Care Home Fees - FAQs

Frequently Asked Questions โ€“ NHS Continuing Care

NHS Continuing Healthcare โ€“ What is it?

It's a service arranged and funded by the NHS, for people outside hospital with ongoing health needs. These could be brought about due to physical or mental ill-health, or the result of disability or an accident.

Like all other NHS services, Continuing Healthcare is free and there is no means test. It can be provided in your own home or in a specialist, residential or nursing home setting.

In order to qualify you must be able to show that your main needs are health related needs. This is determined by the:

  • Nature
  • Intensity
  • Complexity, and
  • Unpredictability

of your health needs. However your health needs must be more than incidental or secondary to the provision of your accommodation and social care needs.

How is eligibility determined?

It is the responsibility of the Continuing Healthcare team of your local Clinical Commissioning Group to determine eligibility for NHS Continuing Healthcare.

This is usually a 2 stage process:

The 1st stage of the process is for a health or social care professional to complete a checklist. This is a way of screening claims to see who should be referred for a full assessment of needs.

If a full assessment is recommended then this will be done by a multi-disciplinary team who will use a 'decision support tool' to determine the full extent of your care needs. The decision support tool looks at both physical and mental health needs and should identify whether needs are complex, intense or unpredictable.

There is also a fast track process for anyone with a rapidly deteriorating health condition.

Copies of the checklist, decision support tool, and fast track tool can be here.

In order to qualify for fully funded NHS Continuing Healthcare, you must show that the majority of your care is focused on addressing or preventing health needs, and that the nursing care you need is more than incidental to the provision of your accommodation and social care needs.

What's the difference between Health Care and Social Care?

Social care is the help that you may need with personal care and the activities of daily living. This includes the provision of a safe and secure environment where someone is no longer capable of living independently in their own home.

Health care involves the treatment or prevention of an injury, disease or disability.

The distinction between health and social care is very blurred and is often the cause of dispute in determining eligibility for NHS Continuing Care. This is why it is important to seek clear, honest advice on where you stand, and the options available to you.

I have previously applied for NHS Continuing Care, but have been told that I do not qualify - Can I appeal?

If only a checklist has been completed and you have not been referred for a full assessment then you can only make a complaint and ask the Clinical Commissioning Group to look at the matter again. If they refuse to do so then your only recourse is to the Health Service Ombudsman.

If a full assessment has been undertaken by a multi-disciplinary panel, then your local Clinical Commissioning group will have a local disputes resolution procedure and through this you can ask for your case to be looked at again.

If you are still unhappy following a further review of your case, you can apply to NHS England and ask that your case be considered by an Independent Review Panel.

In certain circumstances, you may be able to appeal to the Health Service Ombudsman.

You should be aware that applications for reviews and appeals may be subject to separate time limits and usually need to be made within 6 months of the decision being made.

You may be able to bring an appeal after this time if there is a good reason for the appeal being late, or the NHS have not followed procedures, or given you bad advice.

Can I apply for my claim for NHS continuing Healthcare to be backdated?

This depends on the period of care you are claiming for.

Claims for periods of care between 1st April 2004 and 31st March 2012 were subject to deadlines imposed by the Department of Health in September 2012 and March 2013. If you have missed these deadlines then you can only make a backdated claim in exceptional circumstances.

These deadlines only apply however to unassessed periods of care and you may still be able to appeal against a refusal to grant funding. This may be worth looking into.

If you live in Wales then the deadlines do not apply.

Why are you providing this service? Do I need a solicitor?

The continuing healthcare process is very complex and bureaucratic. Many people find it helpful for someone to guide them through the process and to assist them in providing evidence to appeal panels.

We advise people of their right to seek assessment and funding and, where necessary, how to appeal against a decision.

It's not uncommon for people to find they've exhausted their funds, and many end up selling their home to pay for their care home or nursing home fees. We may be able to help reclaim some of this money or there may be alternatives to selling the family home.

Our independent financial advisers may also be able to provide advice on preparing for long term care costs.

Even if you're not eligible for Continuing Healthcare then we may still be able to offer you advice and assistance as we have a team of experienced lawyers and we can provide you with an all round advice service.

Simpson Millar LLP has always taken pride in representing those members of society who need and deserve help โ€“ the very reason why we're providing this service.

Call us now on freephone: 0808 129 3320 or email us using our Online Enquiry Form


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Janet Cooper - Care Homes Recovery Solicitor - Leeds/Gateshead

Janet Cooper
Head of Care Home Claims

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