Does Dementia Qualify for NHS Continuing Healthcare Funding?

Whether or not an individual suffering from dementia will qualify for NHS Continuing Healthcare Funding is not straightforward.

The simple answer is that the diagnosis of any medical condition, including dementia, is not enough for NHS Continuing Healthcare Funding (also called CHC Funding) to be awarded. That’s because eligibility is not assessed on the medical condition alone, but the level and type of care required to meet that person’s health care needs.

Dementia can come in various forms, such as Alzheimer’s, Lewy Body Dementia and Vascular Dementia. There are varying forms of severity and it can affect people in vastly different ways, and so, therefore, their care needs will be different.

This means that some people who are suffering from dementia may be assessed as having a Primary Health Need, whereas others may not.

For a discussion with no obligation please call our Care Home Fees Solicitors.

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Assessing a Person’s Healthcare Needs

The National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care* sets out the guidelines for whether a person is eligible for CHC Funding to be awarded.

There are a couple of key points to address here:

  • An individual is eligible for CHC Funding if they have a Primary Health Need
  • The term Primary Health Need can be interpreted in different ways. A person might have a condition where their primary need is for healthcare, which can be provided for by the NHS. A different person might have a condition where their primary need is better suited to care through social services

Paragraph 55 of the National Framework states:

“Having a Primary Health Need is not about the reason why an individual requires care or support, nor is it based on their diagnosis; it is about the level and type of their overall day-to-day care needs to be taken in their totality.”

To determine whether an individual has a Primary Health Need, there is an assessment process, which is detailed in the National Framework.

CHC Funding Assessment Process

Not all claims for CHC Funding will be successful, and the Department for Health sets out guidelines in terms of how a person’s care needs are assessed.

Although the assessment process and, indeed that of challenging a negative assessment decision is pursued under NHS process rather than through the Courts, having a specialist Care Home Fees Solicitor to advise you can often be the best course of action when dealing with this complex and time-consuming process.

The assessment process usually works like this:

  • Anyone involved in the patient’s care who understands NHS Continuing Healthcare should refer the patient for a CHC Funding eligibility assessment but this sometimes does not occur for a variety of reasons. If you want to make a claim for Continuing Care, then start by contacting your local Clinical Commissioning Group (CCG) for an assessment
  • An NHS Checklist will then be completed, which is effectively a screening tool to outline the specific needs of the patient. This determines whether those needs meet the threshold for full eligibility assessment
  • Once through to a full assessment, this will usually take place with a Nurse and a Social Worker who will complete the Decision Support Tool and recommend whether you are eligible. For more information see the UK government publication NHS Continuing Healthcare Decision Support Tool.

How Does Dementia Affect a Patient’s Needs?

Dementia can have a dramatic impact on an individual’s mental capacity and can lead to episodes of confusion, short and long-term memory loss and disorientation. It can affect other aspects of an individual’s needs, but being such a complex disease it can affect everybody in different ways.

Cognition and Communication

People suffering from dementia can become forgetful during a conversation or become repetitive with their words. It can be damaging to a person’s confidence if they are aware in the early stages that this is happening to them, and they may rely on carers to anticipate their needs. Dementia can lead to social isolation and loneliness and poses a severe risk to their emotional state.

Behaviour

One key aspect of CHC Funding assessment focuses on how challenging an individual’s behaviour is. The person may not fully understand the nature of their needs and may cause harm to others when in care. Their mobility might suffer and lead to falls, and coupled with memory loss this can be dangerous because they may forget they require the use of a mobility aid.

An individual may also refuse medication, not recognising the need for it and even challenging their carers over things like food intake.

Hygiene

A carer could be prevented by the individual from providing personal hygiene care, which can lead to all sorts of skin-related issues.

These are just some of the impacts dementia can have on an individual’s care needs. These needs will have several layers and can be very complex in the more extreme cases. The level of care may need to be intense, including the support of professionals such as a GP or the community mental health services, though the involvement of these services is not a prerequisite for needs to be deemed as intense.

If you would like to know whether your needs or those of a loved one, maybe sufficient to qualify for NHS Continuing Healthcare Funding, then get in touch with one of our Care Home Fees Solicitors for a free initial assessment.

We can carry out the time-consuming work involved in the CHC Funding assessment procedure, and with Simpson Millar representing you or your loved one, you’ll have an assurance that we can ensure your relative’s needs are met and funded appropriately.

Where possible, we will offer a No Win, No Fee agreement for your claim. We’ll be completely upfront about our costs from the very first discussion.

*See GOV.UK The National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care

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