, the ICB should put any proposed
changes in writing, with reasons, telling you from which date it proposes
to implement the decision. Alternative funding arrangements must be put
in place to ensure continuity of care before CHC funding is withdrawn.
You have a right to request a review of the ICB decision, as described in
section 9.
9 Challenging an eligibility decision
9.1 Submitting a request for a review of the decision
To challenge a decision following a full assessment and completion of
DST, you or your representative have six months, from the date you
received written notification of the decision, to ask the ICB for a review. It
should acknowledge your request in writing within five working days and
explain the appeal process.
Depending on the local appeals process there may be other steps with
more limited deadlines to adhere to, so it is a good idea to ask about
their processes prior to submitting your request. You can contact Beacon
if considering whether to appeal.
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Composing your letter
Explain the reasons for your challenge, supporting it with as much
evidence as you can. Where possible, relate it to DST domains. If you
believe you should have been placed at a higher level for a particular
domain, give examples from your experience or refer to a report you
believe the DST did not capture. You can also highlight any gaps in
evidence supporting the decision, or failures to follow the Framework.
Funding your care once you challenge the ICB decision
The ICB’s original decision remains valid and in place unless, or until,
either stage of the review process recommends you should be eligible.
You should receive appropriate care while awaiting the outcome of the
review.
You may have to contribute towards the cost of your care package during
this time, with your financial circumstances affecting who is responsible
for arranging and paying for it. If you are responsible for funding some,
or all, of it and your appeal is successful, you can claim costs incurred if
you provide receipts (See section 10).
9.2 Review process
There are two stages in the review process:
⚫
a Local Resolution (LR) managed by the ICB, and
⚫
an Independent Review managed by NHS England (NHSE) if unhappy
with the local review outcome.
NHSE has discretion to put your case straight to independent review, if
having LR would cause undue delay. The review process is only related
to if you are dissatisfied with the ICB’s ‘primary health need’ decision, or
the procedure the ICB followed to reach the eligibility decision, including
application of eligibility criteria.
Local Resolution stage
The ICB should publish a local resolution process with timescales, that is
fair and transparent. This must take account of the following guidelines:
⚫
There should be an attempt to informally resolve any concerns through
meaningful discussion between you or your representative and a ICB
representative. You should be able to ask questions to help you
understand the decision and provide information not already considered.
⚫
If a formal meeting is required, it should involve a ICB representative
with authority to decide what the next steps should be and allow you to
explain why you are still dissatisfied. It should result in a written record of
the meeting for both parties, including the agreed next steps.
⚫
Following this meeting and outcome of next steps, the ICB either
upholds or changes its decision. It should share its decision with you in
writing and explain how, if still dissatisfied, to apply for an independent
review.
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Independent Review stage and timescales
You have six months after hearing the final outcome of the local
resolution to ask NHSE, in writing, for an independent review.
NHSE is responsible for arranging an independent review panel (IRP).
They can decide not to convene one on the advice of an independent
individual who can chair a panel. It may decide to ask the ICB to attempt
further local resolution prior to review. If NHSE decides not to convene
an IRP, it should write explaining the reasons and your right to use the
NHS complaints procedure if you disagree with their decision.
Role of the Independent Review Panel and your contribution
The IRP has a scrutiny and reviewing role. There is no need for you or
the ICB to be legally represented at panel, although you may wish a
family member, advocate, or advice worker to represent you. If you want
advocacy support, your ICB should have details of local services.
The panel has a chair, independent of the NHS, and panel members,
who are experienced health and social care professionals and who are
independent of the ICB making the eligibility decision.
At the meeting, you can explain why you are appealing, based on points
raised in your letter, and answer the panel’s questions. You can speak to
Beacon to discuss how to prepare your case for the meeting.
The National Framework, Annex D, explains IRP procedures.
Key elements of an Independent Review
The key elements of an Independent Review include:
⚫
scrutiny of all available and appropriate oral or written evidence from
relevant health and social care professionals, from you or your
representative, and from the completed DST and MDT deliberations and
audit of any attempts to gather records said not to be available
⚫
involving you or your representative as far as possible, giving you an
opportunity to contribute to, and comment on, information at all stages
⚫
access to independent clinical advice to advise on clinical judgements.
Independent Review Panel recommendation
The IRP role is advisory and in all but exceptional circumstances, NHSE
and subsequently the ICB should accept its recommendation. NHSE
should tell you and the ICB of the decision in writing.
If the ICB decision is overturned, it should refund the cost of services you
have paid for since their ‘not eligible’ decision.
If the ICB decision is upheld and you still disagree, their letter should
explain how to refer your case to the Parliamentary and Health Service
Ombudsman. You should do this within 12 months of receiving written
notification of the outcome of the review.
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10 Refunds if NHS should have paid for your care
You only become eligible for NHS CHC once the ICB has reached a
decision informed by completion of the DST or Fast Track Tool. Annex E
of the Framework describes situations when you may be entitled to a
refund and explains what happens if a ICB eligibility decision is:
⚫
unjustifiably delayed beyond 28 calendar days, or
⚫
revised after reconsideration using the ICB local review process or IRP.
You may be entitled to a refund if a retrospective review shows you
should have been considered for NHS CHC, you are assessed and thus
found eligible.
When you incur costs due to unjustifiable delay in decision-making
If the ICB finds you are eligible but ‘unjustifiably’ takes longer than 28
calendar days from receiving the Checklist to reach its decision, it should
refund the costs of services provided from day 29 to the date of the
decision to the LA. The LA should reimburse contributions you made
towards your care.
As a self-funder, the ICB should make an ex-gratia payment to restore
your finances to the state they would be in, had the delay not occurred
and to remedy any injustice arising from the delay.
Examples of ‘justifiable’ delays include delay in receiving records or
assessments from a third party; delays outside the ICB’s control; or
delay in receiving a response from the individual or their representative
asking for essential information or for participation in the process.
Refunds following a revised decision
If the ICB revises its initial decision, it should reimburse to the LA any
care costs the LA incurred, starting from the date of the ICB’s initial
decision (or earlier if unjustifiable delay occurred) until date the revised
decision came into effect.
The LA should reimburse any contributions you made to the cost of your
care. As a self-funder, the ICB should, in line with guidance in Managing
Public Money, make an ex-gratia payment with aim of restoring your
finances to state they would have been in, if a correct decision was
reached at the outset.
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11 Retrospective reviews
If you think you should have been considered for NHS CHC but were
not, you can request a review of a previously unassessed period of care
(PUPoC) from your local ICB CHC team. The PUPoC guidance applies
to periods of care after 1 April 2012, ICBs will only consider periods of
care before this date in exceptional circumstances. If seeking a review in
respect of a deceased relative, the ICB may require evidence to prove
you are entitled to any money that may be forthcoming.
Refunds following a retrospective review
A PUPoC assessment may show you were eligible for NHS CHC during
the period under consideration. If so, and you were funding your care in
part or in full during this time, the ICB should reimburse you, restoring
you to the financial position you would have been in had CHC eligibility
been agreed at the appropriate time.
See www.gov.uk/government/publications/continuing-healthcare-
previously-unassessed-periods-of-care
12 Care planning if you have a negative Checklist
If you do not progress beyond the Checklist stage, and staff did not ask
at the outset to carry out CHC and social care assessments at the same
time, they should ask if you would like a Care Act 2014 assessment, to
identify your ongoing social care needs.
Subject to meeting specific eligibility criteria, your needs and views on
how they can best be met form the basis of your care and support plan.
If you require services that are the responsibility of social services, these
are means-tested. However, you should not be asked to pay for aids
needed to assist with home nursing or daily living or for a minor
adaptation that, with fitting charges, costs £1000 or less.
If you do not meet eligibility criteria, social services should provide
information and advice on how you could meet your care needs.
NHS services are free and can be provided on a regular or ad-hoc basis.
They include:
⚫
NHS-funded nursing care in a nursing home (see section 14)
⚫
rehabilitation and recovery services such as physiotherapy
⚫
assessment and support from community-based NHS staff such as
district nurses, continence nurses, mental health nurses
⚫
palliative care services (emotional support and control of symptoms,
including pain management) if diagnosed with a terminal illness or
nearing end of life.
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13 Effect on benefits of NHS CHC funding
Disability benefits
You should notify the Disability Benefits Centre if you get a disability
benefit - Attendance Allowance (AA), Disability Living Allowance (DLA) or
Personal Independence Payment (PIP) and are awarded NHS CHC.
If you receive NHS CHC in a nursing home, AA and both components
of DLA and PIP are suspended after 28 days from when ICB funding
begins, or sooner if you were recently in hospital.
If you receive NHS CHC in a residential home, AA and the care
components of DLA and PIP are suspended after 28 days from when
ICB funding begins, but DLA or PIP mobility components continue.
If you live at home with an NHS CHC care package, you can continue
to receive these disability benefits. Check you are receiving them at the
appropriate level.
The rules can be quite complex so seek advice if unsure about the effect
of NHS CHC on these benefits.
State Pension and Pension Credit
State Pension is not affected by eligibility for NHS CHC.
However, if you receive Pension Credit, you lose the severe disability
addition if payment of AA, DLA care component, or PIP daily living
component stops.
14 NHS-funded nursing care
NHS-funded nursing care (NHS-FNC) is a fixed rate payment. It is made
directly to a nursing home by the local ICB, to support the provision of
nursing care by the home’s registered nurses to those residents
assessed as eligible for NHS-FNC.
If you move from a nursing home in one ICB area to one in another ICB
area, the new ICB is responsible for making NHS-FNC payment to the
home.
Residential homes do not employ registered nurses, as residents receive
necessary nursing care from NHS nurses based in the community, such
as district nurses. Consequently, these homes are not paid NHS-FNC.
Registered nurse input includes time spent on stand-by, paid breaks,
receiving supervision and time spent in circumstances ancillary to or
closely connected with nursing care.
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14.1 How is eligibility for NHS-funded nursing care decided?
If staff propose your best option is to move into a nursing home, they
must consider your eligibility for NHS CHC and agree that you are not
eligible, before considering eligibility for NHS-FNC. If you are found to be
not eligible at the Checklist stage, and so did not have a full NHS CHC
assessment, you must have a nursing needs assessment to identify your
day-to-day nursing care and support needs.
You are eligible for NHS-FNC if you are assessed as having such a
need, and it is decided your overall needs would most appropriately be
met in a nursing home.
For information, see NHS-funded nursing care practice guidance
www.gov.uk/government/publications/nhs-funded-nursing-care-practice
14.2 NHS-funded nursing care payments
NHS England reviews NHS-FNC weekly rates annually, usually in April.
The following rates apply for the year starting 1 April 2024.
If you moved into a nursing home on or after 1 October 2007, you are on
the single band of nursing care and the weekly rate is £235.88. If you
moved into a nursing home before 1 October 2007 and were on the high
band in place at the time, the weekly rate is £324.50.
If placed on the high band in 2007, you stay on it until no longer resident
in a nursing home; or become eligible for NHS CHC; or a review finds
you no longer need nursing care; or your nursing needs no longer match
high band criteria, in which case you transfer to the single band rate.
FNC and care home fees
If self-funding your nursing home place, ask them to explain how your
fees take account of NHS-FNC payments. Check your contract for
details of the fees you must pay, including if FNC rate changes. You may
not be entitled to a refund of fees already paid if FNC payments rise.
The NHS-funded nursing care practice guidance says:
‘The care home with nursing provider should set an overall fee level for
the provision of care and accommodation, and share this with whoever is
contracting the service. This should include any registered nursing care
supplied by the provider.
Where an ICB assesses that the resident’s needs require the input of a
registered nurse, they will pay the NHS-funded nursing care payment (at
the nationally agreed rate) direct to the care home with nursing to meet
that need, unless there is an agreement in place for this to be paid via a
third party (such as a local authority). The balance of the fee will then be
paid by the individual, their representative or the local authority unless
other contracting arrangements have been agreed.’ (para. 59).
Age UK factsheet 20 July 2024
NHS Continuing Healthcare and NHS-funded nursing care Page 31 of 36
The Local Government and Social Care Ombudsman has guidance for
nursing homes about NHS-FNC payments and ensuring contracts
properly reference them, see www.lgo.org.uk/information-
centre/news/2018/feb/ombudsman-offers-practical-guidance-on-
contracts-for-social-care-providers
The Competition and Markets Authority looked at FNC payments in a
study into care homes for older people. They publish a guide Care
homes: consumer rights for residents and their families, see
www.gov.uk/government/publications/care-homes-short-guide-to-
consumer-rights-for-residents
Effect on disability benefits
NHS-funded nursing care payments do not affect eligibility for AA or
DLA, if you are self-funding. However, it may affect your PIP award, and
you may need to seek further advice if in this situation.
14.3 Review of NHS-funded nursing care needs
The NHS FNC guidance says you should have a review within three
months of the original NHS-FNC eligibility decision being made, and
usually at least annually after that.
When reviewing your need for NHS-FNC, staff must always consider
your potential eligibility for NHS CHC. This may involve completing the
Checklist or where indicated, carrying out a full NHS CHC assessment,
including completion of the DST.
However, it is not necessary to repeat the Checklist or DST:
⚫
if staff reached their initial not eligible for NHS CHC decision following a
Checklist or full assessment with completion of a DST, and
⚫
it is clear there has been no material change in your needs.
If staff reach this decision, they should record it in your notes, tell you of
their decision and the reason for it.
To determine whether there has been a material change in your needs,
staff should review the previously completed Checklist or DST and
consider each domain and level of need, involving you or your
representative or someone who knows your care needs.
The assessor should annotate each domain according to their findings,
advise you of their findings, and provide a copy of the annotated tool.
They should tell you how to request a review of the outcome, if you
disagree with the finding that no material change in needs has occurred.
If staff complete a new Checklist and it indicates a full assessment is
required, an MDT should be appointed, the DST completed, and the
normal decision-making process followed.
Age UK factsheet 20 July 2024
NHS Continuing Healthcare and NHS-funded nursing care Page 32 of 36
14.4 Admission to hospital or a short stay in a nursing home
If you are admitted to hospital, the home does not receive funded
nursing care payments during your hospital stay. The NHS-FNC
guidance says ICBs should consider paying a retainer to help safeguard
residents’ nursing home place while they are in hospital.
If you go into a nursing home on a temporary basis for a period of
less than six weeks, you qualify for the NHS-funded nursing care
payment.
There is no need for a nursing needs assessment if the stay is for less
than six weeks and you have already been assessed for nursing care in
the community. This may apply if you have a trial period in a home or are
admitted for respite care or in an emergency because your carer is ill.
15 Glossary
• Checklist: screening tool used to determine whether you need a full
assessment for NHS CHC.
• Decision Support Tool (DST): assessment tool completed by the
Multidisciplinary Team to help determine an eligibility
recommendation for NHS CHC.
• Domains: twelve areas of need or domains considered when
assessing eligibility for NHS CHC, see section 5.3.
• Fast Track Tool: process to enable people who have a rapidly
deteriorating condition that may be entering a terminal phase to
access NHS CHC quickly, not requiring the completion of the DST,
see section 7.
• Funded Nursing Care (FNC): a fixed payment made directly to
nursing homes to support the provision of nursing care by the homes
registered nurses, see section 14.
• Integrated Care Boards (ICB): Responsible for the commissioning
of NHS services in their local area, responding to the needs of their
populations.
• Joint packages of care: may be offered if you are not eligible for
NHS CHC but the care you need is beyond the power of the LA to
meet on its own. The LA and the ICB must agree their respective
responsibilities.
• Key characteristics: are considered by staff completing an
assessment for NHS CHC, includes nature, intensity, complexity and
unpredictability, see section 3.3.
• Local authority: responsible for services in a particular area,
includes social services.
• Multidisciplinary Team (MDT): team made up of different disciplines
who complete the DST assessment tool, see section 5.2.
• NHS Continuing Healthcare (CHC): a complete package of on-
going NHS and social care support arranged and funded by the NHS.
Age UK factsheet 20 July 2024
NHS Continuing Healthcare and NHS-funded nursing care Page 33 of 36
• NHS CHC National framework (2022): sets out the principles and
processes staff must follow when deciding eligibility for NHS CHC,
including the paperwork to be completed.
• Nursing care home: care home registered to provide nursing care.
• Person centred: placing the person at the centre of the assessment
and planning processes by seeking their views throughout.
• Practice Guidance (PG): guidance to support staff in the delivery of
NHS CHC, part of the national framework.
• Primary health need: the main aspects or the majority part of the
care you need is focused on addressing and/or preventing health
needs.
• Residential care home: a care home not registered to provide
nursing care.
• Top ups: usually paid by a third party where you choose a more
expensive care home out of preference not need. This is permissible
under social care legislation but not under NHS legislation.
Age UK factsheet 20 July 2024
NHS Continuing Healthcare and NHS-funded nursing care Page 34 of 36
Useful organisations
Alzheimer’s Society
www.alzheimers.org.uk
Telephone helpline 0333 150 3456
Provides information and offers support to people, their families and
carers affected by any type of dementia.
Beacon
www.beaconchc.co.uk/
Telephone 0345 548 0300
Offers free and paid for services, including up to 90 minutes of
independent advice about the NHS CHC assessment and appeals.
Competition and Markets Authority
www.gov.uk/government/organisations/competition-and-markets-
authority
Telephone 020 3738 6000
Produces guidance for care homes on complying with consumer law.
Disability Service Centre
www.gov.uk/disability-benefits-helpline
• Attendance Allowance (AA)
Telephone 0800 731 0122
• Disability Living Allowance (DLA)
If you were born on or before 8 April 1948
Telephone 0800 731 0122
If you were born after 8 April 1948
Telephone 0800 121 4600
• Personal Independence Payment helpline
Telephone 0800 121 4433
Office of the Public Guardian
www.gov.uk/government/organisations/office-of-the-public-guardian
Telephone 0300 456 0300
Supports and promotes decision-making for those who lack capacity or
would like to plan for their future under the Mental Capacity Act 2005.
Parliamentary and Health Service Ombudsman
www.ombudsman.org.uk
Telephone 0345 015 4033
Can look into your complaint if dissatisfied following an IRP decision
about NHS CHC eligibility as well as complaints about NHS care.
Age UK factsheet 20 July 2024
NHS Continuing Healthcare and NHS-funded nursing care Page 35 of 36
Age UK
Age UK provides advice and information for people in later life through
our Age UK Advice line, publications and online. Call Age UK Advice to
find out whether there is a local Age UK near you, and to order free
copies of our information guides and factsheets.
Age UK Advice
www.ageuk.org.uk
0800 169 65 65
Lines are open seven days a week from 8.00am to 7.00pm
In Wales contact
Age Cymru Advice
www.agecymru.org.uk
0300 303 44 98
In Northern Ireland contact
Age NI
www.ageni.org
0808 808 75 75
In Scotland contact
Age Scotland
www.agescotland.org.uk
0800 124 42 22
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Age UK factsheet 20 July 2024
NHS Continuing Healthcare and NHS-funded nursing care Page 36 of 36
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Next update July 2025
The evidence sources used to create this factsheet are available on
request. Contact [email protected]
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