NHS CHC funding: How can nurses better advocate for patients?

Navigating the complexities of NHS Continuing Healthcare (CHC) can be a daunting task – not just for patients and families, but also for the nurses supporting them clinically through the process, says solicitor James Urquhart-Burton. Here he offers some advice from a legal perspective.

NHS Continuing Healthcare (CHC) is a fully funded package of care provided by the NHS to adults with significant ongoing health needs. Unlike means-tested social care, CHC is free at the point of delivery and based solely on the primary clinical need of the patient in question.

It is not based on diagnosis or financial status, but on the nature and type of the care required to meet the individual’s needs and can cover the entire cost of care in various settings, including the patient’s own home, a care home or a nursing facility.

This article aims to offer some key insights and practical tips on the often misinterpreted, undoubtedly complicated process of applying and appealing for NHS CHC funding can help them to better understand it, and advocate more effectively for patients.

The CHC assessment process

Here is a step-by-step guide to the process.

1. Checklist screening

Typically performed by a nurse or social worker to decide if a full assessment is warranted.

2. Full assessment from the multidisciplinary team (MDT)

This team will use the Decision Support Tool (DST) to evaluate whether or not the patient meets the eligibility criteria.

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3. Final decision from the Integrated Care Board (ICB)

Based on the findings from the MDT.

4. Fast track assessment

Available for patients with rapidly deteriorating conditions in need of urgent assessment and care support.

Common myths about CHC

Understanding and dispelling any of the common misconceptions around CHC funding is essential for anyone supporting patients and their families through the process.

Here are some of the most prevalent myths:

‘You won’t qualify for CHC Funding if you have substantial financial savings or own property.’

False: CHC is not means-tested.

‘CHC Funding is only available to those already living in care homes.’

False: CHC can fund home-based care as well.

‘Diagnosis of an illness/condition guarantees eligibility for CHC Funding.’

False: Eligibility is based on care needs, rather than the specific condition that a patient has been diagnosed with.

How nurses can better advocate for patients and their families

Spotting early signs

Nurses may be in a good position to be able to recognise when a patient’s condition meets the criteria for CHC funding. Those with severe dementia, advanced neurological conditions or terminal illnesses should always be considered. Using the NHS Checklist screening tool is a transparent and lawful way to ensure an individual is properly considered.

Facilitating the assessment

Ensure the NHS Checklist is completed as accurately and quickly as possible, and – if necessary – push for a full DST-based assessment of the patient if they believe they should qualify.

Educate families

Help families to navigate the process by explaining that CHC is not determined by diagnosis or financial status of the patient and reassure them that the process is about needs-based support.

Avoiding pitfalls associated with CHC

Misapplication of criteria, complexity of the process, and lack of awareness – even among professionals – are common reasons why many elderly citizens in the UK are paying for care that should be free to them.

Here are a selection of the most common pitfalls that nurses can help to avoid:

Not applying in the first place

Families often don’t even know that CHC funding exists, so encouraging applications where appropriate is highly recommended.

Poor documentation

Missing key information out of an application for CHC funding can be the difference between approval and denial, so ensuring all healthcare needs and specifications are well documented is vital.

Misinterpretation of care needs

It’s crucial to clarify the distinction between the healthcare needs and the social care needs of a patient applying for CHC funding, as mislabeling the former as the latter is a common reason for rejection. Careful thought should be given the skill needed to meet the individual’s needs, rather than the type of carer or professional caring for them, or the setting in which the care is provided.

When CHC funding is denied

Even if a checklist rejection can’t be formally appealed, families can still raise a complaint under NHS procedures.

If a full eligibility assessment was undertaken and a decision made to decline, families may wish to appeal, resulting in reconsideration of the decision. Families can pursue:

A local review within 6 months
An Independent Review Panel via NHS England thereafter.

Nurses can support families who wish to appeal by signposting families to the appeals process and make them aware that there are professional organisations that can help with appeals if need be.

Challenges within the system

Patients living with dementia can be particularly at risk of being overlooked when it comes to CHC funding and applications:

Their needs are often misclassified as social care rather than healthcare
Family-provided care may hide the extent of the patient’s needs
Communication challenges may obscure the patient’s condition.

Nurses may help by ensuring that dementia-related needs, such as psychological distress, behavioural issues and pain, are accurately recorded, as the CHC assessment process is evidence-based.

Furthermore, systematic issues like regional inconsistencies, delays, and underfunding can affect patients’ access to CHC, with recent austerity leading to administrative delays and fewer assessments taking place.

Nurses could help mitigate these issues by:

Highlighting delays in assessments
Escalating notable concerns to case managers
Supporting legal or advocacy involvement when necessary.

Professional services can have a role when CHC decisions appear flawed. Proper representation by a skilled and experienced professional, such as a legal advocate, can ensure that the patient’s voice is heard during assessments and appeals, and timely intervention can lead to successful funding appeals and better outcomes for patients.

James Urquhart-Burton is head of continuing healthcare claims at Winston Solicitors