Continuing Healthcare

NHS-funded Nursing Care

NHS-funded Nursing Care (FNC) is the funding provided by the NHS directly to care homes with nursing to support the provision of nursing care by a registered nurse. Where the individual lives in their own home or care home without nursing, the NHS will provide such care via community services, such as district nurses.

How is eligibility for NHS-funded Nursing Care assessed?

In all cases, individuals will be considered for eligibility for NHS Continuing Healthcare (CHC) before a decision is reached about the need for NHS-funded Nursing Care.

If a checklist indicates that no referral is necessary for a full assessment, but registered nursing needs are identified, then FNC can be awarded without needing a further assessment.

If the Decision Support Tool identifies that the patient is not eligible for CHC, it will consider whether they are suitable for FNC.

The registered nursing needs are services a registered nurse provides and involve either the provision of care or the planning, supervision or delegation of the provision of care.

Applying for NHS Continuing Healthcare or NHS-funded Nursing Care

A nurse, doctor or other qualified healthcare professional or social care practitioner can apply the checklist to refer individuals for a total consideration of eligibility from within the community or hospital setting.

A referral can also be made through a telephone call, email or letter from a patient or their representative. This will usually result in the completion of a checklist by the CHC Team.

What is a Fast Track?

The Fast Track application is there to ensure that individuals with a rapidly deteriorating condition and may be entering a terminal phase have access to NHS Continuing Healthcare funding with minimum delay and without needing to complete a DST.

A completed Fast Track Pathway Tool, which evidences that an individual is rapidly deteriorating and may be entering a terminal phase, is sufficient to establish eligibility.

The Fast Track Tool will be completed by an 'appropriate clinician' described in the National Framework as a person who is:

• responsible for the diagnosis, treatment or care of the individual under the National Health Service Act 2006 in respect of whom a Fast Track Pathway Tool is being completed and;
• a registered nurse or a registered medical practitioner.

The appropriate clinician will be knowledgeable about the individual's health needs, diagnosis, treatment or care and be able to provide an assessment of why the individual meets the Fast Track criteria.

If you are involved in supporting those with end-of-life needs (including those in broader voluntary and independent sector organisations), you should contact the appropriate clinician responsible for the individual's diagnosis, care or treatment and ask for consideration to be given to completion of the Fast Track Pathway Tool.

Appealing a decision for Continuing Healthcare Care or NHS-funded Nursing Care

Stage 1 - Submit an appeal

Where an individual has been found not eligible for NHS Continuing Healthcare or NHS-funded Nursing Care following completion of a DST, they or their representative can appeal the decision within six months of the date of the outcome letter.

When an appeal is received, it will be acknowledged by a phone call from a clinician, allowing the opportunity to establish any process issues that the appellant may have in addition to the outcome of the DST. A letter will then be sent to the appeallant together with a questionnaire to complete and a request for documentation concerning their authority to act.

Once this has been returned, evidence will be obtained from all parties involved in the patient's care for six weeks before and two weeks after the DST completion date being appealed. This evidence will be reviewed by a clinical assessor who was not previously involved in completing the DST. The appellant will then be advised in writing of their decision.

Stage 2 - Local Resolution Meeting

If the appeal is not resolved at this point, the next stage of the local appeal process is the offer of a Local Resolution Meeting (LRM). The individual and their representatives will be invited to attend the virtual LRM and participate in the discussion. The meeting will be chaired by a clinical team member who a Clinical Assessor will accompany. 

This meeting will review the original DST decision and the outcome of the first appeal. Notes will be made of the meeting discussion and these, together with the Clinicians' decision, will be sent to the appellant. We aim to offer a date for the LRM as soon as the request is received and these meetings are currently taking place within two months.

Where it is identified at the Appeal stage that the DST was not conducted as an MDT, the team will make every effort to hold the LRM as an MDT. Although the Local Authority is not required under the terms of the National Framework to attend the LRM, an invitation is always sent to them ahead of the meeting, allowing attending if they wish to do so. Where the DST was not completed as an MDT and the Local Authority chose not to attend, the LRM will be held using clinicians from different backgrounds wherever possible.

Stage 3 - Independent Review

If following the LRM, the individual or their representative remains unhappy with the ICB's decision; they can approach NHS England to request an Independent Review Panel (IRP) by emailing:

england.southeast-chc@nhs.net

If an individual or their representative does not have access to an email account, the Appeals Team is happy to assist should they be approached.

The CHC Team will have taken all appropriate steps to resolve the case locally before an IRP is convened.

The IRP can be asked to review either or both of the following:

• the procedure followed by an ICB in deciding that person's eligibility for NHS Continuing Healthcare
• the primary health need decision made by an ICB.

The IRP meeting, arranged and hosted virtually by NHS England in accordance with the National Framework, will recommend to the CHC Team considering its findings on the above matters.

Stage 4 - complain to the Parliamentary and Health Service Ombudsman

Following an IRP, if the original decision is upheld, but there is still a challenge, the individual has the right to complain to the Parliamentary and Health Service Ombudsman (PHSO).

The complaint needs to be made in writing within 12 months of the date of the IRP outcome letter to the PHSO at the following address:

Parliamentary and Health Service Ombudsman
Millbank Tower
Millbank
London
SW1P 4QP

Making a retrospective claim for care already received

The CHC Team will only consider requests for retrospective reviews where it is satisfied that one or more of the following grounds for the review exists:

• The CHC Team failed to assess the patient's eligibility for NHS Continuing Healthcare funding when requested.
• The request for a retrospective review is for periods of unassessed care.
• The period to be considered is after 1st April 2013, as the opportunity to claim for periods before that date has now passed.

Requests for a retrospective review, which should detail the period you want to be considered, should be sent to:

NHS Continuing Healthcare Team
Block C Floor 1
Dukes Court
Dukes Street
Woking
GU21 5BH

syheartlandsicb.chcappeals@nhs.net 

If the CHC Team agrees to undertake a retrospective review, the applicant will be asked to complete a questionnaire and provide documentation concerning their authority to act.

Once this has been returned, evidence will be obtained from all parties involved in the patient's care for the claim period.

The evidence will be reviewed by a clinical assessor who will complete a Portrayal of Needs (PON) document detailing the individual's health needs throughout the review. Once met, the PON will be shared with the applicant, who will be requested to confirm the details presented and provide any further comments they may have.

The clinical assessor will use the PON and any comments made to produce the retrospective Decision Support Tool(s). The DST(s) will contain a recommendation on the individual's eligibility for NHS CHC or NHS-funded Nursing Care (FNC) for the review period. That recommendation will be submitted to a multi-disciplinary team (MDT) panel, as the Local Authority does not participate in the retrospective process.

Wherever possible, the MDT will comprise two healthcare professionals from different backgrounds within the CHC Team. The MDT panel will consider the clinical assessor's recommendation and decide on eligibility.

The applicant will send a letter detailing the retrospective review's outcome. The outcome will be either:

• The individual was eligible for Continuing Healthcare Funding/NHS-funded Nursing Care throughout the Retrospective Review 
• The individual was eligible for Continuing Healthcare Funding/NHS-funded Nursing Care for part of the period of the Retrospective Review
• The individual was not eligible for Continuing Healthcare Funding/NHS-funded Nursing Care for any part of the period of the Retrospective Review

If the CHC Team decides that the individual was eligible for all or part of the period under consideration, reimbursement arrangements will be made.

If the applicant is unhappy with the outcome of the Retrospective Review, they can notify the Appeals Team within six months of the date of the outcome letter that they wish to appeal the decision further. Any appeal of a retrospective review will follow the appeals process.