NHS continuing healthcare
Who's eligible for this free care, and why you shouldn't pay to apply
If you're an adult with any long-term, complex health needs you could qualify for free care arranged and funded by the NHS – known as NHS continuing healthcare. The eligibility criteria is notoriously strict, but you don't need to pay anyone to help you apply or qualify. This guide explains what continuing healthcare is, how it's assessed and how to navigate the process.
This is the first incarnation of this guide. If you've any feedback or tips, let us know in the NHS continuing healthcare forum thread.
Free social care for adults with complex health needs
NHS continuing healthcare (CHC) is free social care for adults aged 18 or over residing in England or Wales. It's assessed, arranged and funded solely by the NHS for those with long-term and complex health needs that have typically arisen as a result of disability, accident or illness.
Most people won't qualify for CHC, as the eligibility criteria are strict. It's specifically for the relatively small number of people with high levels of need who are found to have a ‘primary health need’.
Although there's no clear definition of a 'primary health need', your health and care needs must go beyond what could be provided by regular social services – meaning the NHS needs to meet those needs. Deciding whether you qualify is complicated and requires assessment; we go into more details on this below.
CHC isn’t means-tested, so it doesn’t depend on how much money you have, and it covers extra costs, such as help with washing or dressing, or paying for specialist therapy. Even if you don't qualify for CHC, there may be other help available – use the 10 minute benefit checker to find out.
The decision about whether someone is eligible for NHS continuing healthcare will be based on their needs, not their condition. Having a particular diagnosis does not determine eligibility, as people with the same health condition can have very different needs.
In Northern Ireland, continuing healthcare is available but it isn’t as easy to access and the assessment process is different. You can find out more on the Department of Health’s website.
Scotland stopped using NHS continuing healthcare in 2015. If someone in Scotland got NHS continuing healthcare before it was stopped, they will continue to receive it so long as they’re eligible.
To get help with paying for social care in Scotland, including paying for a care home, you will normally need to have an assessment from your local council. You can ask your GP or nurse about this, or you can ask the council for an assessment yourself.
Personal care is free if you live in Scotland. Personal care covers things like help with bathing, showering, preparing food, going to the toilet and help with medicines. It doesn’t include all aspects of social care, including housework or paying for shopping. You may need to pay for these. Whether you need to pay, and how much, is decided by the local council.
If you’re in Scotland and you need to be cared for in hospital, this is free. It’s called Hospital Based Complex Clinical Care
NHS continuing healthcare in Northern Ireland
NHS continuing healthcare in Scotland
You DON'T need to use a claims management company to apply
If you feel you (or someone close to you) needs an assessment for continuing healthcare you should ask your GP, social worker, district nurse, care home nurse or other health professional for a checklist assessment – below we explain more on eligibility.
Alternatively you can contact your Integrated Care Board’s (ICB) Continuing Healthcare department to request an assessment.
The process can seem daunting at first, but you don't need to use the services of a claims-management company (CMC), who'll usually charge high fees (sometimes in the thousands) for helping to make the application. The whole process is designed to be done by individuals, with the help of family and friends if necessary.
The NHS has teamed up with a company called Beacon to provide free information and advice. You can access up to 90 minutes of free advice with a trained NHS continuing healthcare adviser by calling 0345 548 0300.
Note: the same company (Beacon) also provide a paid-for service, the exact thing we say you don't need to use (which may seem confusing). So utilise the free service and advice, and then do the rest yourself.
How eligibility for NHS continuing healthcare is assessed
Generally, eligibility for NHS continuing healthcare is assessed in two stages:
Initial assessment: In most cases, a screening process using an initial checklist is used, and the assessment can be completed by a nurse, doctor, other healthcare professional or social worker. In theory it should be done automatically if your health deteriorates to the point where an assessment is necessary and your care is being overseen by a health or social care professional.
You should be told that you're being assessed and what the assessment involves. The checklist has 11 care 'domains' broken down into three levels: A, B or C (where A represents a high level of care need, and C is a low level of care need).
Depending on the outcome of the checklist, you'll either be told that you do not meet the criteria for a full assessment of NHS continuing healthcare and are therefore not eligible, or you'll be referred for a full assessment of eligibility.
Being referred for a full assessment does not necessarily mean you'll be eligible for NHS continuing healthcare. The purpose of the checklist is to enable anyone who might be eligible to have the opportunity for a full assessment, so the threshold has been set deliberately low. In fact, the majority of people who get referred for a full assessment are found not to be eligible once that's completed.
Usually checklists are completed outside of hospital to ensure an accurate assessment. The hospital should have a discharge team responsible for identifying who needs a checklist. If they agree it's needed, they should arrange for one to be completed when you've left hospital – whether you're at home or in a care setting.
Depending on local policy, there might be some temporary funding available for after discharge. This could be to support recovery at home or further assessment of needs. Check with the hospital whether funding is available. If a checklist is actioned as part of a discharge, temporary funding should continue until a decision is made on eligibility.
Ideally, the discharge team should action a checklist for anyone with significant ongoing support needs, or who moves to a care home registered for nursing. It's a good idea to ask the discharge team if they will action a checklist, and for the reasons for their decision, in writing
If you're discharged without a checklist, or are already at home or in a care setting, you can ask any health or social care professional to fill out a checklist – as long as they're trained to do so. This could include a member of the local council such as a social worker or care manager, a GP, or a registered nurse such as a district nurse. Depending on local policy, this might also include a registered nurse from a care home.
If there are no professionals who can fill out the checklist, you should contact the local Integrated Care Board (ICB). This is the institution responsible for continuing healthcare assessments. The ICB doesn't have to complete checklists themselves initially, but they do have a responsibility to ensure you have access to it. If you're struggling to get the checklist filled out, the ICB should send an assessor, or support you in getting local professionals to complete it.
If you're still in hospital
If you're back home/in a care home
2. Full assessment: This next stage of assessment involves a multidisciplinary team (MDT), made up of a minimum of two professionals from different healthcare professions – usually both health and social care professionals who are already involved in your care – and you should be told who is co-ordinating the assessment.
They will undertake a comprehensive assessment and evaluation of your health and social care needs, reviewing evidence such as medical records, examinations and assessments to make an assessment of eligibility for CHC using a standardised tool called a ‘Decision Support Tool’ (DST) to help inform the decision.
The team's assessment will consider your needs under 12 headings. These needs are given a weighting marked 'priority', 'severe', 'high', 'moderate', 'low' or 'no needs':
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breathing
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nutrition (food and drink)
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continence
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skin (including wounds and ulcers)
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mobility
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communication
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psychological and emotional needs
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cognition (understanding)
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behaviour
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drug therapies and medicine
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altered states of consciousness
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other significant care needs
If you have at least one priority need, or severe needs in at least two areas, you can usually expect to be eligible for NHS continuing healthcare.
You may also be eligible if you have a severe need in one area plus a number of other needs, or a number of high or moderate needs, depending on their nature, intensity, complexity or unpredictability. In all cases, the overall need, and interactions between needs, will be taken into account, together with evidence from risk assessments, in deciding whether NHS continuing healthcare should be provided.
The assessment should take into account your views and the views of any carers you have. You should be given a copy of the decision documents, along with clear reasons for the decision.
Continuing healthcare isn't restricted to care homes
If you qualify, the care provided is outside of hospital – typically in your own home or a care home – but it can also be in a hospice.
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At home: the NHS will pay for your package of care and support to meet your assessed health and associated social care needs.
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Care home: the NHS will pay for your care home fees, including board and accommodation.
Fast-track assessment for NHS continuing healthcare
If your health is deteriorating quickly and you're nearing the end of your life, you should be considered for the NHS continuing healthcare fast-track pathway, so that an appropriate care and support package can be put in place as soon as possible – usually within 48 hours.
Below we cover what happens when you are eligible for NHS continuing healthcare, or if you're not successful and want to challenge the decision, you can jump to how to appeal.
You ARE eligible: what happens now
If you're eligible for NHS continuing healthcare, the next stage will be to arrange a care and support package that meets your assessed needs.
Depending on your situation, different options could be suitable, including support in your own home and the option of what's called a 'personal health budget' – where you choose to receive funding for your care as direct payments. A personal health budget can give you more choice and control over how to plan and pay for your healthcare and wellbeing needs.
However, this can't be used to pay care home fees. If it's agreed that a care home is the best option for you, there could be more than one local care home that's suitable.
Your ICB should work collaboratively with you and consider your views when agreeing your care and support package and the setting where it will be provided. However, they can also take other factors into account, such as the cost and value for money of different options.
Your benefits could be affected
If you’re getting NHS continuing healthcare and living in your own home, your Attendance Allowance, Disability Living Allowance and Personal Independence Payment remain the same.
If the NHS is paying your care home fees, the care component of Disability Living Allowance and the daily living component of Personal Independence Payment and Attendance Allowance will normally stop after 28 days. Your pension shouldn’t be affected.
You could get a refund for any delays
ICBs will normally make a decision about eligibility for NHS continuing healthcare within 28 days of getting a completed checklist or request for a full assessment, unless there are circumstances beyond its control.
The NHS says if your situation is complicated it could take longer. But if you’re awarded NHS continuing healthcare and the process has taken more than 28 days, you should get a refund for care costs from the 29th day onwards.
NHS Continuing Healthcare doesn't necessarily last indefinitely
You should normally have a review of your care package after three months, and then every 12 months. The focus of these reviews should be on whether your care plan or arrangements remain appropriate to meet your needs. If your needs have changed to such an extent that they might impact on your eligibility for NHS Continuing Healthcare, then the ICB may arrange a full reassessment of eligibility.
This may mean your funding arrangements change, as eligibility for NHS Continuing Healthcare is based on needs rather than on the condition and/or diagnosis.
You're NOT eligible: how to appeal step-by-step
If you find out you're not eligible for NHS continuing healthcare and you want to appeal the decision, you DON'T need to pay someone to help you do this.
Some solicitors and claims management companies may apply a 'no-win, no fee' structure, while others will be on a fixed-fees basis. Again, this part of the process is designed for you, or friends and family if needed, to work through yourself. You can find out more about where to get free help here. If you do decide to use a representative to help you, the NHS will ask them for proof they're authorised to act on your behalf.
The Health Service Ombudsman has said that a large number of recent claims to the NHS have been put through professional representatives, such as solicitors and claims companies, who charge for their services. It says it rarely finds there has been a need for someone to pay somebody else to bring their complaint to it, or to the NHS.Because of this, it is unusual for the Health Service Ombudsman to recommend the NHS reimburses you for any fees you may have paid to have someone represent you.
You must explain your reasons for the appeal in writing or over the phone, within six months of the date of the decision letter.If you're unable to represent yourself as part of the appeals process someone who is your legal representative can represent you on your behalf – ideally someone with Lasting or Enduring Power of Attorney.
Step 1: Local resolution meeting (LRM)
The first stage of the appeals process will be a call arranged between you and the assessor who undertook the assessment. This stage of the process is quite informal and is a chance for you to raise any concerns and discuss how the decision was made. The case will be reviewed to make sure the process was followed correctly. This is your chance to provide any additional information you want to be considered. Following this discussion, it may be decided that a reassessment is required, or alternatively that the original decision is upheld.
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If you are satisfied with the discussion the appeal case will be closed.
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If you do not agree, the appeals process can move to step 2.
Step 2: Local Review Panel (LRP)
The local review panel will consist of a multidisciplinary team who have had no previous involvement in the decision making process. You will need to be able to explain to the panel why you are appealing the decision. If you are still unhappy with the results of this stage of the process, you can move to step 3.
Step 3: Independent Review Panel (IRP)
If you are still not happy, then you have a right to appeal to NHS England. NHS England will advise you how the IRP will be conducted and will write directly to you regarding the outcome of the IRP.
The IRP will make a recommendation to NHS England and the integrated care board (ICB) which will usually be accepted by the ICB. Where the recommendation to overturn the original decision of the ICB is accepted by it, the ICB will fund the care of the assessed individual back from the date of the original decision and will determine when a new assessment on eligibility will take place, if appropriate.
Step 4: The Health Service Ombudsman
Following an Independent Review Panel, if the original decision is upheld, and you remain dissatisfied with the outcome, you have the right to make a complaint to the Parliamentary and Health Service Ombudsman. You can ask the ombudsman to look into your complaint about CHC funding if:
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You are not happy with the NHS’s checklist decision, have made a complaint to the NHS about this and are not happy with its response, or
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You have had a full assessment by the NHS, have been turned down for funding and have already been through the Independent Review process, or
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You have been given funding but are not happy with the amount and have made a complaint to the NHS about this.
There is an online form you can fill out to complain.
Bringing a complaint after an Independent Review
If you bring a case to the ombudsman following an Independent Review, you need to make sure you tell it how you think the Independent Review process was unreasonable or unfair. You will have had the opportunity to raise your concerns about the assessment process with the Independent Review and the health ombudman's investigation will look at how the Independent Review addressed your concerns. It will usually only investigate issues that you have previously raised with the Independent Review.
If it does find a specific fault and upholds your complaint, it will usually ask the NHS to take action. For example, it might ask it to explain how it reached its decision, or to look again at its decision. It can’t make the NHS change its decision, and it can’t make its own decision about whether you are eligible for funding, but it will say what it thinks the NHS needs to do to put things right.
Step 5: Check if you're entitled to other help
If you decide not to appeal, or the decision isn't overturned, you can ask to be referred to your local authority. They'll look at whether you’re eligible for care and support and if you are they'll apply a means test to see how much you should contribute to your care.
If you don’t qualify for NHS continuing healthcare, but have been assessed as needing to live in a nursing home, and need help from a registered nurse, the NHS pays a flat rate contribution to the home – known as NHS-funded nursing care.
This payment is to support the provision of nursing care by nurses employed by the home. You won’t usually need a separate assessment for NHS-funded nursing care if you had the full assessment for NHS continuing healthcare. Your nursing needs should be reviewed no more than three months after the initial decision, and then at least once every year.
Check if there's other benefits you might be eligible for
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Attendance Allowance - this is one of the most underclaimed benefits, so it's worth checking if you're eligible. It's a non means-tested weekly payment to help cover costs of pensioners (aged 66+) who need someone to 'attend' them. You could claim over £100 a week - see the What is attendance allowance and how do I claim it guide for full info.
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Personal Independence Payment (PIP) - this is non means-tested support for those with long-term health conditions. The amount you get depends on how your condition affects you, not the condition itself. You will be assessed by a healthcare professional to work out what level of help you need. Use the 10-minute benefits check to see if you qualify.
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Universal Credit - this is a monthly benefit to support those on low incomes (or no income) with living and housing costs. Claiming Universal Credit also opens up access to other forms of support. See the Universal Credit guide for full info.
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