CHC Funding and care costs: When should NHS Continuing Healthcare be considered?

What is CHC funding?

NHS Continuing Healthcare is a package of ongoing health and associated social care arranged and funded solely by the NHS for an adult who has been assessed as having a “primary health need”.  

In England, the relevant Integrated Care Board (ICB) is responsible for deciding eligibility and commissioning the care package. The ICB must follow the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care. 

CHC funding may be provided:  

• in the person’s own home;  

• in a residential care home;  

• in a nursing home; or  

• in another appropriate care setting.  

Eligibility is not determined by where the person lives, who provides the care or the reason care is required. It should be based on the totality of their assessed needs. 

What care costs can CHC funding cover?  

Where a person is eligible for CHC, the NHS is responsible for arranging and funding a care package that meets their assessed health and associated social care needs.  

In a care home, this can include accommodation as well as the care itself. At home, CHC funding may cover an appropriate package of nursing, personal care and other support. 

This differs significantly from local authority funding. 

Local authority support is subject to a financial assessment (means test). CHC funding is not means-tested, so a person’s savings, income and property should not determine whether they qualify.  

The key question is not: 

Can my relative afford the care fees?  

Instead, ask: 

Has their possible eligibility for NHS Continuing Healthcare been properly considered before they are treated as responsible for the cost?  

A request for financial information does not confirm that the correct funding route has been determined. 

When should CHC funding be considered?

CHC funding should be considered where an adult may have significant, ongoing or complex health-related care needs.  

There is no single diagnosis or condition that automatically establishes eligibility. Equally, a person should not be excluded merely because they are elderly, have dementia, live in residential care or receive support from carers rather than registered nurses.  

Closer consideration may be required where your relative:  

• needs frequent supervision or intervention to remain safe;  

• has needs that change quickly or are difficult to predict;  

• requires close monitoring of medication, behaviour, nutrition or other health symptoms;  

• cannot communicate pain, distress or deterioration reliably;  

• is at risk of falls, choking, pressure damage, infection or other harm;  

• has several needs that interact and make care difficult to manage;  

• requires substantial support during both the day and night.  

These factors do not guarantee eligibility, but they suggest the person should be screened and assessed before being considered liable for the cost of their care. 

The key question is whether the overall nature, intensity, complexity or unpredictability of the person’s needs demonstrates a primary health need.  

These characteristics look at the type and severity of the needs, the quantity and quality of care required, how different needs interact, and the risks created when needs fluctuate or cannot be predicted.  

Eligibility should not be reduced to a diagnosis or a mechanical count of assessment scores.  

Why might CHC funding be overlooked?

In practice, NHS Continuing Healthcare may not be raised when care arrangements are first discussed.  

A family may be told that their relative is a “self-funder” because they own a property or have savings. That may be relevant to local authority support, but it does not answer the separate question of whether the NHS should fund the care.  

Other problems may include:  

• focusing on a diagnosis instead of actual day-to-day needs;  

• treating managed needs as though they no longer exist;  

• looking at each need in isolation;  

• relying on incomplete or inaccurate care records;  

• assuming residential care cannot involve a primary health need;  

• proceeding directly to a means test without considering CHC.  

A need remains even if effective care is preventing harm. 

For example, incidents of severe aggression may have reduced because staff are adhering to a skilled support plan.  Pressure damage may be healing due to an intensive management plan. Medical symptoms may appear more stable with a complex regime of medications in place.   

The assessment should account for the care needed to maintain apparent stability. 

This does not mean every person receiving substantial care will qualify. Nor does every refusal justify a challenge. The merits depend on the evidence, the assessment and how the National Framework was applied.  

What should you check before paying care fees?  

Necessary care should not be delayed while the funding position is investigated. However, families should take practical steps to establish who may be responsible for the cost. This varies according to local policy. 

Ask whether CHC has been considered  

For most people, the process begins with the NHS Continuing Healthcare Checklist. This is a screening tool used to identify whether a full eligibility assessment may be required. It is not, however, the final funding decision. 

Ask whether a Checklist has been completed. If it has, request a copy together with the written reasons for the outcome.  

Where no Checklist has been completed despite significant health-related needs, make a written request to an appropriate health or social care professional or contact the relevant ICB.  

Check the underlying evidence  

The assessment should reflect the person’s needs over time, rather than a brief snapshot.  

Relevant evidence may include:  

• care plans and daily records;  

• nursing and medical records;  

• medication records;  

• risk and incident reports;  

• food, fluid and weight records;  

• evidence of night-time care and preventative interventions.  

Check whether vague descriptions such as “stable”, “settled”, “well-managed” or “needs support” conceal a significant level of care.  

Keep financial records  

Retain care home contracts, invoices, bank statements, receipts and correspondence about fees.  

These documents may become important if the funding position is later challenged or reimbursement is sought. Farley Dwek has previously helped a family reclaim more than £200,000 in care fees after securing NHS Continuing Healthcare funding. 

Each case depends on its own evidence, but this example highlights the importance of keeping assessment documents and proof of payments. 

Do not confuse the two assessments  

A local authority financial assessment and a CHC assessment answer different questions.  

The financial assessment considers whether a person must contribute towards care falling within the local authority’s responsibilities. A CHC assessment considers whether the person has a primary health need for which the NHS is responsible.  

Completing financial forms does not confirm that CHC eligibility has been properly considered. 

When might specialist advice be needed?

Specialist advice may be appropriate where:  

• CHC has not been considered despite significant health needs;  

• a Checklist appears to understate the person’s needs;  

• important care or medical records have been omitted;  

• the assessment does not reflect the reality of day-to-day care;  

• managed needs have been treated as insignificant;  

• the ICB’s reasons appear inconsistent with the evidence;  

• substantial care fees are being paid while funding remains disputed.  

A refusal is not always incorrect, but it should be reviewed carefully if the records and assessment do not align. 

Farley Dwek’s successful CHC appeal case study demonstrates how the withdrawal of funding was overturned where the evidence showed that the person’s needs had changed but had not reduced.  

Farley Dwek’s specialist solicitors and experienced nurses can review care, nursing and medical records, identify factual or procedural errors and advise whether there are reasonable grounds to pursue the matter.  

Do not assume care costs are always a private responsibility

CHC funding will not apply to everyone who needs care. However, families should not accept substantial care costs without first understanding whether NHS Continuing Healthcare may be relevant.  

The correct funding route should depend on the person’s assessed needs—not assumptions about their age, diagnosis, savings or place of residence.  

If your relative has significant health-related needs, ask whether CHC has been considered, obtain the assessment documents and check whether the evidence accurately describes the care they require.  

Are you concerned that your relative’s health needs have not been properly considered, or that the assessment does not reflect the underlying records? Speak to Farley Dwek for an initial discussion. Our specialist lawyers and experienced Nurse Assessors can review the evidence and help you understand whether further action may be justified.