NHS Continuing Care

The NHS is responsible for providing nursing care to people who need it. This can be delivered in any setting and in some cases be part of a complete care package of fully funded NHS continuing care.

People not eligible to fully funded continuing care living at home or in a care home that only provides personal care have access to their district nurse for nursing needs. However, people living in nursing homes instead of this, have part of their fees paid by a contribution from the NHS direct to the care home. This is called ‘NHS Funded Nursing Care’. New guidance covering this and NHS Continuing Healthcare is contained in a National Framework for NHS Continuing Healthcare implemented from 1st October 2007 and revised in July 2009.

NHS Continuing Care can include the full cost of a place in a care home, however, there is a very fine line between what is considered to be free health care provided by the NHS and means tested social care which is the responsibility of local authorities.

The NHS is responsible for arranging and funding a range of services to meet the needs of people who require continuing physical or mental health care. To assist in deciding which treatment and other health services it is appropriate for the NHS to provide the Secretary of State has developed the concept of ‘a primary health need’. Where a person’s primary need is a health need, the NHS is regarded as responsible for providing for all their needs in any setting. The main areas of responsibility are:

The decision as to whether one is eligible for NHS Continuing Healthcare is based on an assessment which should look at the totality of the relevant needs. This assessment is conducted in accordance with the National Framework for Continuing Healthcare used by all Primary Care Trusts (PCTs) in partnership with their local authorities. It clearly sets out the principles and processes for establishing primary health need and eligibility to NHS Continuing Healthcare.

The framework has a ‘checklist’ to identify people who are most likely to be eligible for NHS Continuing Healthcare and who should be referred for full consideration and assessment.
A decision support tool is then used to ensure the full range of factors which have a bearing on eligibility are taken into account in making a decision on whether there is a continuing care need.

The Decision Support Tool

The decision support tool covers 12 areas called ‘care domains’ which are subdivided into statements of need representing no need, low, moderate, high or severe level of need with four (marked ‘P’) having a priority level.

These are behaviour (P), cognition, psychological & emotional, communication, mobility, nutrition, continence, skin & tissue viability, breathing (P), drug therapies and medication: symptom control (P), altered states of consciousness (P) and other significant care needs.

Eligibility Criteria

If an assessment reveals priority needs in one of the four priority care domains or severe levels of need in two or more domains then it is likely that the person would be eligible to NHS continuing care.

If there are a number of domains with high and/or moderate needs, this can also indicate a primary health need. In this case, the overall need, the interactions between needs in different care domains, and the evidence from risk assessments, should be taken into account in deciding whether to recommend eligibility to NHS Continuing Healthcare.

If needs in all domains are recorded as low or no need, this would indicate ineligibility.

The result of completing the tool should be an overall picture of the persons needs and the care required to meet those needs. The assessment tools, combined with the health practitioners’ own experience and professional judgement, should enable them to make a decision about eligibility for NHS Continuing Healthcare.

The assessment should be multi-disciplinary, include user and family involvement, be based on needs not location and be independent of budgetary constraints.

Fast Track Pathway Tool

There is also a fast track pathway tool for people who have a rapidly deteriorating condition which may be entering a terminal phase and need an urgent consideration of their eligibility for NHS Continuing Healthcare.

Reviews

Following an initial assessment, a review of eligibility for NHS Continuing Healthcare should be undertaken within 3 months and then on an annual basis or more frequently if there were to be a significant change in your nursing needs. As a matter of course potential eligibility for NHS Continuing Healthcare should always be checked during the review, using the NHS Continuing Healthcare Checklist explained above

It is important to realise that many of the conditions requiring older people to move into nursing homes can lead to considerable deterioration of health and if this were the case, remember a review can be requested at anytime through the nursing home.

If receiving NHS Funded Nursing Care but you disagree with the assessment, for example consider that the nursing requirements are so intense that eligibility for fully funded NHS Continuing Healthcare should apply, the Health Authority will have a review procedure.

Immediate concerns should be addressed to the nursing home co-ordinator employed by the Primary Care Trust, Health Authority or local authority. It’s this person’s responsibility to ensure nursing care needs are fully met. This may lead to referral to the Health Authority’s continuing care panel for a review of the decision.

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