Continuing Health Care (CHC) for adults

Eligibility

The government has set out a national framework which states eligibility should be based on someone’s healthcare needs and not their diagnosis. It is not linked to savings or income levels.

Visit the GOV.UK website to read the national framework for NHS CHC and NHS-funded nurse care here (opens in new window).

Many people who are assessed for CHC are reaching the end of their lives or face a long-term condition, because of a disability, accident or illness and have a wide range of healthcare conditions. This includes people with physical disabilities, learning disabilities, older adults with complex physical and psychological needs as well as young people transitioning from childhood to adulthood who become entitled to receive NHS CHC, if eligible, at the age of 18.

Assessments

The CHC assessment process involves an initial screening checklist followed by a full assessment. After the full assessment, a recommendation will be made to the Integrated Care Board about whether the person is eligible for CHC.

The initial screening is usually carried out by a health or social care professional who knows the individual and uses the checklist to decide whether people need a full assessment. The person who completes the checklist will send it to the CHC team.

The full assessment is usually carried out by a registered nurse and a group of health and social care professionals who have been involved in the patient’s care. In Derby and Derbyshire this assessment is led by staff employed by Midlands and Lancashire Commissioning Support Unit.

They will consider the person’s combined healthcare needs across 11 areas of need to complete an initial checklist and across 12 areas to undertake the full assessment.

The team will then make a recommendation to the Integrated Care Board about whether the person has a primary health need and is eligible and the Integrated Care Board will make the final decision.

If approved for CHC, patients will have their care needs reviewed after three months. This will then be followed by annual reviews to ensure the care provided is still relevant and providing the right support, and that CHC is still required.

Where a care needs review identifies a change in need and that CHC is no longer required, a full assessment will be planned with to determine ongoing eligibility of the patient.

Personal Health Budgets (PHB)

If you are eligible for CHC, you have the right to a Personal Health Budget (PHB). These allow more choice and control over the services and care you receive and can be used to pay for a wider range of items and services, including therapies, personal care and equipment.

A PHB is an amount of money to support your health and wellbeing needs, as agreed between you and your local NHS team.

You can find out more about PHBs on the NHS England website (opens in new window).

Your health and wellbeing needs will be set out in a personal centred care and support plan which will be developed by you together with a health care professional. 

Arrangements for managing this budget will be agreed between yourself / your representative and the CHC team.

PHBs support the vision of a more personalised, patient-focused NHS. NHS England’s website has more information and advice about the new scheme. Find out more about personal health budgets on the NHS website.

Currently, only individuals in receipt of NHS CHC have the right to have a PHB – although Integrated Care Boards can offer this to other groups if appropriate.

Derby and Derbyshire Integrated Care Board also offers non-CHC PHBs to any eligible adult or child. Check out our section on PHBs for more information.

Appealing a CHC eligibility decision

You can appeal against the outcome of a CHC assessment where a decision support tool has been completed when you:

• Disagree with the outcome of the decision support tool
• Do not consider the process used was in line with the national framework
• Do not consider the correct evidence was considered at the assessment.

Appeal requests must be received by the Integrated Care Board CHC service no later than six months from the date recorded on the outcome letter identifying non-eligibility for CHC funding. This time frame may be extended in exceptional circumstances.

Patients or their representative should write to Continuing Health Care Retrospective Review and Disputes (Appeals) Team, Midlands and Lancashire CSU, Jubilee House, Lancashire Business Park, Leyland, PR26 6TR

The purpose of our Local Resolution Appeals Process:

1. To establish that the patient had been comprehensively assessed to allow full consideration in respect of their care needs.
2. To establish that the procedures used in the original multi disciplinary team were compliant with those laid down in the National Framework for NHS Continuing Healthcare and NHS Funded Care.
3. To ensure that the application of the criterion within the National Framework has been properly and consistently applied.
4. To ensure this is a robust documentation in respect of the decisions made inclusive of the decision-making rationale.

Stage one of the appeals process is to attempt to resolve any concerns initially through an informal two-way meaningful discussion between the ICB representative and the individual and/or their representative. There will be a written summary of this for both parties. The discussion will be an opportunity for the individual or their representative to receive clarification of anything they have not understood. The ICB will explain how it has arrived at the decision regarding eligibility, including reference to the completed Decision Support Tool and primary health need assessment. Where required this will also be an opportunity for the individual or their representative to provide any further information that had not been considered.

Following this it may be necessary to proceed to stage two of the Local Resolution Process.

Stage two involves a formal meeting between the ICB the individual and/or their representative. To facilitate this, the ICB may require additional information, including records and reports. Once all the information has been gathered by the ICB the meeting will be arranged. The individual will be able to put forward the reasons why they remain dissatisfied with ICB’s decision. 

The outcome of the formal meeting will be communicated to the individual and/or their representative within 4-6 weeks of the meeting. The individual and/or their representative will receive a full record of the deliberations of the meeting. Clear and evidenced written conclusions on the process followed by the continuing health care team and on the individual’s eligibility for NHS Continuing Healthcare, together with appropriate recommendations on actions to be taken.

In the event you remain dissatisfied, stage three of the appeals process is that you are entitled to submit a request for an independent review to NHS England, which is the organisation responsible for the Independent Review Process to consider your case, this would need to be submitted in writing within 6 months of the outcome of Local Resolution Panel.

Part of the appeals process is that we will ask that you complete a consent form, doing this will enable the appeals team to request the relevant health and social care records for the appeal.

Should you require assistance or advice relating to the appeal process the following organisations can offer support:

• Healthwatch
• Age UK
• The Advocacy People – can provide you with support if you wish to make a complaint regarding the Continuing Healthcare process.
• A variety of third-party advocacy service can also offer support.

Whilst you have the right to seek legal advice or advocacy support, this should not be necessary and may incur a significant cost to yourself which the NHS will not reimburse.

If a Solicitor is appointed, it is important for them to be aware that the appeal meetings are not a legal process. Chairs of appeal meetings will not allow discussions to be held on points of law.

Fast-track to continuing health care funding

If your health is rapidly deteriorating and you may be entering the terminal phase, you should be considered for the NHS continuing health care fast track funding, so that an appropriate care and support package can be put in place as soon as possible. NHS continuing healthcare fast track funding provides an urgent package of care in the last days or weeks of life.

In the fast-track pathway there is no requirement to complete a checklist or the decision support tool. Instead, an appropriate clinician will complete the fast track tool to establish your eligibility for NHS Continuing Healthcare.

This clinician will send the completed fast track tool directly to your ICB, which should arrange for a care package to be provided for you, normally within 48 hours from receipt of the completed fast track pathway tool.

Continuing health care for adults commissioning policy

The continuing health care for adults commissioning policy describes the way in which the ICB will plan and commission services for people who have been assessed as eligible for an episode of fully funded NHS Continuing Healthcare, and patients who are eligible for continuing health care who wish to have a personal health budget. It also sets out ICB principles for joint funded packages of health and social care.