What is NHS Continuing Healthcare funding?
NHS Continuing Healthcare funding is a resource that pays for all care costs for anyone who is deemed to have a ‘primary health need’. However, many people don’t realise that the NHS could potentially pay the full cost of care fees if they have a primary health need and so they miss out on this funding. It is personal health and social care arranged and funded by NHS Clinical Commissioning Groups (CCGs), regardless of whether a person is in a residential or nursing facility or at home. NHS Continuing Healthcare covers all those care requirements that arise caused by a primary health need.
Is there a means test for NHS Continuing Healthcare?
NHS Continuing Healthcare is not means-tested – unlike local authority funding for social care. Your eligibility for NHS Continuing Healthcare does not depend on your savings or whether you own property. It is paid according to need, regardless of your personal assets or income.
Could I be eligible for NHS Continuing Healthcare?
Eligibility for NHS Continuing Healthcare does not depend on having a particular condition or diagnosis. To be eligible, you must have ongoing care needs that arise from a ‘primary health need’. Sounds simple? Unfortunately, it is anything but. The problem is the concept of a ‘primary health need’ is not straightforward; there is no legal definition.
The Court of Appeal case known as ‘Coughlan’ clarified the law on eligibility for NHS Continuing Healthcare funding. Since 2007, there has also been a National Framework on NHS Continuing Healthcare in place, including The Care Act 2014 that provides standardised guidance to CCGs. However, there is still wide disagreement about what constitutes a primary health need. Many people are wrongly paying substantial care home bills, despite living with the devastating effects of health issues such as Alzheimer’s disease and other forms of dementia, Multiple Sclerosis, Parkinson’s disease, the effects of stroke and cancer.
How is eligibility for NHS Continuing Healthcare assessed?
In standard cases (which aren’t ‘fast-tracked’), a ‘multi-disciplinary team’ of appropriately trained health and social care professionals should carry out the NHS Continuing Healthcare assessment. There are usually two stages.
‘Checklist’ stage – The Checklist is designed to decide quickly whether someone requires a full assessment and should be considered for eligibility for NHS Continuing Healthcare. If the Checklist suggests you or a loved one may be eligible, you will move to the next stage in the process. If it is does not, you can make a ‘formal complaint’ to the CCG within 12 months. However, there are often mistakes at the Checklist stage. These mistakes can come about with how a primary health need is listed or categorised, impacting whether an individual is deemed eligible. We can help you identify these and challenge them. At Just Caring Legal we find that if you get help from us sooner, your chances of success are improved.
‘Decision Support Tool’ (DST) stage – This is a full assessment by a multi-disciplinary team. The DST sets out different levels of needs in relation to 12 care ‘domains’, basically assessing someone’s health needs. This includes looking at behaviour, cognition, mobility, and more. For each domain the assessors should identify which description most closely matches the individual’s needs. But the tool is not designed to be a full assessment in itself. Assessors should use the DST in conjunction with a comprehensive assessment of the nature, severity, complexity and unpredictability of the individual’s overall care needs in line with the National Framework.
Just Caring Legal can help you assess whether the CCG has followed the Framework and guidelines correctly and taken all the relevant evidence into account. The whole process should be completed in no more than 28 calendar days, but wherever possible sooner than this. At Just Caring Legal we can guide you through this complex process.
The Fast Track Pathway Tool – This is a much quicker way to assess eligibility and is the process specifically for those reaching the end of their lives. If an individual has a rapidly deteriorating condition which may be entering a terminal phase this tool is designed for use by ‘an appropriate clinician’ so that those who may be eligible can receive NHS Continuing Healthcare quickly.
Reassessments for NHS Continuing Healthcare
Once eligible for NHS Continuing Healthcare, the individual receives a reassessment at three months and then at least once a year. But here at Just Caring Legal, we are hearing more and more cases where the CCG withdraws funding following reassessment despite there being no ‘significant changes’ to their care needs or presentation. True, there may be times when withdrawing funding is justifiable (such as if care needs have reduced). However, clients are increasingly reporting withdrawal of funding even when their condition is deteriorating. This can mean the reduction or complete loss of their care package, with all the distress and anxiety that causes. Just Caring Legal can help you avoid this by ensuring the reassessment has been carried out correctly.
Could I be eligible for a refund of care fees?
Recent evidence gathered from NHS Continuing Healthcare applicants nationwide, as well as testimony from our own clients, has flagged up that many CCG’s are failing to follow the National Framework correctly. We have seen at first hand that delays are common, families and carers are often kept out of the loop and vital evidence is often not gathered or taken into account. At Just Caring Legal we can help ensure a full and robust assessment is carried out to achieve the best outcome for all of our clients. The sooner you get in touch, the sooner we can help you to improve your chances of success by navigating you through this complex process.
When you successfully challenge a decision retrospectively, the CCG must refund care fees for a stipulated period. If you believe you or your loved one has a primary health need, you can challenge a decision by way of local disputes resolution – this must usually be within six months of the decision outcome date. If this stage fails, the next step is to take the case to an Independent Review Panel, then the Parliamentary Health Service Ombudsman and eventually, only if there are strong grounds to do so, possibly to court via the process of judicial review.
How can Just Caring Legal help?
Challenging NHS Continuing Healthcare decisions can be perplexing, frustrating and distressing. It requires first-class knowledge of the complexities of the National Framework and the case law, and hands-on experience of dealing with NHS Continuing Healthcare decision-makers. This is why Just Caring Legal is here to help. This is all we do.
As a solicitor’s firm specialising in NHS Continuing Healthcare cases, your Just Caring Legal solicitor can construct and deliver strong evidence-based medico-legal arguments to challenge ineligibility decisions and ensure full and robust assessments and reassessments.
The first thing we need is information about you or your loved one’s care needs, health, situation and history. It is vital you help us with this as early as possible so we can maximise your chances of success. We have constructed an initial questionnaire so we can get as much information as we can, as quickly as we can. As soon as you have completed this questionnaire, we will contact you to provide bespoke advice and discuss funding options.
Could you be eligible for a refund of care fees? Time limits may apply so please click here without delay to fill out our free initial assessment questionnaire.
Fee Option 1: Full refund process on no-win-no-fee basis
Depending on your circumstances, a Just Caring Legal solicitor will carry out the full process of seeking to recover NHS Continuing Healthcare refunds from start to finish on your behalf with no initial fees to pay. This could be done on a Contingency Fee Agreement (a no win no fee basis). This means we will deduct an agreed percentage from the total sum we recover on your behalf. In the unlikely event that we recover nothing, there will be nothing to pay.
Option 2: Possible one-off service options for a fixed fee
- Free initial telephone advice on NHS Continuing Healthcare.
- Review of papers and initial advice and/or drafting a formal complaint at Checklist stage.
- Review of documents at checklist stage and help to maximise your chances of successfully triggering to the DST stage.
- Review of documents with a view to preparing written representations in advance of the pre-panel/DST multi-disciplinary stage.
- Attending with you multi-disciplinary meetings, local disputes resolution meetings and Independent Review Panel meetings.
- One-off appeals to challenge ineligibility decisions (without a review of healthcare records). An additional fee will be added for review of the full healthcare records.
- Help and assistance with appeals where NHS Continuing Healthcare funding has been withdrawn.
- One-off appeals to the Independent Review Panel where local dispute resolutions stage has failed. An additional fee will be added for full review of medical records.
- A complaint to the Parliamentary and Health Service Ombudsman.
We can make a real difference in helping you win your battle to secure NHS Continuing Healthcare funding. Do you think you have been wrongly paying care fees? Call today on 0191 556 1078 to find out how we can help you through this complex process and obtain more details of our services.
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