NHS Continuing Healthcare (CHC) Solicitors

What is CHC funding?

NHS Continuing Healthcare (CHC) is a non-means tested package of fully funded care at home or in a care home for individuals assessed as having primary health needs. Eligibility decisions are handled by the clinical commissioning groups (CCGs) in England.

Read on to learn more about who qualifies for CHC funding and the assessment criteria for primary health needs.

Who qualifies for NHS Continuing Healthcare?

To qualify for NHS Continuing Healthcare funding, you must be assessed as having a primary health need (i.e. you need care primarily because of your health, not due to personal or social care needs). The assessment typically involves two stages: an initial Checklist Assessment, then a Full Assessment to determine eligibility.

There are lots of myths surrounding NHS CHC funding. Not all people with care needs are eligible – the requirement for care must be due to a primary health need. Other factors that have no impact on a person’s eligibility include their diagnosis, the placement in which care is provided, the ability to manage care needs, and how well these needs are currently being managed.

The four characteristics or key indicators of a primary health need are:

1. Nature: the particular characteristics of your physical, mental, and psychological needs will be considered, along with the type of care required as a result of these needs (the care required must not be something that is normally provided for by social services).
2. Intensity: the frequency and severity of your health condition will be taken into account, as well as the support you require. The need for sustained or ongoing care is a key factor.
3. Complexity: considers how your needs present and interact with one or more other conditions, demanding greater skill to monitor symptoms, treat the condition(s), and manage care.
4. Unpredictability: refers to the degree to which your needs fluctuate, and the potential risk if a sudden change in your condition is not treated quickly and adequately. Those with rapidly deteriorating or unstable health conditions fit the criteria for unpredictability.

There is no strict legal definition of what does or does not amount to a primary health need. Your case must be argued and determined based on these four key indicators. This is where our experienced CHC solicitors can help you to achieve the right outcome and obtain funding. Get in touch today.

The CHC assessment process

If you or a family member are not automatically referred for an initial CHC assessment when a person develops long term care needs, then you can initiate the process by contacting the relevant clinical commissioning group (CCG).

Typically, the CHC assessment is a two-stage process involving:

1. A Checklist Assessment
2. A Full Assessment – the Decision Support Tool (DST) stage

A fast track pathway is also available for individuals with a rapidly deteriorating condition that may be entering a terminal phase. This assessment route is applicable if the person has an increased level of dependency and needs an urgent package of care. In some cases, this can take as little as 48 hours.

Get in touch with our team immediately if this could apply to you or a family member and we can expedite the process.

Checklist Assessment

The first stage of your CHC funding application is a checklist and acts as a screening process:

• Your needs are assessed in 11 healthcare domains: breathing; nutrition; continence; skin integrity; mobility; communication; psychological and emotional needs; cognition; behaviour; drug therapies and medication; symptom control, and altered states of consciousness.
• Your condition in relation to each of these healthcare domains is scored A, B, or C.
• If you meet any of the following criteria, you will pass the checklist and move through to a full CHC assessment using the Decision Support Tool (DST): two or more A Scores, one A score and four B scores, five or more B scores, or one score in a domain marked as a priority weighting.
• You cannot appeal against a negative checklist result, but you can follow the NHS complaints system to challenge the decision if you feel the checklist outcome is wrong.
• Alternatively, you can submit evidence to the CHC team dealing with the checklist setting out why you feel scored incorrectly.

It is not mandatory to use the checklist. It may be appropriate to move straight to the full assessment.

The Decision Support Tool (DST) stage – Full Assessment

If you pass the checklist stage, you will move on to a Full Assessment by a multidisciplinary team. At this stage, the Decision Support Tool (DST) will be used. The DST is used to apply and allocate scores in the care domains but also apply the primary healthcare indicators (nature, intensity, complexity, and unpredictability).

There would be a clear recommendation of eligibility to NHS CHC if there is: a level of priority needs in any one of the four domains that carry this level, or, two or more severe needs across all of the care domains. An eligibility decision may also be found if there is a severe in one domain together with needs in other domains, or several domains with a high or moderate need.After completing the DST, the multidisciplinary team will make a recommendation as to whether you have a primary health need.

CHC appeals

If you are assessed as being ineligible at this stage, you can submit a CHC appeal. However, it is advisable to seek legal support quickly. The time limit is generally 6 months from the date of the letter confirming ineligibility, although you should check that a shorter time period has not been imposed by the CCG.

It is highly recommended that you seek the advice and support of our specialist CHC solicitors prior to submitting your appeal. Our team can guide you through the process and assist you with making a persuasive case against the ineligibility decision. Contact us today.

Retrospective applications

You or a family member may have paid for private health and social care in the past without realising that CHC funding was available for those with primary health needs. If this applies to you, our specialist CHC solicitors can support you with making a retrospective Continuing Healthcare claim for any funds paid out after 1st April 2012.

In such cases, there will be a need to look back at the individual’s health condition and care requirements during the time when the care was privately financed and submit a Needs Portrayal Document (similar to the DST, but accounting for needs spanning several years). This process is likewise overseen by your local CCG, but due to the additional complexity involved it is recommended that you seek expert legal advice.

Reach out to our team of CHC solicitors for support with retrospective Continuing Healthcare claims.