Frequently Asked QuestionsHow do I know if I’m eligible?
If a person has health needs, there is no way of knowing if they are eligible for Continuing Healthcare until they have been through the assessment process to identify whether they have a primary health need. Individuals with a primary health need should, by law, have the cost of all their care needs met by the NHS, including social needs and accommodation. What is a Primary Health Need?
A person may a primary health need if the main aspects of their day-to-day care are focused on addressing or preventing health needs. The care needs should also be more than the local authority could be be expected to provide for. It doesn’t rely on any specific diagnoses of a health need, or the environment in which the person is being cared for. If I have a health need, does that mean I am eligible for NHS Continuing Healthcare?
No. Not everyone who has a health condition is eligible for funding – having a particular diagnosis certainly does not determine eligibility. NHS Continuing Healthcare eligibility focuses on the totality of a person’s care needs across 12 specific areas (domains), which are featured in two different assessment processes. If I have been told that my relative won’t qualify for funding but they have not been assessed, should I bother trying to get it?
If you believe that you or a loved one may have a primary health need, it is very important that you do not listen to anyone who tells you that you won’t qualify for funding. There is no way of knowing if a person is eligible for NHS CHC until they have been through the assessment process. If you believe that you or a loved one may have needs that are primarily health-related, over and above their social care needs, contact ARROW to discuss these. How does the assessment process establish eligibility for funding?
The assessment process examines the key characteristics of a person’s needs across these 12 care domains and evaluates the impact these have on their care. The key characteristics are based on the nature, intensity, complexity and unpredictability of an individual’s needs, and whether, primarily, the care they are receiving focuses on addressing or preventing these needs. The NHS assessment tools (known as the Checklist Tool and Decision Support Tool) give the health or social care professionals carrying out the assessments a standardised format in which to record details about individual's health needs. How is NHS Continuing Healthcare paid?
Continuing Healthcare is generally paid directly to the care provider by the NHS, but payments will be made via a Personal Health Budget (PHB), where care is being provided at home. The funding does not cover rent, mortgage, food or usual utility bills, but a contribution can be made towards substantially higher running costs of specialist equipment, if this is deemed appropriate. What is a Personal Health Budget?
Individuals who are eligible for Continuing Healthcare have the right to receive an allocated sum of money, known as a Personal Health Budget (PHB), to support their identified healthcare and wellbeing goals, which are planned and agreed between the individual (or their representative), and the Integrated Care Board (ICB). This gives individuals greater choice and control over who manages and provides their care, if they wish to be cared for at home. Can I still use a direct payment to manage my Personal Health Budget?
Individuals who have been in receipt of direct payments from the local authority towards the cost of their social care at home can still use a direct payment to manage their PHB. This means that the amount of money agreed in the individual's PHB will be transferred directly to individuals (or their nominee or representative), who will contract for the necessary services or expenditure. The ICB should aim to arrange services for individuals to a maintain a similar package to that previously offered by the LA for their social care. Can I use my Personal Health Budget to pay a relative to care for me at home?
Yes. It is not widely known that a family member can become their loved one's primary carer, but it is perfectly possible, and if the ICB agrees to a home-based package and a family member is an integral part to delivering the care plan, the ICB will identify and meet their training needs and will also provide paid cover, so that the family member has sufficient breaks away from caring responsibilities. Should my loved one always be assessed for NHS Continuing Healthcare before they are discharged from hospital?
No. Continuing Healthcare assessments rarely take place in acute hospital settings. The National Framework for Continuing Care stipulates that an assessment of longer-term or end-of-life care needs should take place once patients have reached a point of recovery, where it is possible to make an accurate assessment of their longer term needs. Do I need to hire a solicitor to help me secure NHS Continuing Healthcare?
The National Framework for NHS Continuing Healthcare specifies that individuals are entitled to nominate a person to represent their views or speak on their behalf. If you choose to have a solicitor acting as your advocate, the Framework states that ‘that person would be acting with the same status as any other advocate nominated by the individual concerned’ This means that if you engage a solicitor, they would be treated the same as any other advocate you might choose to represent you. The Continuing Healthcare eligibility process is focused around assessing a person’s needs, rather than it being a legal or adversarial process. This means that individuals do not need to have legal representation during the eligibility process and incur the expense that engaging a solicitor would entail. Having a specialist ARROW consultant to represent you, instead, would bring distinct advantages to fighting your case, at the fraction of the cost of legal representation. Are there any other companies that specialise in NHS Continuing Healthcare and what do they charge?
There are a number of companies, including legal firms, who offer representation and advocacy to individuals seeking to secure Continuing Healthcare. The fees they charge are variable, some offering hourly rates in the region of £250 per hour (citing 36 hours as a guideline for completing a case, so roughly £9000), while others offer a fixed rate for each part of the process but fail to tell you at the outset what the next set of charges will be. This gives the misleading impression that the first set of charges (in the region of £3000) will be all it takes to secure Continuing Healthcare. This is not true, due to the two-pronged nature of the Continuing Healthcare assessment process. Some solicitors also offer a ‘no win no fee’ service, which may seem ideal for peace of mind, but it is important to check what percentage of restitution they will be taking, if your case is successful, including VAT and interest. What are the Informal Review and Local Review stages?
A Informal Review At the start of the appeal stage, the local Integrated Care Board (ICB) dealing with your case should first attempt to resolve any concerns by holding an informal discussion between the individual who has been found ineligible for funding and/or their representative, and an ICB representative. Depending on the process followed by the local ICB, this is likely to involve a resolution meeting, in an attempt to resolve things, informally, without the need to take things to the next stage. If the CHC ineligibility decision is not overturned, individuals then have 6 months to lodge an appeal for a Local Review. On receiving a request for a Local Review, the ICB has 3 months from the date they receive the request to review the decision and complete the review. It is possible to bypass this stage, however, and for the matter to be taken straight to the Local Review stage. Local Review The next appeal stage is the Local Review stage. This is for individuals who are dissatisfied with the outcome of the informal review stage, or who decide to skip this step and take the matter straight to Local Review. Local Reviews are managed by the ICB. The Local Review is a formal meeting which provides individuals with the opportunity to explain why they are still dissatisfied. It is convened by ICB representatives with authority to decide what the next steps should be. The panel from the ICB generally consists of nurses and/or managers. They listen to your reasons for appeal and can alter the levels of need awarded on the DST, thus potentially changing the funding outcome to ‘eligible’. The Local Review should result in a written record of the meeting and include agreed next steps. I am unhappy with the outcome of the Local Review stage and want to appeal. Can you explain the process for an Independent Review Panel appeal?
Independent Reviews are the second stage of the Decision Support Tool Appeals mechanism. These are managed by the NHS Commissioning Board, NHS England (NHSE). NHSE must convene an Independent Review Panel (IRP) within 3 months of receiving the request. The panel consists of a Chair, who is independent of the NHS, and panel members who are experienced health and social care professionals. All panel members are independent of the Integrated Care Board (ICB) making the eligibility decision. The IRP provides individuals with the opportunity to explain why they are appealing, based on points raised in their letter, after which the panel will ask questions. It will also examine the ICB’s decision and the process followed, in case these are unsound. Preparation for the independent review is key, as the panel will scrutinise all relevant oral and written evidence available from health and social care professionals, including audits of any attempts to gather records which are unavailable. It will also examine the completed full Decision Support Tool assessment (DST) and deliberations from the Multidisciplinary Team meeting (MDT). The IRP will involve individuals and/or their representatives as far as possible, offering the opportunity to contribute and comment on information during all stages of the meeting. The panel of health and social care professionals will also be able to provide independent clinical advice based on clinical judgements made during the full assessment. Following the IRP, individuals will receive a full report from the IRP with its recommendation regarding eligibility. The IRP role is advisory but, in most circumstances, NHS England and subsequently, the ICB, should accept its recommendation. NHSE will inform individuals and the ICB of its decision in writing. If the ICB decision is overturned, individuals will receive a refund for the cost of care paid for from the date the ‘not eligible’ decision was made. If the decision is not overturned, the letter outlining the eligibility decision will explain how to refer cases to the third and final appeal stage, the Parliamentary and Health Service Ombudsman. What is the final appeal stage of an ineligible decision for Continuing Healthcare?
The third final stage of the appeal process is the Parliamentary and Health Service Ombudsman (PHS Ombudsman) stage. Appeals to the Ombudsman should be made within 12 months of receiving written notification of the outcome of the IRP review panel. Contrary to popular belief, the PHS Ombudsman cannot overturn the decision of the Board or the ICB to find you eligible, but it can investigate procedural irregularities or failings in the earlier assessment processes; the PHS Ombudsman would be able to examine, therefore, the manner in which the IRP responded to those irregularities and/or failings. Why have we been asked to attend a review of our relative's Continuing Healthcare funding?
Reviews are the part of the NHS CHC process. Around three months after the initial eligibility decision, individuals in receipt of funding will normally have a review to focus on whether the care plan in place remains appropriate to meet their needs. Following this, it is expected that a review will take place at least annually. In most cases, there is no expectation that there will be a need to reassess for eligibility; however, assessors must not misinterpret a situation where an individual’s care needs are being well-managed as a reduction in the need itself. A well-managed care need is still a need. However, in some cases, if the ICB can demonstrate that there has been a significant reduction in care needs since completing the previous DST, the ICB will arrange for a new MDT to complete a DST to make an eligibility recommendation. In these circumstances, it is advisable to contact Arrow CHC Consultants for advice and support. The ICB must ensure the individual’s needs continue to be met during this period, but it will normally involve the Local Authority in the eligibility decision at the new MDT DST meeting. Should both bodies support a decision to remove eligibility, the ICB will write to individuals telling them the reasons why they are no longer eligible and the date from which the changes will take place. Individuals should contact their Local Authority to see if they are eligible for financial support. If funding is removed, individuals have the right to request a review of the ICB decision. They can also argue that the NHS should continue to pay for care until their appeal has been heard and resolved. Funding cannot be legally taken away until a person's care needs have been reassessed in line with the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care and relevant case law. |
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