THE funding of residential care is a thorny topic and the subject of much controversy. Who pays for treatment – the NHS or local authorities – is a perennial debate that raises the hackles of politicians and campaigners alike. Although big changes have occurred in recent years, it is still a complex subject and here we try to untangle the red tape to outline the latest advice and information…

Continuing Care

IF you have a need for long-term care, you often require services from your local social services department or NHS, or both. In a lot of cases, it is obvious whether it is the NHS or social services that should fund your care. But if your needs are complex, the boundaries between social care and health may become blurred. Whereas NHS services are free, those supplied by social services undergo a means test, so the result of who has responsibility for your care has major financial consequences for all parties.

The Health Service Ombudsman has investigated several complaints about the guidelines and criteria used when making such decisions and it was amid this background that the National Framework for NHS Continuing Healthcare and NHS-Funded Nursing Care was developed in England.

Health workers tend to use specific terms when discussing the different support available. So before we go any further, let’s briefly explain what they are:

Continuing Care: A general term describing care provided over an extended length of time to those over 18 to meet physical and mental health needs caused by an accident, disability or illness. It may require services from the NHS and/or social services.

Continuing Health and Social Care: This is available in various settings and may involve social services and NHS support.

NHS Continuing Healthcare: A package of ongoing care funded and arranged by the NHS.

NHS-Funded Nursing Care This is the funding given by the health service to homes to support the provision of care from a registered nurse.

Intermediate Care: This can be available for up to six weeks and is free of charge. The aim is to allow the patient to return to his or her own home following treatment at hospital.

Also, take note that in 2002 residential homes became known as “Care Homes” and nursing homes became known as “Care Homes registered to provide Nursing”.

NHS Continuing Healthcare

THIS is a total package of care funded and arranged by the NHS to meet the mental health and physical needs of a patient. You can receive this care in any location, including your home or a Care Home. If you live at home, the NHS funds your assessed health and personal care needs. If you are in a Care Home, the NHS draws up a contract with the Home to pay the fees for your care and accommodation.

The NHS Primary Care Trust (PCT) covering the area where your GP is based decides if you are eligible and, if so, is then responsible for the funding and arrangement of your care.

The Department of Health published the National Framework for NHS Continuing Healthcare and NHS-Funded Registered Nursing Care” in June 2007. This guidance document sets out the principles and procedures to be followed across England for identifying if your need for care is mainly due to your physical and mental health. The intention of this guidance is to improve the transparency and consistency of decision-making by PCTs across the country.

Who Is eligible?

YOU are entitled to NHS Continuing Care if it is shown you have a primary health need. Decisions on eligibility cannot be influenced by who cares for you, where the care is and your diagnosis. They should be made based on your physical and mental health needs

Your eligibility should be considered if you have a deteriorating condition that may be terminal; before you are discharged from hospital and a Care Home place may be necessary; or when your current care package seems inadequate for your needs. A PCT must take reasonable measures to make sure an assessment for NHS Continuing Healthcare is carried out according to the national guidance.

When deciding eligibility, staff should follow the procedures in the national guidance using one or more of the three tools: the fast-track tool, checklist tool and decision-support tool.

National Framework Decision-Making

STAFF will seek your consent before assessing your eligibility. You can also request that your family’s views are considered and can select a relative or friend to be your advocate. Best practice guidance was issued in March 2010 and provides a practical explanation of how the Framework should work on a day to day basis and includes examples of good practice.

If it is decided you lack the mental capacity to make decisions over your health and don’t have a relative or carer who can be consulted, the PCT must think about appointing an Independent Mental Capacity Advocate (IMCA) if it is proposing major medical treatment or a change of accommodation. More details about these issues are available from the Office of the Public Guardian (0845 330 2900). The role of the IMCA would be to decide what would be in your best interests.

Fast-Track Tool: This is used if you have a condition that is rapidly deteriorating, or if you are terminally ill. Although usually used in hospitals, it can also be used by a GP, or specialist nurses. The decision to fast-track needs PCT approval and should be followed by a needs assessment.

Checklist Tool: This is used once it is agreed fast-track is unnecessary. Checklist encourages assessments that may be appropriate to your needs and assist health and social care experts identify who is eligible for NHS Continuing Healthcare. The Checklist is based on the Decision-Support Tool and involves 11 areas of need being assessed. The idea is a variety of health professionals can use this Checklist.

Once it is decided that a full consideration of NHS Continuing Healthcare is needed, the PCT appoints a co-ordinator to oversee the Multi-Disciplinary Assessment (M-DA) of your needs until a final decision is reached and your Care Plan is written. The M-DA takes into account your own perception of your needs and how you wish to be supported. It should involve your family and relevant health professionals. Involving social services and NHS staff in your assessment will streamline the planning of your future care.

Decision-Support Tool (D-ST): Eleven areas of need are described in the D-ST. They are behaviour, cognition, psychological and emotional needs, communication, mobility, nutrition, food and drink, continence, skin and tissue viability, breathing, drug therapies and medication: symptom control and altered states of consciousness. For each area, there is space in the tool to justify why a specific level of need has been chosen.

Decision Time: The co-ordinator liaises with the Multi-Disciplinary Team (M-DT) to complete the D-ST. They have to match your level of need, which has been identified during your assessments, as closely as possible with one statement for each of the 11 areas of the D-ST tool. In cases where the D-ST doesn’t support a recommendation of eligibility, the Multi-Disciplinary Team (MDT) uses the D-ST, national guidance notes and their professional judgment to reach a decision and make their recommendation to the PCT.

Although the final decision is with the PCT, the national guidance states that only in exceptional circumstances should the M-DT’s recommendation not be followed.

The PCT should tell you in writing once a decision is reached, usually within two weeks of a referral for full consideration. Your care can be provided in a Care Home, although you don’t have the right to choose the Home. You can also go to a Care Home in another PCT area, although the fees remain the responsibility of the PCT that initially agreed your placement. If you are already in a Home when the decision to grant fully-funded care is made, you need to talk to the PCT as to whether you can stay there. A hospice may also be appropriate if you are terminally ill. You can be treated in your own home but this is usually a more complex care package to arrange and depends largely on local resources.

Challenging A Decision

YOU and your family can approach the PCT if you are unhappy with its decision. The first step is the PCT’s local resolution process, which may involve a review of its decision by a panel from its own or a neighbouring PCT. Once local procedures have been exhausted, if you still remain unhappy, your case can be referred to the appropriate Strategic Health Authority (SHA) for an independent review (IR).

You should receive a written decision from the SHA of the review outcome. If the original decision is upheld, you can refer your case to the Healthcare Commission and, finally, the Parliamentary and Health Service Ombudsman.

State Benefits

IF you’re living in a Care Home and claiming Disability Living Allowance (DLA) or Attendance Allowance (AA) when you’re awarded Continuing NHS Healthcare, you should immediately inform the Disability Benefits and Carers Service (DBCS) by calling 0845 712 3456. Your benefit will stop on the 29th day after the PCT begins to fund your care. If you are living in your own home and claiming DLA or AA, but will need to move into a Care Home, you should also notify the DBCS. Again, your benefit will stop the 29th day after the PCT begins paying for your care. If you are given NHS Continuing Healthcare and receive care in your own home, you should continue receiving AA or DLA. Also, NHS Continuing Healthcare doesn’t have any effect on your State Pension.

Ongoing Reviews

THESE reviews reassess your care needs and eligibility for NHS Continuing Healthcare and make sure they are being met. Reviews should take place at least annually. Please bear in mind that eligibility for NHS Continuing Healthcare can be overturned at a later date.

Care Packages If Ineligible

IF you are ineligible for NHS Continuing Healthcare, your needs may be provided via a joint social care and health package. Crucially, your PCT and social services will have to agree where the funding responsibilities lie. You will undergo a means test for services that are the responsibility of social services.

The following NHS services might be provided in their own right or alongside a social care package: palliative care, rehabilitation and recovery services, respite health care services, care provided by a nurse in a nursing home and GP care. You should get the same primary and community health services in a Care Home as you receive in your own home.

Rehabilitation and recovery services are there to promote recovery and independence, which might include speech therapy, physiotherapy and occupational therapy. Respite services are usually provided by councils if you are cared for at home by a relative or friend. They are normally provided when your regular carer is ill or to give them a break. But the NHS also has responsibilities for the provision of respite care. Crossroads, a charity, also offers respite care in your own home although you may have to pay for this (0845 450 0350). You may also be entitled to receive specialist health services. This might include continence advice, stoma care and diabetic advice.

Also, if you have a terminal illness, you might be entitled to palliative care, which is designed to keep you comfortable and ensure the best quality of life. Treatment includes pain relief and emotional support.

If you believe you or a relative may have been wrongly denied NHS Continuing Healthcare before the introduction of the National Framework in October 2007, you can ask the PCT to review the case. Call NHS Direct on 0845 46 47 if you don’t know which PCT to contact to request a review.

NHS-Funded Nursing Care

This is NHS funding to Care Homes registered to provide Nursing Care. This supports care for residents by a registered nurse employed by the Care Home. The payment is made by the PCT in the area where the Care Home is based.

Need For Nursing Care: Decisions about eligibility for NHS Continuing Healthcare have to be made before considering the need for NHS-Funded Nursing Care. If you don’t meet the Checklist threshold for full consideration of NHS Continuing Healthcare, your nursing needs are assessed via a joint NHS and social services assessment. If it is agreed a Care Home that provides nursing will best suit your needs, your nursing needs can be recorded in your Care Plan.

The National Framework also altered the payment system from a three-band system to a single rate for residents who entered a Care Home on or after October 1, 2007. The current payment is £103.80 per week and the rate is reviewed annually in April.

Hospital Admission

IF YOU are admitted to hospital from your Care Home, the PCT doesn’t pay nursing care costs during that time. If you pay for your own care, discuss with the Care Home when agreeing terms the level of fees necessary to retain your place should you go into hospital.

Care Home Fees/NHS Payments For Nursing Care: New guidelines introduced in September 2006 oblige Care Homes to specify in their service user’s guide the “total fees payable”, arrangements for payment and procedures for charging and paying for additional services. The National Minimum Standards for Care Homes for Older People requires that residents have a written contract with the Care Home. The booklet Fair Terms for Care is produced by the Office of Fair Trading (OFT) (0845 722 4499) to assist you in deciding whether the terms of a Care Home contract are fair.

Intermediate Care

THESE services help increase your independence by helping to prevent unnecessary hospital admission. Intermediate care must be:

• Targeted at those who might otherwise endure unnecessary hospital stays, prolonged residential care, or continuing inpatient care
• Provided after an assessment, which results in a Care Plan
• Aimed at a planned result outcome that allows you to maintain or regain ability to live in your own home
• Time limited – usually a maximum of six weeks

There are no fees for any health and/or social care services offered as part of intermediate care which is provided for up to six weeks. Services include: rapid response teams and personal care at home, hospital at home scheme, residential rehabilitation and occupational therapy.

Intermediate care must include active therapy, treatment and an opportunity for recovery. It isn’t intended to be used while you’re waiting for a Care Home place to become available.

Contacts List

Alzheimer’s Society: 0845 300 0336, www.alzheimers.org.uk

Crossroads Caring for Carers: 0845 450 0350, www.crossroads.org.uk

Healthcare Commission: 020 7448 9200, complaints helpline: 0845 601 3012, www.healthcarecommission.org.uk

Hospice Information: 0870 903 3903 or 020 7520 8232, www.hospiceinformation.info/index.asp

Macmillan Cancer Relief: (free) 0808 808 2020, www.macmillan.org.uk

Marie Curie Cancer Care: 020 7599 7777, www.mariecurie.org.uk

NHS Direct: 0845 46 47, www.nhsdirect.nhs.uk/

Office of Fair Trading: Consumer helpline: 0845 722 4499, www.oft.gov.uk

Office of the Public Guardian: 0845 330 2900, www.publicguardian.gov.uk/

Parliamentary and Health Service Ombudsman: Helpline 0845 015 4033, www.ombudsman.org.uk

*Please note the details published on this page are targeted at people aged 50 or more and refers to the situation in England.

**Also, please note that the information included here may change from time to time, so please take legal advice if you are in any doubt.