PART 1 - PAYING FOR ADULT CARE
SECTION B - NHS FUNDING
In October 2007, the Department of Health produced new guidance that sets out a system for deciding eligibility for NHS Continuing healthcare and Funded Nursing care payments.
This is called the National Framework for NHS Continuing Healthcare and NHS-Funded Nursing Care (revised 2018) and it sets out the principles and processes for determining eligibility.
This was revised to reflect the new NHS framework and structures created by the Health and Social Act 2012 and effective from 1 April 2013, Primary Care Trusts (PCTs) had the legal duties for NHS Continuing Healthcare until 31 March 2013 but from 1st April 2013 these responsibilities transfer to Clinical Commissioning Groups (CCG’s). FIND A CLINICAL COMMISSIONING GROUP
COVID – 19 has led to Discharge to Assess pathways for Hospital Discharge with short term funding either at home or in a short term placement to enable ongoing care needs to be assessed.
Joint NHS and Local Authority Funding
If someone doesn’t qualify for NHS continuing healthcare, the NHS may still have a responsibility to contribute to that person’s health needs – either by directly commissioning services or by part-funding the package of support, this is known as a ‘joint package’ of care with both the Local Authority and the NHS contributing to the cost of the care package, or the Clinical Commissioning Group commissioning part of the package. Joint packages of care may be provided in a nursing or residential care home, or in a person’s own home. The overall aim of recent and future reform is to promote integrated Health and Social Care provision to provide a joined-up service which may include a single funding stream. From April 2015, older people should have a named GP.
Personal Health Budgets
Personal health budgets provide an amount of money to support someone with an identified health and well being need is planned and agreed between the person and their local NHS team. This enables people with long term conditions and disabilities to have greater choice, flexibility and control over the health care and support they receive.
Someone who is already receiving NHS Continuing Care will have a right to ask for a personal health budget from April 2014. Clinical commissioning groups will also be able to offer personal health budgets to others that they feel may benefit from the additional flexibility and control.
Section 117 (Mental Health Act 1983) – FREE aftercare
Services provided to someone discharged under this section are not chargeable, whether provided by health or social care.
CHAPTER 11 - FUNDED NURSING CARE PAYMENT
Since 2007 new awards have been at one rate, also known previously as the RNCC Registered Nursing Care Contribution which had 3 rates of payment. From 1st April 2021 the Funded Nursing Care Payment weekly rate will rise to £187.60 (2021/22)
FNC is another name for the RNCC which was paid at three different rates and for those who received the higher rate in 2007 this will increase from 1st April 2021 to £258.08. This is only relevant for people who were already on the higher rate in 2007 when the single band was introduced to support the provision of nursing care provided by a registered nurse.
Assessed by a nurse assessor from the clinical commissioning group it is not payable to a residential care home or to someone living in a registered nursing home without any nursing needs.
Claimed by and paid straight to the home please check whether the amount you are quoted for the cost of care is inclusive of the Funded Nursing Care Payment
The payment may take a while to process, check how it will be invoiced - will the home wait or does the whole cost need to be paid in advance and the FNC payment refunded or credited back to the resident?Can be paid for up to 6 weeks for temporary care before checklist for CHC must be considered
This is different from continuing healthcare/continuing care (CHC) and in all cases eligibility for NHS continuing healthcare should be considered before a decision is reached about the need for NHS-funded nursing care.
CHAPTER 12 - CONTINUING HEALTHCARE
Also known as continuing care or fully funded NHS care this is a package of care funded solely by the NHS for
people outside of hospital who have primary health and ongoing healthcare need.
This care is provided to people aged 18 or over, to meet needs that have arisen because of disability, accident,
Continuing Healthcare can be paid in ANY setting, including your own home or a care home and should be
The Clinical commissioning group that holds the contract with the GP practice responsible for care at the time of
application is responsible for deciding eligibility
Continuing Healthcare Process
The assessment of eligibility for NHS funding begins with consent. Consent can be given by an applicant with
assessed mental capacity or their legal representative (either a Lasting Power of Attorney for Health and Welfare
or a Personal Welfare Deputy appointed by The Court of Protection).
If capacity has been lost and no one has been appointed as above a ‘Best Interest’ decision should be made by
all involved, considering the five principles of the Mental Capacity Act 2005.
Best interest decisions
Five principles of the Mental Capacity Act 2005;
A presumption of capacity: A person must be assumed to have capacity unless it is established that they lack capacity.
Individuals being supported to make their own decisions: A person is not to be treated as unable to decide unless all practicable steps to help him or her to do so have been taken without success.
Unwise decisions: A person is not to be treated as unable to make a decision merely because he makes an unwise decision.
Best interests: An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his or her best interests.
Least restrictive option: Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action
For most people, there’s an initial checklist assessment, which is used to decide if it is appropriate to go onto a full assessment. However, if someone needs care urgently they should be assessed under the "fast track pathway"
The assessment process begins with the National Screening Continuing Healthcare checklist which can be carried out by a trained health or social care professional/care home manager.
If appropriate a full assessment follows the initial checklist screening and is done by a multi-disciplinary team using the Decision Support Tool.
In an acute hospital setting, the checklist should not be completed until the needs on discharge are clear. Discharge to Assess Pathways provide short term, funded support for discharge care at home (where appropriate) or another community setting to allow time for assessment of longer-term care and support needs to be undertaken in the most appropriate setting and at the right time for the person.
If a Checklist has been done with a positive outcome the CCG should continue funding care until the CHC decision made following an assessment
Comparing the domain descriptors to the needs of the individual, practitioners should select level A, B or C, as appropriate, choosing whichever most closely matches the individual.
A full assessment for NHS Continuing Healthcare is required if there are:
two or more domains selected in column A;
five or more domains selected in column B, or one selected in A and four in B; or
one domain selected in column A in one of the boxes marked with an asterisk (i.e. those domains that carry a priority level in the Decision Support Tool), with any number of selections in the other two columns.
If you disagree with a decision not to proceed to full assessment of eligibility for NHS Continuing Healthcare following completion of a checklist, you can ask the CCG to reconsider the decision.
The Decision Support Tool is used during a full assessment (where appropriate), following a positive Checklist. It is not an assessment in itself but a way of bringing together and applying evidence in a single practical format to provide an overview of the levels chosen and a summary of the person’s needs, used by the Multi-Disciplinary Team to make a recommendation to the CCG about eligibility or ineligibility
The primary health need should be assessed by looking at all the care needs and relating them to 12 care domains and four key indicators: Nature, complexity, intensity, and unpredictability
nature – the type of condition or treatment required (quality and quantity)
complexity - symptoms that interact; therefore, difficult to manage or control
intensity – one or more health needs, so severe they require regular intervention
unpredictability – unexpected changes in condition that are difficult to manage and present a risk to you or to others.
If someone’s condition is deteriorating quickly and they are nearing the end of their life, they should be assessed under the NHS continuing healthcare fast track pathway so that an appropriate care package can be put in place as soon as possible.
A terminal diagnosis does not automatically lead to continuing healthcare eligibility. The need may be primarily health and very high but if it isn’t intense, complex, or unpredictable it may not lead to an eligibility for continuing healthcare, PLEASE seek advice as this is an extremely complex area and at a time of crisis when the priority is not necessarily funding this can be overlooked or left unpursued.
It cannot be assumed that this funding is indefinite, regular reviews should be carried out, the first no later than three months after the initial decision, and then at least once a year subsequently.
If you disagree with the eligibility decision or if you have concerns about the process used to reach the decision, you can ask the clinical commissioning group to review the decision.
This is a complex area, if you are considering an appeal or an Independent Review Panel request please seek advice. FIND A CARE ADVISER
APPENDIX 6 – CODE OF GOOD PRACTICE
APPENDIX 7 - ADVICE TEMPLATE