What can make someone eligible for NHS continuing healthcare can be a bit of a grey area. The test for eligibility is quite subjective. Time and time again, Clients ask, ‘What do I need to be eligible?’ so here we have set out to answer this question.

What is the Test for Eligibility?

The test for eligibility is laid down in the National Framework. In order to prove that a patient should have been entitled to full NHS funding for their care, we need to show that their health and nursing care needs were more than what a social services department could provide. If that’s the case, then their primary need would be for health and they would have been entitled to full NHS funding.

This is, unfortunately, a particularly stringent test. To be eligible for full funding, the patient’s needs must also be found to be intense, complex, unpredictable or of a health care nature.

What Does This Mean in Practice?

In order to prove that your loved one is eligible for NHS continuing healthcare, your claim must go through the following three stages:

1. Completion of an Assessment Checklist

To begin, when a patient is assessed for continuing healthcare, a checklist is completed. This checklist is a screening tool which determines whether a patient’s needs warrant a full assessment. The threshold for the checklist is set low.

2. Completion of a Decision Support Tool (DST)

Upon completion of a positive checklist, a DST is then completed. A DST is an assessment tool used to investigate whether a person’s needs are primarily healthcare needs that would be eligible for NHS continuing healthcare.

A DST is also designed to measure the level of an individual’s needs in each of the 12 care domains. The 12 care domains are:

  • Behaviour
  • Cognition
  • Psychological and emotional
  • Communication
  • Mobility
  • Nutrition
  • Continence
  • Skin integrity
  • Breathing
  • Medication
  • Altered states of consciousness
  • Other needs

The level of need is assessed for each of the 12 care domains by assigning one of the following six levels:

  • Priority
  • Severe
  • High
  • Moderate
  • Low
  • No Needs

The DST is a tool to identify health needs, but it does not determine eligibility for NHS continuing care, but it is a contributing factor. The Department of Health’s guidance states that a DST will support eligibility if it reflects the following outcomes:

  • A level of priority (in any of the four care domains that carry this level – behaviour, breathing, medication and altered states of consciousness ); or
  • Two or more incidences of identified severe needs;

The guidance also indicates that a DST may indicate eligibility if it reflects the following outcomes:

  • One domain recorded as severe, together with needs in a number of other domains, or
  • A number of domains with high and/or moderate needs.

Put another way, if a patient’s level of need is assessed as being priority in any area, eligibility for full funding is automatic. Or, if a patient’s level of need is assessed as being severe in any two areas, eligibility for full funding is also automatic.

A patient can still be found eligible without a priority level of need in any one care domain or two care domains with a severe level of need. This is where determining eligibility becomes increasingly grey and open to interpretation. If a patient is assessed as having one severe and a number of other needs, or a number of high needs, this can still indicate eligibility.

Simply put, the lower the levels of need, the less likely a patient is to be found eligible. Health authorities are obliged, under the National Framework, to consider the totality of a patient’s needs, how they interact and the level of skill required to meet those needs.

Is my loved one eligible if they suffer from dementia?

Many of the cases dealt with by Hugh James Nursing Care involve patients who sadly suffer from cognitive impairments such as dementia or Alzheimer’s.

Unfortunately, it is wrong to assume that a diagnosis alone can make a person eligible for NHS continuing healthcare. This is the same for any diagnosis whether it be mental or physical. A diagnosis of dementia, for example, may give rise to a high scoring under cognition, but may not constitute eligibility on its own. The health authority must consider the patient’s needs across all domains before reaching a verdict on eligibility.

Eligibility depends on someone’s assessed needs, the type and amount of care required, not a diagnosis or condition. If a person’s needs change, so may their eligibility for funding.

Can someone be found eligible if they receive care at home, or in a residential home?

The short answer is yes.

However the long answer is a little more complicated. A person cannot be denied full funding if they receive care at home or in a residential home. This is set out in the National Framework. However, if a patient is determined to be eligible for NHS continuing healthcare, it may be a requirement of the local health authority that they are moved into a nursing care setting in order to receive the funding.

Conclusion

In conclusion, all health authorities must determine eligibility for full funding based on the criteria within the National Framework. A decision must be made based on a detailed assessment of all of the patient’s care needs across all domains. The test for eligibility is a subjective but stringent one and the threshold for eligibility is set high.