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NHS Continuing Healthcare Claims

With the average cost of nursing care costing between £35,000 and £55,000 per year, how the cost of your care or care for a loved one can be met may cause people and their families a great deal of stress and worry.

Most people turn to the Local Authority means tested system of funding and quickly realise that if they have capital assets above £23,250 they will need to self-fund their care in full and sell the family home to pay for it.

Over the years, many thousands of people have paid for their care not realising that they may have been eligible for NHS Continuing Healthcare Funding, or at the very least that they should have received an assessment of their eligibility.

NHS Continuing Healthcare Funding is the name given to a package of care which is fully funding by your local NHS Integrated Care Board (ICB) and is available to anyone who is assessed as having a “Primary Health Need”.

Elderly Couple

What is a Primary Health Need?

Whether or not you have a “Primary Health Need” and are eligible for NHS Continuing Healthcare Funding is determined following a detailed assessment of your needs. Contrary to popular belief, diagnosis of a medical condition or residing in a nursing home do not, of themselves, indicate eligibility. Instead, consideration is given to the care needed to meet your needs and professional judgment is required to determine whether the majority of the care you need is focused around addressing health needs.

You are likely to be eligible for NHS Continuing Healthcare if your care needs are:

  • Intense
  • Complex; and/or
  • Unpredictable

The National Framework for NHS Continuing Healthcare lays down the eligibility criteria and complex procedural requirements in relation to eligibility assessments and can be found here.

How Can We Help?

At Ridley & Hall, our specialist solicitors can offer expert advice on:

  • NHS Continuing Healthcare Funding
  • Reclaiming care home fees which have already been paid
  • Assessments for Continuing Healthcare Funding
  • Appeals against decisions of ineligibility at Local Resolution stage
  • Appeals against decisions at NHS England Independent Review Panel stage
  • Evidence review and advice about prospects of success
  • Preparation of written appeal arguments
  • Representation at meetings and appeal panels

Get in touch for a free initial discussion with no obligation.

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Frequently Asked Questions

If you have care needs the level of support you need should be assessed by your Local Authority. Once the level of care needed is established, the Local Authority will usually look at your financial means to determine how much you should contribute towards it.

The rules are complex and specific to your individual circumstances, but generally you are at the very least expected to make a contribution to your care fees from your income. The Local Authority will also look at your capital and decide whether you have enough money to pay for your care and this can sometimes include your home. Sometimes people do decide to sell their homes to fund their care.

It important that eligibility for NHS Continuing Healthcare is considered as an alternative source of funding. Further information is available in this FAQ guide.

If you feel that the Local Authority has not assessed you correctly, get in touch with Ridley and Hall for advice.

NHS Continuing Healthcare Funding is a package of care which is the responsibility of the NHS to maintain. In order words, if you are eligible for NHS Continuing Healthcare Funding, the NHS must fully fund the care.

You can be eligible for NHS Continuing Healthcare Funding wherever you are – it doesn’t matter. Whether you receive care at home or live in a residential or nursing home, the NHS must by law meet the cost of your care, if you have been assessed as eligible.

The National Framework for NHS Continuing Healthcare sets out the basis for eligibility and best practices which should be followed by NHS and social care professionals when undertaking eligibility assessments.

You are eligible for NHS Continuing Healthcare Funding if, following a detailed assessment of the care which is needed to meet your needs, you have a “Primary Health Need”. Although there is no legal definition of what a Primary Health Need is, the guidance does make it clear that your needs should be over and above the provision of social care, which refers to maintaining nutrition, hygiene and safety among other things.

The National Framework goes on to describe the key characteristics of eligibility for NHS Continuing Healthcare Funding, which requires assessors to consider the Nature, Intensity, Complexity and Unpredictability of your needs.

Needless to say, the criteria is complicated and because so much comes down to the professional judgment of the people assessing you, decisions on eligibility can be inconsistent and unfair. The procedural requirements for the assessment are also complicated and so mistakes can be made.

Everyone who has needs which might qualify them for NHS Continuing Healthcare Funding needs to get an assessment. This usually starts with a nurse or social worker or nursing assessor completing an NHS Checklist, which will determine whether or not you need a full assessment of your eligibility.

If the Clinical Commissioning Group decides you need a full assessment of your eligibility then a meeting will be arranged with a multi-disciplinary team (MDT) which will complete the Decision Support Tool and make a recommendation on your eligibility.

The rules are complex, but generally once you have been assessed for NHS Continuing Healthcare Funding, your eligibility should be reviewed every 12 months, unless your needs change sooner than this.

If you are assessed as ineligible following an NHS Continuing Healthcare assessment, you have a right of appeal, usually within 6 months. Despite this, Clinical Commissioning Groups (CCGs) will wrongly advise shorter time frames, sometimes only 21 or 28 days. This is not very long to decide whether or how best to appeal.

Get in touch with Ridley & Hall for advice on your prospects of a successful appeal.

If you or your loved one has been receiving care for a while but hasn’t had an assessment for NHS Continuing Healthcare Funding, it is possible to ask for a retrospective assessment of your eligibility.

The CCG will gather available care home and medical records in order to paint a picture of your needs. They should also take account of your views or the views of a family member.

If the CCG decides that you are eligible for NHS Continuing Healthcare Funding then it will refund the care fees paid, usually with interest.

Yes. Get in touch with our specialist solicitor James Urquhart-Burton to find out more.

If you are not sure whether you are eligible for NHS Continuing Healthcare Funding, James Urquhart-Burton is a Partner at Ridley and Hall Solicitors and a leading expert in this field. James can discuss your needs in complete confidence and advise you whether you might have a case. He has recovered many thousands of pounds for people who were never assessed when they should have been or who have been assessed incorrectly.

At Ridley and Hall we recognise the importance of being sensitive to a client’s individual needs and wants. Some people want their solicitor to take the reins and work with them to achieve the best possible outcome. Others want a solicitor to speak for them at an Independent Review Panel to ensure their case is put forward in the best possible way.

We would always recommend getting advice early on, as this means the right arguments are raised and the case has the best possible chance of success. However, whatever a client’s journey through this complex process, we will always do our utmost to find the best possible solution and be clear about what the next steps should be.

We are passionate about helping people to call out cases where the CCG has wrongly turned applicants away. These cases can be both evidentially and procedurally complex and many people feel that it helps to have a legal expert on hand. You often only get one shot and for many, it is a relief to know that you put your best foot forward.

We are very open about how we charge for the work we do and will discuss the options with you straight away. Depending on our assessment of your case, we may be able to help you on a no win no fee basis. We can also help you on a “pay as you go” basis and we can also offer a fixed fee for your peace of mind.