NHS Continuing Healthcare: Find out if you are entitled

What is NHS Continuing Healthcare?

People living with long-term primary healthcare needs may be able to get NHS Continuing Healthcare. 

This is funding, paid for by the local NHS Trust. It covers the cost of care support for your long term health needs.

The health needs must be classed as ‘complex’ to be eligible for NHS Continuing Healthcare.

The funding can be applied to care at home, or in a residential care setting. 

As the funding is related to your health care – rather than personal care – your financial status is not relevant. 

The particular health condition you have is also not necessarily relevant, nor how much time you spend in hospital.

What does NHS Continuing Healthcare cover?

There is no list of conditions that NHS Continuing Healthcare covers. 

Rather, qualifying criteria relate to how complex your care needs are. 

Crucially, the need must be a ‘primary health need’ rather than a social care need – sometimes the boundary between these can get a little blurry.

That’s why the difference between primary health needs and social care needs is tricky to pinpoint. 

Each individual case is assessed separately – there is no simple framework to fit into here, sadly.

The difference between primary health need and social care

Generally speaking, requiring support such as help with getting dressed or cooking, is considered a ‘social care need’. 

A person requiring oxygen or constant medication might come under the bracket of ‘primary health need’.

In essence, the complexity, unpredictability and intensity of health needs is what is assessed for NHS Continuing Healthcare.

Try to think of how much support the condition or illness needs, rather than what you in general need. 

How much worse would your health be if you were not in receipt of ongoing healthcare for the condition itself? 

How can I find out if I’m eligible?

A multidisciplinary healthcare team will assess your case to see if you are eligible for NHS Continuing Healthcare. 

They will look at all aspects of your health care needs.

They can assess how complex, intense and unpredictable your healthcare needs are, as well as what type or level of care you need. 

Risks to health by delaying healthcare will also be taken into account. 

For instance, if medication must be administered every six hours and missing a dose would be harmful, this may be classified as a risk of delayed care. 

It’s all about impact

It is important to note that a particular condition or illness does not qualify a person for NHS Continuing Healthcare. 

Rather, it is how that illness or condition impacts their life and care needs that is assessed. 

It is also important to note that, if you are currently not eligible, you might be if your needs change or worsen. 

Throughout the assessment, the person being assessed should be involved. Their needs should be taken into account by the assessment panel. 

Families and carers may also be asked for their input.

How long will it take to get funding?

Once you have applied for an initial or full assessment, a decision should be made within 28 days. 

Should you be found ineligible for NHS Continuing Healthcare, you may still be able to claim support from the local authority funding for care in your own home.

In some cases, a joint package of financial support might be proposed. This is where the NHS and local authority both pay something towards your overall care costs.

Why would I not be eligible for NHS Continuing Healthcare?

Having a particular condition or illness doesn’t always mean you will be eligible for funding. 

For instance, many people in the early stages of dementia care or those needing arthritis care, may be deemed to require social care initially. 

This precludes them from receiving NHS Continuing Healthcare at this stage of the condition.

‘Unpredictable’ related to dementia could mean several possibilities. 

For instance, someone might need frequent intervention to take medication. 

They may also need to be kept safe from their own actions.

Hallucinations, disorientation and becoming deeply confused, wandering into dangerous situations, and drastic mood swings could come under this category.

How much funding will I get?

The NHS will pay for any care you need to deal with your healthcare. This means that there is no cap on the funding. 

There is no way to gauge how much you might be eligible for.

However, your own financial status will not be taken into account. 

This is because the NHS is free at the point of use for everyone in the UK.

This funding is to cover your ongoing healthcare needs outside of a hospital, so comes under the same founding principal. 

This is different to local authority funding for care.

Council funding for care

Local authorities require a financial assessment before deciding on the level of financial aid they can give.

This might be for the provision of social or nursing care.

If your care is to service a medical need, be sure to check first for NHS Continuing Healthcare eligibility. 

Note that you are not expected, nor permitted, to privately ‘top up’ this care funding. 

All of your medical care costs will be covered by it. You should not be expected to pay for additional care pertinent to your condition.

You may of course pay other carers, should you wish. 

Home helps, cleaners, meals on wheels services – these may not necessarily be covered by continuing healthcare, depending on your needs.

Who does my funding assessment?

Your local Clinical Commissioning Group (CCG) is key to assessing how much, if any, funding you are eligible for. 

In essence, they decide who and what gets funding for their local NHS.

They make the decisions on how clinics, healthcare centres and hospitals are run. 

A multidisciplinary committee will look at each case individually. 

They will decide how much care each person’s condition requires, and how much funding to allocate for it. 

You will have a review of your funding after three months to make sure it is set at the right level. 

Thereafter, a yearly review will take place. You can ask for an earlier assessment if the care needs of the recipient have changed. 

What if the funds are insufficient?

What happens if you are accepted for funding, but you feel the offer falls short of the care you need?

Write to the Clinical Commissioning Group to explain why you feel the offer isn’t enough to cover your care.

You can also appeal a decision against offering you funding, should you feel you deserve it. 

Do apply for the funding before you go to your local authority. 

You or your local authority may not consider that you are eligible for this funding.

The CCG are the only people to decide if you are or are not.

How do I apply for NHS Continuing Healthcare?

Firstly, NHS Continuing Healthcare is not always well known through the social care structure. 

Healthcare professionals, social services and local authority employees may not have a good understanding of the funding. 

Asking a well-intentioned nurse or social worker may not give you the information you need.

It is a good idea to follow the below instructions for the best results.

If you are in hospital:

If you are in hospital, your first point of contact should be the ward consultant.

They will have daily rounds at which point you can ask to speak to them about further care. 

Feel free to ask them if they are trained in NHS Continuing Healthcare.

If they are, they can start the initial part of the assessment, known as the checklist, with you. This checklist looks at 11 key areas of your health.

If they are not familiar with the process, ask them to refer you to the NHS Continuing Healthcare team.

This team will be able to help you with the first lot of assessment paperwork you need to fill in.

If your ward consultant is too busy, or otherwise can’t help you, don’t give up. 

There is also a Patient Liaison and Advice service within hospitals who should be able to help. Alternatively, see the next section.

If you are not in hospital:

You do not need to be/have been hospitalised to be eligible for this funding.

If you are not in hospital but would like to find out your eligibility, first try your GP. 

Your district nurse may also know about the funding stream.

Either might be able to help you start the process of application. If they can’t, they can still refer you onto the NHS Continuing Healthcare team.

You may be able to go directly to your NHS Continuing Healthcare team at the CCG.

Check on the NHS website for the contact details of your local group. 

However, it is helpful to have a medical professional familiar with your needs on your side. Also, a referral is often helpful within healthcare settings. 

Don’t give up when you apply for funding

So there you have it, our overview of NHS Continuing Healthcare payments.

If you think you, or a loved one, may qualify for this payment do investigate further. 

It can feel a little daunting at first and you might have to make a few calls, but don’t give up and make sure you get what you are entitled to.

And check out our guide to financial benefits for elderly if you want to see what other funding may be available.

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