Nursing Home Fees in the UK: Who Should Pay for Your Relative’s Care?

Who is responsible for nursing home fees in the UK?

There are three main funding possibilities: the resident pays privately, the local authority provides means-tested support, or the NHS funds the care through NHS Continuing Healthcare. 

Broadly, nursing home costs may be met privately, with means-tested local authority support, or through NHS funding. For residents who do not qualify for CHC but require registered nursing care, NHS-funded Nursing Care may also contribute towards the nursing element of the placement. 

This distinction matters because the two routes treat finances differently. Where local authority funding applies, the person’s capital, income and other financial circumstances can affect how much they contribute towards their care. 

CHC is different. Eligibility is based on assessed needs, not the person’s ability to pay. Someone with savings or property can therefore still qualify for fully NHS-funded Continuing Healthcare. 

Being described as a “self-funder” does not establish that NHS responsibility has been properly considered. Where your relative has significant health needs, the funding question should be addressed before private payment is simply accepted as inevitable. 

When can the NHS pay nursing home fees?

If your relative qualifies for NHS Continuing Healthcare, the NHS is responsible for arranging and funding the package required to meet their assessed health and associated social care needs. 

Eligibility does not depend on a particular diagnosis or care setting. Having dementia, Parkinson’s disease, a stroke or another serious condition does not mean an individual automatically qualifies for CHC. Equally, living in a residential home does not rule out eligibility. 

The assessment should consider the totality of the person’s needs and whether their nature, intensity, complexity or unpredictability demonstrates a primary health need. 

This can require looking at how different needs interact. A resident with severe cognitive impairment may not recognise that they are unsafe to mobilise, may resist assistance and may be unable to communicate pain or distress. What initially appears to be a mobility problem may therefore require considerably more monitoring and intervention because of the person’s other needs. 

The relevant question is what care the individual actually requires, why it is necessary and what risks arise if it is not provided. 

What if your relative appears stable?

A nursing home resident may appear settled or stable precisely because staff are successfully managing their needs through medication, supervision, repositioning, behavioural interventions or other care. 

The National Framework makes clear that well-managed needs are still needs. An assessment should consider the underlying need and the care required to manage it, rather than looking only at how the person appears during the assessment. 

The practical question is not simply whether your relative appears stable, but what staff have to do throughout the day and night to maintain that stability. 

How is NHS Continuing Healthcare assessed?

For most people, the process starts with the NHS Continuing Healthcare Checklist. This is a screening tool used to decide whether the person should proceed to a full CHC assessment. 

If a full assessment is required, a multidisciplinary team (MDT) should assess the person’s needs using the Decision Support Tool (DST), which captures necessary care interventions across 12 categories, before the eligibility criteria are applied. The MDT then makes a recommendation about whether the person has a primary health need, with the relevant Integrated Care Board (ICB) making the final decision. 

Although the ICB is ultimately responsible for the final eligibility decision, the National Framework states that an MDT recommendation should only be departed from in exceptional circumstances and for clearly explained reasons. The verification process should not be used as a financial or gatekeeping exercise.  

Families should be involved and given an opportunity to provide evidence. Before an assessment, it can be useful to identify recent falls, behavioural incidents, medication difficulties, night-time interventions, periods of deterioration or other events that demonstrate how much care is actually required. 

A relatively calm assessment day should not override evidence showing what the person’s needs are like over time. 

What should you check before accepting self-funding?

If your relative has significant health needs and nursing home fees are being charged, establish what consideration has actually been given to CHC. Ask for the relevant documents rather than relying on a verbal statement that your relative is unlikely to qualify. 

You should check: 

• Checklist and outcome 
• Completed Decision Support Tool 
• Verification panel minutes 
• Written eligibility decision 
• Evidence considered 
• Family evidence considered 
• Accurate needs descriptions 

The documents should then be compared with the underlying care and clinical evidence. A completed DST is of little reassurance if its descriptions do not correspond with what the records show about your relative’s day-to-day needs. 

The question is not simply whether the CHC process took place. It is whether the resulting decision is supported by the evidence. 

What evidence can reveal understated needs?

For someone living in a nursing home, some of the most useful CHC evidence will be found in the records created by those providing day-to-day care. 

Relevant evidence can include: 

• Care plans 
• Daily care notes 
• Nursing records 
• Medication records 
• Incident records 
• Risk assessments 

Other records may also be important depending on the person’s needs, including behaviour charts, nutrition records, skin-integrity documentation and relevant clinical records. 

The detail behind apparently reassuring descriptions can be revealing. A resident may be described as “settled” without the record explaining the medication, supervision or behavioural management required to maintain that stability. Notes may record that someone is assisted with transfers without explaining how many carers are needed, how often intervention is required or what happens when assistance is resisted. 

A care plan may similarly describe a risk as “managed” without explaining what staff must do to prevent that risk from materialising. 

When reviewing the evidence, consider whether the severity, frequency, risks and management of the person’s needs have been accurately captured. A brief summary can present a very different picture from the underlying records viewed over time. 

What if the NHS offers funded nursing care?

If your relative is refused CHC but receives NHS-funded Nursing Care (FNC), do not assume the FNC award proves that the CHC decision was correct. 

FNC is a contribution from the NHS towards care provided by a registered nurse for eligible nursing home residents who do not qualify for CHC. NHS Continuing Healthcare is different: where a person has a primary health need, the NHS funds their assessed package of health and associated social care. 

FNC should not be treated as a lesser alternative to CHC where the evidence may actually establish a primary health need. 

If the CHC assessment understates your relative’s needs or does not reflect the supporting evidence, an FNC award does not prevent the CHC decision itself from being examined. 

When can a CHC refusal be challenged?

Not every refusal of NHS Continuing Healthcare is wrong. Whether there are grounds for challenge depends on the assessment, supporting records and how the eligibility criteria were applied. 

A refusal may warrant closer examination where: 

• Needs were understated 
• Evidence contradicts the DST 
• Incidents were overlooked 
• Managed needs were discounted 
• Interactions were inadequately considered 
• Reasoning lacks evidential support 

For example, a DST may describe mobility needs as unproblematic while the care records show repeated falls, unsafe attempts to mobilise and frequent intervention by staff. A material difference between the assessment and contemporaneous records may provide grounds for challenging how the needs were assessed. 

The purpose of a challenge is not simply to seek higher levels of need on the DST. Rather, it is to establish whether the assessment presents an accurate, evidence-based picture of the person’s needs and whether the eligibility decision properly follows from that evidence. 

Can nursing home fees already paid be recovered?

Potentially. If a CHC challenge subsequently establishes that your relative was eligible for NHS Continuing Healthcare during a period when their care was privately funded, there may be a claim for reimbursement of fees paid during the period for which NHS responsibility is established. 

The position will depend on the circumstances and the period for which eligibility is established. If funding is being challenged, keep: 

• Nursing home invoices 
• Payment receipts 
• Bank records 
• Fee statements 
• Residence dates 
• Payer details 

Care and clinical records are needed to establish whether NHS funding responsibility existed for the relevant period. Financial records can then establish what was actually paid, when and by whom. 

Put simply, the financial evidence establishes the loss; it does not establish CHC eligibility by itself. 

How Farley Dwek can help

Farley Dwek’s specialist Case Managers can review a CHC assessment alongside the underlying care and clinical records to establish whether the decision accurately reflects your relative’s needs. 

We can examine what those needs look like in practice, including the frequency of interventions, risks and care required to manage them. We can consider how that evidence has been reflected in the assessment and eligibility decision, and the potential merits of an appeal. 

This can be particularly important where a Decision Support Tool appears reasonable when read on its own but does not match the day-to-day evidence recorded by the nursing home or clinicians involved in the person’s care. 

Depending on the stage of the case, we can review CHC documentation, assess the merits of a challenge, prepare and pursue an appeal and consider the recovery of care fees already paid. 

If you are paying substantial nursing home fees and are concerned that your relative’s health needs have been overlooked or understated, speak to our team for an initial discussion. 

Frequently asked questions about nursing home fees

Do you have to sell your house to pay nursing home fees?

Whether a property is taken into account depends on the applicable funding route and the person’s circumstances. 

Where your relative has significant health needs, NHS Continuing Healthcare should not be overlooked simply because they own property or have savings. CHC eligibility is based on needs and is not means-tested. 

Does the NHS pay nursing home fees for someone with dementia?

It can. Dementia itself does not determine CHC eligibility. What matters is the nature and extent of the needs arising from it and how those needs interact with the person’s other health and care needs. 

For example, cognitive impairment combined with aggression, resistance to care or other significant health requirements may substantially increase the supervision and intervention required. The assessment should consider the individual rather than relying on the diagnosis alone. 

Can nursing home fees be recovered if CHC was wrongly refused?

They may be recoverable where a subsequent challenge establishes NHS Continuing Healthcare eligibility for a period during which care was privately funded. 

The position will depend on the period for which eligibility is established and evidence of the fees paid. Families considering a challenge should therefore retain invoices, statements and payment records.