NHS Fully Funded Continuing Care at Home

Please note: this guidance is based on information provided by a number of health authorities; detail including eligibility to continuing care may vary in different parts of the UK.

Many people who have a serious medical condition or disability want to lead fulfilling, independent lives away from hospitals, nursing homes and other institutions. The continuing care programme can support this.

NHS continuing care is for people who have a long-term chronic or degenerative illness or a severe disability. The scheme may pay for

• Long-term rehabilitation and recovery after hospital
• Palliative care
• Intensive nursing and support for persons with chronic illnesses
• Respite care for family members who act as carers

NHS continuing care is free to people who qualify under guidelines set by their local Strategic Health Authority (Regional Health Board in Scotland or Local Health Board in Wales) and/or social services.

If NHS continuing care is provided in an individual’s own home, the NHS will meet the full cost of the service user’s health needs including equipment and adaptations to the home. The NHS does not usually meet the cost of accommodation, food or other household bills though the local social services may provide additional financial help. Applications for funding should be made as early as possible.

Consultus Live-in Nursing and the NHS

Categories of Continuing Care

There are three categories of continuing care. Category 1 is a package of care arranged and funded entirely by the NHS. It may be provided in a hospital, hospice, care home or increasingly in the service user’s own home. When considering eligibility for Category 1, the most important consideration is whether, looking at an individual’s overall assessed needs, their primary need is for “health care”. Such needs may include, but are not limited to the need for nursing from a registered nurse.

Category 2 describes a package of care that involves services from both the NHS and social services where the prime need is for appropriate accommodation and personal care rather than for nursing or other NHS care.

Category 3 is for service users entitled to receive community and personal care services provided by social services subject to their eligibility within the Fair Access to Care Services (FACS) arrangements as adopted by their local authority.

Patients should be assessed for Category 1 care before any other assessments are undertaken.

Funding Criteria

To fall within Category 1 criteria, clients must be 18 years or older (there is an equivalent scheme for children) and be registered with a NHS GP.

An individual may be eligible for Category 1 care when:

The need for the care or supervision of a registered nurse and/or a GP is not by itself sufficient reason to receive Category 1 care.

Some specific conditions should automatically qualify under Category 1, for example:

• Persistent vegetative state
• 24-hour mechanical ventilation via a tracheotomy
• Unconsciousness
• The individual is in the final stages of a terminal illness. This should not, however, be applied restrictively and individual circumstances will be considered.

Depending on the nature and intensity of their needs, other individuals may be eligible for fully funded NHS continuing care. Such eligibility will be determined by the application of the local criteria against the multi¬disciplinary assessment carried out for each such individual.

Eligibility for continuing care is based on need not diagnosis and is not condition-specific. It is not determined by an individual’s ability to pay.

Assessment for Category 1 Care

A panel of health and social care professionals makes the identification of health care needs. The panel may include the applicant’s GP, physiotherapist, district nurse, or ward sister if the patient is in hospital, and a social services care manager. The panel will use a nationally standardised health and social care assessment ‘tool’ specific to one of the following care groups:

• Adults with a physical disability and/or an organic mental health disorder
• Adults with a learning disability
• Adults with functional mental health problems

The panel will determine the individual's needs and take into account the nature or complexity or intensity or unpredictability of the individual's mental and physical health care needs (and any combination of these needs).

The tool that will be used to determine whether or not an individual is eligible for funding is the ‘Primary Health Needs Test (PHNT)’, which was introduced in the Coughlan judgement and reaffirmed in the 2006 Grogan judgement.

The assessment will determine the application of the criteria to any particular individual. It will provide a logical and structured method of drawing out the health care elements of a care package. If the panel’s professional judgement is that an individual’s needs are predominantly health care needs the placement will be funded by the health authority. If it decides the individual’s nursing needs are incidental or ancillary to the client's accommodation or personal/social care needs then funding may be denied or they will be reconsidered for Category 2 or 3, though the district nursing service will be available as deemed necessary.

In the latter case, the placement will be made and funded by the Local Authority in accordance with the Social Services eligibility criteria.

Hence, decisions on eligibility for 100% NHS funded continuing care under the local criteria will be taken with the assistance of the health needs assessment tools. Individuals who are assessed as not having the requisite number of needs may still be entitled to 100% NHS funded continuing care if the overall scale of the individual's health needs is such that they should be regarded as wholly the responsibility of the NHS.

The cost of continuing care is a prime consideration of some health authorities and it is usually considered acceptable for the authority to weigh up the cost of various continuing care options as part of their evaluation.

Equally, the views of the patient and their next of kin should be sought and considered as an important factor in the decision-making process. If the individual would, for example, like to receive the nursing they need in their home (perhaps by a Consultus live-in nurse) it is important for the panel to know this; the patient or their representative should inform the assessor of their wishes and press strongly for their option to be chosen.

Cases such as Coughlan and Grogan have inspired many individuals to successfully overturn decisions so they may benefit from fully funded intensive nursing at home. Specialist solicitors, charitable groups or other professional advisors are able to help people make their case.

Those assessed as not eligible for continuing care may still be entitled to other support from organisations such as their local council or the Independent Living Funds.

Further reference

Consultus and the NHS

The Consultus Live-in Nursing Service works closely with District Nurses, Nurse Assessors and GPs in areas throughout England, Scotland and Wales. Together we determine whether live-in nursing or care is the most appropriate and cost-efficient option for an individual Continuing Care recipient; in many instances we go on to provide a tailored, closely managed service that meets the needs of the patient and the requirements of the commissioning organisation.

Our NHS-funded clients typically are people who need palliative or complex 24/7 care. Sometimes we provide staff only periodically to give family carers respite. When a nurse needs to be awake around the clock we provide two nurses to live in.

The range of home palliative and other community nursing services provided by or on behalf of local health authorities varies from area to area and we currently do not work with every primary care trust or health board. But, as an analysis of NHS services by Marie Curie Cancer Care showed: “place of death is not random…A strong preference for dying at home increases the likelihood of a home death”. Determined individuals may therefore be successful in applying to any NHS trust for live-in nursing care where rationalization for the service can be proven.

Prospective continuing care recipients, their carers or representatives may wish to pass on to continuing care panels the contact details of our Nursing Manager, direct line: (01732) 771924 / 770403.

Care and Nursing at Home

Other Help with the Costs of Long-Term Care

Further reference:

Continuing Care: NHS and local councils’ responsibilities
Publication: HSC 2001/015:LAC (2001) 18
Customer Service, The Department of Health, Richmond House, 79 Whitehall, London SW1A 2NL. Tel: 0207 210 4850.
Email: dhmail@dh.gsi.gov.uk.
Website: http://www.dh.gov.uk/PolicyAndGuidance/OrganisationPolicy/
IntegratedCare/ContinuingCarePolicy/fs/en

Appeals over NHS Funding for long term care. The Health Service Ombudsman (2003)
The Health Service Ombudsman, Millbank Tower, Millbank, London SW1P 4QP. Tel: 0845 015 4033/020 7217 4051.
Email: OHSC.Enquiries@ombudsman.gsi.gov.uk.
Website: www.ombudsman.org.uk

Should the NHS be paying for your care?
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