At PJ Care we appreciate that securing funding for your loved one is a daunting prospect and understanding the landscape of what, who and how can be difficult
We work with all funding bodies whether it’s Local Council, NHS, personal injury claims or private individuals.
Below is some information that outlines the national framework for funding but as every case can be different its worth researching in detail. We are not experts in this field as we do not arrange funding, but as we deal with funded referrals every day please call our team if you have any questions and we will help where we can.
Ask your local council or social worker for a care needs assessment. If the council decides you need support, it will carry out an assessment of your finances.
This financial assessment (‘means-test’) will determine if the council will pay for your care, whether you have to contribute to the costs or whether you need to pay the full costs yourself.
You will have to pay the full cost of your care if you have more than £23,250 in savings. Unless you're going into a care home this amount does not include the value of your property.
If your savings are less than £23,250 but more than £14,250, then your local council will pay for your care, but you will have to contribute £1 to the fees for every £250 of savings you have. If you have less than £14,250 in savings, your appropriate care will be fully paid for by the council.
For further information: https://fullfact.org/health/adult-social-care-england/
NHS Continuing Healthcare is the name given to a package of care which is arranged and funded solely by the NHS for individuals outside of hospital who have ongoing health care needs. You can receive NHS continuing healthcare in any setting, including your own home or in a care home. NHS continuing healthcare is free, unlike support provided by local authorities for which a financial charge may be made depending on your income and savings. If you are found to be eligible for NHS continuing healthcare in your own home – this means that the NHS will pay for health care (e.g. services from a community nurse or specialist therapist) and associated social care needs (e.g. personal care and domestic tasks, help with bathing, dressing, food preparation and shopping). In a care home, the NHS also pays for your care home fees, including board and accommodation.
To be eligible for NHS Continuing Healthcare, you must be assessed by a team of health care professionals (a ‘multi-disciplinary team’). The team will look at all your care needs and relate them to
• 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.
Your eligibility for NHS Continuing Healthcare depends on your assessed needs, and not on any particular diagnosis or condition. If your needs change then your eligibility for NHS Continuing Healthcare may change.
You should be fully involved in the assessment process and kept informed, and have your views about your needs and support taken into account. Carers and family members should also be consulted where appropriate.
A decision about eligibility should usually be made within 28 days of it being decided that the person needs a full assessment for NHS Continuing Healthcare.
Initial assessment for NHS Continuing Healthcare
The initial assessment or “CHC checklist” as its usually called can be completed by a nurse, doctor, other health care professional or social worker who are currently involved in your care.
Depending on the outcome of the checklist, you will either be told that you don't meet the criteria for a full assessment of NHS Continuing Healthcare and are therefore not eligible; or you'll be referred for a full assessment of eligibility. Being referred for a full assessment doesn't necessarily mean you'll be eligible for NHS Continuing Healthcare. The purpose of the checklist is to enable anyone who might be eligible to have the opportunity for a full assessment.
Full assessment for NHS Continuing Healthcare
Full assessments for NHS Continuing Healthcare are undertaken by a ‘multi-disciplinary team’ made up of a minimum of two health or care professionals who are already involved in your care. You should be informed who is co-ordinating the NHS Continuing Healthcare assessment and is should be carried out within 28 days.
The team's assessment, using a Decision Support Tool (DST), will consider your needs under the following headings:
• cognition (understanding)
• psychological/emotional needs
• nutrition (food and drink)
• skin (including wounds and ulcers)
• symptom control through drug therapies and medication
• altered states of consciousness
• other significant needs
These needs are given a weighting marked ‘priority’, ‘severe’, ‘high’, ‘moderate’, ‘low’ or ‘no needs’.
If you have at least one priority need, or severe needs in at least two areas, you should be eligible for NHS Continuing Healthcare. You may also be eligible if you have a severe need in one area plus a number of other needs, or a number of high or moderate needs, depending on their nature, intensity, complexity or unpredictability.
In all cases, the overall need, and interactions between needs, will be taken into account, together with evidence from risk assessments, in deciding whether NHS Continuing Healthcare should be provided.
The assessment should take into account your views and the views of any carers you have. You should be given a copy of the decision documents, along with clear reasons for the decision.
If you are not eligible for NHS Continuing Healthcare, there are two further options:
• You may be referred to your local authority who can discuss with you whether you may be eligible for support from them. If you still have some health needs, then the NHS may pay for part of the package of support. This is sometimes known as a "joint package" of care
• You may be eligible for NHS Funded Nursing Care (FNC) if:
o you are not eligible for NHS Continuing Healthcare but have been assessed as needing care from a registered nurse
o you live in a care home registered to provide nursing care
If you do not agree with the outcome you can appeal with supporting evidence.
If you are eligible for NHS Continuing Healthcare, the next stage is to arrange a care and support package that meets your assessed needs.
Depending on your situation, different options could be suitable, including support in your own home and the option of a personal health budget. If it's agreed that a care home is the best option for you, there could be more than one local care home that's suitable.
Your CCG should work collaboratively with you and consider your views when agreeing your care and support package and the setting where it will be provided. However, they can also take other factors into account, such as the cost and value for money of different options.
Once all information has been gathered, along with appropriate costs this will then be taken to the CCG Panel for a decision on the cost of funding
MDT - Multi-Disciplinary Team
An MDT is a group of health professionals with expert knowledge in your type of condition(s), presentation and care needs who will manage your treatment.
This group can vary depending on your dependency in various health areas and the team in place if you are in a care home environment.
Example: this could be a unit manager and HCA/nurse in a care home or it could include people covering areas such as psychology, psychiatry, occupational health and physiotherapy in a hospital or specialised care centre.
CHC - Continuing Healthcare Team
The continuing healthcare team are part of a Clinical Commissioning Group (CCG) and are tasked with managing peoples care provision needs within their area. The main part of their role is to evaluate and match the most suitable care package with the individual’s requirements.
Clinical nurses will carry out assessments using a Decision Support Tool (DST) to see if someone is eligible for fully funded NHS care.
If eligible then options of possible care are matched and if needed taken to panel (see below) for approval.
Care packages can be limited to the team’s awareness of suitable options & locations so always research yourself and make sure you are involved in the process as your input has to be taken into account.
Some CHC teams are out-sourced and managed by other organisations so don’t be surprised if their organisation name does not match the local area CCG.
DST - Decision Support Tool
The Decision Support Tool (DST) is used in NHS continuing healthcare funding decisions, it’s a document which helps to record evidence of an individual’s care needs to determine if they qualify for continuing healthcare funding.
As the Decision Support Tool (DST) fits into the continuing healthcare decision-making process, it is important to understand the procedure in its entirety to fully appreciate the importance of the DST.
Best Interest Meeting
Some decisions around a person’s care are controversial or complex so it is appropriate to hold a best interests meeting.
Where assessments of mental capacity relate to day-to-day decisions and caring actions they can be recorded on the appropriate care plan and supporting documentation. The Act provides protection from liability for actions taken as long as those actions can be understood to have been in a person’s best interests. Evidence of the assessments of capacity and of the best interest’s process should be recorded to provide robust and clear documentation that records the action that has been taken. As the seriousness of the decision and/or the action increases then the need for a clear documented record increases.
Best interests meetings can be formal or part of a multi-disciplinary meeting. The decision-maker will need to consider what sort of meeting is appropriate and what sort of involvement and support is necessary for making and recording each particular decision.
A best interests meeting should include information from relevant professionals, family members and the person who lacks capacity. If these people don’t attend the meeting their views must be represented. This is a requirement in the best interest’s checklist.
FNC - Funded Nursing Care
NHS Funded Nursing Care is care provided by a registered nurse for people who live in a care home. The NHS will pay a flat rate contribution directly to the care home/agency towards the cost of this registered nursing care being provided.
£158.16 (since 1/4/2018) can be deducted from the overall weekly charge for a care home placement that has registered nurses.
You may be eligible for NHS Funded Nursing Care (FNC) if:
• you are not eligible for NHS Continuing Healthcare but have been assessed as needing care from a registered nurse
• you live in a care home registered to provide nursing care
CCG - Clinical Commissioning Group
Clinical Commissioning Groups are designed to be clinically led and responsive to the health of their local populations. They are membership bodies made up of GP practices in the area they cover. The members set out in their constitution the way in which they will run their CCG. Constitutions are agreed with NHS England and published. The law requires that members appoint a governing body to oversee the governance of the CCG which must have at least six members including a chair and a deputy chair.
• The CCG’s Accountable Officer
• The Chief Finance Officer
• A Registered Nurse
• A Secondary Care Specialist
• Two lay members
Many CCGs have appointed additional members to bring added perspectives to their governing body. Details must be set out in their constitution. Although the members of the CCGs are GP practices, CCGs are required to obtain expert advice from a broad range of health professionals.
The CCG’s are essentially in charge of the budget for healthcare needs in their area, approve care options and depending of the level of spend cases may have to be taken to panel for further discussion and authorisation.