Applying and eligibility

Usually the process starts with a ‘Checklist’ completed by a trained social worker or healthcare professional. The ‘Checklist’ is a screening assessment that gives an indication whether your needs require further assessment for Continuing Healthcare. A positive Checklist outcome does not in itself indicate that you have a primary health need.

If you have a positive Checklist, your needs are then assessed by a ‘multi-disciplinary team’ (MDT) of health and social care professionals using a ‘Decision Support Tool’ (DST). You (and where appropriate, a family member or representative) will be involved in the assessment process. The assessment may take place in your own home or usual place of residence. It may be undertaken face-to-face, or via video-conference.

The assessment team uses a  framework for NHS Continuing Healthcare which is defined by NHS England. To be eligible for NHS Continuing Healthcare, you must be assessed as having a ‘primary health need’ in line with the domains included in the NHS Framework. A ‘primary health need’ does not relate to any particular diagnosis or condition. Whether someone has a ‘primary health need’ is assessed by looking at all of their care needs and relating them to four key indicators:

• Nature – this describes the characteristics and type of the individual’s needs and the overall effect these needs have on the individual, including the type of interventions required to manage those needs. 
• Complexity – this is about how the individual’s needs present and interact and the level of skill required to monitor the symptoms, treat the condition and/or manage the care. 
• Intensity – this is the extent and severity of the individual’s needs and the support needed to meet them, which includes the need for sustained/ongoing care. 
• Unpredictability – this is about how hard it is to predict changes in an individual’s needs that might create challenges in managing them, including the risks to the individual’s health if adequate and timely care is not provided. 

Following your assessment, you will be notified in writing of the outcome. If you are not eligible for NHS Continuing Healthcare, the reasons will be explained in the letter. A copy of the assessment will be provided with that letter. The letter will also tell you how to appeal if you feel the decision is wrong. The professional who referred you for the assessment will also be informed of the outcome of the decision. 

If you are not eligible for Continuing Healthcare, nor awarded Funded Nursing Care, you may still have some health needs that are not within the legal remit of the Local Authority to legally provide. If the MDT agree that this is the case, they will make a recommendation for a jointly funded package of care with the Local Authority. The NHS and Local Authority will agree the split of funding and you will not be subject to any financial assessment for the NHS element of your care package.

Mid and South Essex Integrated Care Board commission our three hospices to coordinate, assess and ensure care is provided to adults who are rapidly deteriorating and may be in a terminal stage of their life.

The hospices (Farleigh, St Luke’s and Havens) will ensure that the range of services provided to support the individual in their preferred place of care will include access to core hospice services and other health services to meet the assessed need.  The team will review each person’s requirements to ensure that their assessed needs continue to be met by the right service for both the individual and their family/carers.

To access this service please contact:

South East Essex (covers the city of Southend, the borough of Castle Point and district of Rochford)
Havens Hospice  – [email protected] and 01702 426 239

South West Essex (covers the boroughs of Basildon, Brentwood and Thurrock)
St Luke’s Hospice – [email protected] and 01268 526259

Mid Essex (covers the city of Chelmsford and the districts of Braintree and Maldon)
Farleigh Hospice – [email protected] and 01245 457300 (Option 4)

If you are eligible for fully funded NHS Continuing Healthcare, the next stage is to arrange a care and support package which meets your assessed needs. Depending on your situation, different options could be suitable. The All Age Continuing Care team will work with you to discuss your needs and consider your views about what support might best meet those needs. Other factors such as risks, cost and value for money of different options will also be taken into account.

If you are eligible for NHS Continuing Healthcare, NHS Funded Nursing Care, or your care package is jointly funded by the NHS and Local Authority, your needs and support package will be reviewed within three months and thereafter at least once a year. This review will consider whether your existing care and support package meets your assessed needs. If your needs have changed, you may require a further full assessment to consider whether you are still eligible for NHS funding for your care and support needs.

The national deadline for submitting retrospective claims for care received prior to 1 April 2012 has now passed. It is still possible to make a retrospective application for any previously unassessed period of care since 1 April 2012. Retrospective assessments can be requested by an individual or their representative, where the individual has never been assessed, not been assessed in recent years, or has died before an assessment could be undertaken. This is generally a paper-based exercise, where an experienced clinical assessor gathers the available evidence and creates a portrayal of needs over a period which may cover a short timeframe to many years. The Integrated Care Board will make a decision based on the recommendation resulting from that retrospective assessment.

If you or your relative has had an NHS Continuing Healthcare (CHC) assessment and you do not agree with the eligibility outcome you have the right to appeal. Throughout the process we advocate your full involvement and would expect that any decision making will be fully explained to you.

You will need to lodge your appeal no later than six months from the date of the letter informing you of the CHC decision. To lodge your appeal, you will need to write a letter clearly evidencing the reasons for your appeal. The reasons for an appeal should be based on;

• Why you do not agree with the outcome.
• Please give details, referencing which areas of the assessment you would like us to review.

You will need to send your completed letter or email to the CHC Team, at the following address within six months of the date of this letter to:

The NHS Appeals Team
Mid and South Essex Integrated Care Board
PO Box 6483
Basildon
Essex,
SS14 0UG

[email protected]

If you have any additional information to support your appeal, please submit this with the forms so that it can be considered during the appeal.

Yes, you can. You will need to provide evidence that you are the patient’s representative and you are able to act on their behalf. You may have already provided us with this information already. Examples of authority would be:

• The patient’s written consent to act on their behalf in this matter; or if the patient lacks the capacity to consent please provide one of the following documents as evidence of authority to act:
  – Lasting Power of Attorney (LPA) for Welfare or Finance.
  – Enduring Power of Attorney (EPA) registered with the Office of Public Guardian (showing the seal of the Office of Public Guardian).
  – Court Appointed Deputy for Welfare or Finance.

Please note that if your authority is for finances only, this may limit the information that can be shared, this is due to patient confidentiality.

To avoid delay in us being able to speak or correspond with you about the appeal it would be helpful to provide the evidence of authority as soon as possible.

If you do not have formal authority to act on their behalf, please contact us to discuss this. It may be possible to proceed on a ‘best interests’ basis.  The information provided may be generic as patient confidentiality may limit what information can be shared.

If the individual has since passed away, the above documents will no longer apply. You will need to provide evidence that you are responsible for dealing with their estate.

No, this is not a legal process and we aim to keep the process as simple as possible. If you feel you need additional support, we can put you in touch with independent advocacy services which may support you free of charge.

If you ask a solicitor, claims firm, independent advocate or other third party to act on behalf of the patient or their authorised representative, we will need written authority for them to act in addition to the consent form.  If you choose to involve a solicitor or claims firm you will be responsible for the payment of any fees they charge.  NHS CPR cannot refund any costs.

Your appeal will be acknowledged within 10 working days of receipt. A Lead Nurse will then complete initial paperwork and review your case.   The Lead Nurse will check that the process has been followed correctly. You will be informed of the outcome and the next step to progress your appeal, which is likely to be inviting you to attend a local resolution meeting (stage 1 of appeal process).

This may involve either a meeting or a telephone discussion between the client/family/legal representative and Lead Nurse/Nurse Assessor. At this meeting we will endeavour to explain our process, answer any questions and document any additional information that you provide us with.

If it is agreed that a further assessment of your needs is required, your representative will be invited to attend to ensure that you are both fully involved in the process. We aim to complete stage 1 within 28 working days, although it may take a little longer if a further assessment is required.

The Local Resolution meeting will not change the decision that has been made. The case would need to progress to stage 2 of the appeals process to enable this to happen. The Local resolution process is an opportunity to discuss areas of concerns and ensure that any further assessment that may be required to reach a final decision has taken place before an appeal panel is convened.

Formal minutes will not be taken at the meeting. Notes of the key action points and outcome/agreements made at the meeting will be taken and you will be provided with a copy for your reference.

If following the Local Resolution Meeting you choose not to proceed with the appeal, the process will stop.

Once stage one has been completed, if you remain dissatisfied with the outcome then you have the right to proceed to stage two of the appeals process (Local Review Panel).

If you choose to proceed with the appeal then the information will be presented to a formal Local Appeal Panel. We will send you and your representative an invitation to attend the panel meeting.

If you have any additional information you wish the Panel to consider, this must be submitted at least 14 days before the panel.  This allows the panel members to fully review the information. At the Appeal Panel you will have the opportunity to inform the panel of your views and to discuss the levels within the assessment (Decision Support Tool) document.

You will be invited to attend the first part of the panel meeting to give the Panel your views of any procedural issues that have arisen and also of your/your relative’s needs. The Panel will consider needs as described in the Decision Support Tool and will want to know from you where there is disagreement with the information in it.  If you want to give your opinion on the level of needs in each of the care domains, you will be able to do this.

The panel will consider the following:

• The process that has been followed in reaching a decision regarding eligibility for NHS CHC.
• Whether the eligibility criteria has been robustly applied in accordance with the National Framework.
• The panel will be unable to consider any challenges against the actual content of the criteria.

The Panel has the power;

• To decide disputes between the parties relating to eligibility and or funding of, Continuing Healthcare in line with the relevant statutory guidance, and,
• To direct reimbursement where it has been determined that the party who has been funding the adult is not liable to do so, or, in the case of jointly funded packages, not liable to do so at the rate they have been.

The Panel will deliberate after you have left the meeting and reach its recommendation regarding eligibility for NHS CHC in accordance with the National Framework. You will not be informed of the decision on the day of the panel.

You will be informed of the Local Appeal Panel’s decision within 21 days of the panel meeting. You will receive a copy of the panel outcome and rationale.

We aim to complete stage 1 and 2 within 3 months of receipt of your request for an appeal.  This may take slightly longer if further assessments are required.

If you do not agree with the outcome you can ask NHS England to review the decision and convene an Independent Review Panel (IRP). The local processes must have been completed before they will consider your request. Details of how to do this and how to contact NHS England will be included with the information sent to you following the local appeal.

If you disagree or remain unhappy with the decision/outcome of the NHS England IRP, you may request a further review by the Parliamentary and Health Service Ombudsman.

The current eligibility criteria are set out in the National Framework for NHS CHC and NHS-funded Nursing Care. You can find the policy and the Decision Support Tool at the following website www.gov.uk search continuing Healthcare.