This year, the average cost of nursing home care in England rose to more than £1,500 per week, or £6,000 per month. This can be even more for those with particularly complex health needs such as dementia or cancer.

If you’re worried about the rising cost of your loved one’s healthcare, NHS continuing healthcare funding may be the answer. For eligible individuals with complex healthcare needs, NHS continuing healthcare can cover the costs of their nursing home fees or self-funded private healthcare; while making sure they receive the expert level of care that their complex needs require.

Find out if your loved one is eligible below.

What is NHS Continuing Healthcare Funding?

NHS continuing healthcare (CHC) is a package of health care for people who have ongoing, significant and often complex healthcare needs. The care package is funded by the NHS and provided outside of the hospital, whether that is to individuals receiving care in their own home or in a care home.

NHS CHC is completely free for those who are eligible and is not means tested, which means those who qualify have the full cost of their care covered by the NHS. For those in care homes, this means that their care home fees will be covered by the NHS. For those receiving care at home privately, this means the NHS will provide the care.

Sadly, the complex application process means that many people who are eligible for free NHS CHC will end up paying privately for their care unnecessarily.

Who is eligible for NHS Continuing Healthcare?

To qualify for NHS continuing healthcare funding, an adult must be deemed to have a ‘primary health care’ need, meaning their care needs are mainly due to significant health issues rather than social care needs. A ‘primary health care need’ is not defined by law and so is often interpreted in different ways. However, the National Framework for NHS Continuing Healthcare has provided guidance. Someone may be considered to have a primary health care need if the nursing or treatment to require are:

1. more than incidental or ancillary to the provision of accommodation which Social Services would be required to meet if the individual were under the means testing threshold or;
2. ‘of a nature beyond which Social Services could be expected to provide’.

Crucially, NHS CHC funding eligibility is not determined by a diagnosis, but rather the nature, complexity, intensity and unpredictability of someone’s care needs. This means that someone simply having a healthcare need such as dementia, that we may consider to be complex, does not automatically qualify them for funding.

To determine eligibility, an assessment must take place by a team of healthcare professionals who will assess the individual’s care needs and relate them to:

• What degree of help is needed
• How complex the healthcare needs are
• How intense the healthcare needs are
• How unpredictable the healthcare needs are.

What is the criteria for NHS Continuing Healthcare Funding?

NHS CHC funding applicants are assessed against four key criteria:

1. Nature: Assesses what the individual’s needs actually are, the health issues they currently experience, the daily issues they face, and the kind of care required.
2. Intensity: Assesses how much care is required and how often.
3. Complexity: Assesses how the individual’s different care needs interact and whether they require specialist care.
4. Unpredictability: Assesses how unstable or changeable the individual’s health needs are and the risk that creates.

Assessors must assess the individual’s health care needs as they are right now, rather than how they might have met the criteria in the past or how they might meet it in the future if their health worsens.

To determine whether someone meets the above criteria, there are 12 domains that are assessed according to six different levels of need. Those 12 domains give the assessor a view of exactly what the healthcare needs are. They include: 

1. Breathing: Covers things like breathlessness, oxygen therapy, tracheostomy care, ventilation, suctioning, or severe respiratory instability.
2. Nutrition – Food and Drink: Includes swallowing difficulties, PEG feeding, risk of aspiration, or needing significant supervision to eat/drink.
3. Continence: Bladder and bowel needs, catheter or stoma management, incontinence, and complications like frequent infections.
4. Skin (including tissue viability): Pressure ulcers, risk of skin breakdown, wound care, dressings requiring skilled intervention.
5. Mobility: Ability to move, need for hoisting, risk of falls, immobility complications, two-person transfers, contractures.
6. Communication: Ability to express needs, understand others, severe cognitive or language impairments, communication aids.
7. Psychological and Emotional Needs: Depression, anxiety, hallucinations, emotional distress, or behaviours requiring clinical support.
8. Cognition: Memory, decision-making, impaired awareness, inability to assess risk, advanced dementia.
9. Behaviour: Challenging or unpredictable behaviour, agitation, aggression, self-harm, risks requiring skilled supervision.
10. Drug Therapies and Medication: Complex medication regimes, injections, side effects needing monitoring, non-compliance due to cognition, or drugs requiring clinical oversight.
11. Altered States of Consciousness (ASC): Seizures, fainting spells, fluctuating consciousness, episodes requiring emergency intervention.
12. Other Significant Care Needs: A catch-all for important needs not fully captured elsewhere.

Each of the 12 domains are assessed based on the individual’s level of need. The levels of need range from the lowest level, No Needs, to the highest level, Priority.

If an individual’s needs are assessed to be Priority in Breathing, Behaviour, Drug Therapies & Medication or Altered States of Consciousness, they will automatically qualify for CHC funding. If an individual’s needs are assessed to be Severe in two of these four domains, likewise they will automatically qualify for CHC funding.

Understanding the application process

The application process can be lengthy, complex and difficult to go through without guidance. While it can seem daunting to start this process, if your loved one is eligible, successfully securing CHC funding means savings potentially thousands of pounds per week all while making sure your loved one receives the specialist care they need.

We recommend getting in touch with us for a free, no-obligation 30-minute consultation before starting the application process so that we can tell you if you are likely to have success and what you can do to strengthen your case.

The application process is as follows:

Request an assessment

Anyone can request an assessment. To request an assessment for your loved one you will need to contact your local Integrated Care Board (ICB). To find yours, you can visit this website. You must contact them directly and say that you believe your loved one has ongoing complex health needs and you’d like a CHC eligibility assessment. You should also provide some details of the applicant and their needs at this stage. They should then be in touch to arrange the “Checklist” assessment.

The Checklist assessment

During the Checklist assessment, a trained healthcare professional will do an initial observation to determine whether the individual meets the criteria for a full assessment. This assessment will take place wherever it is that the individual is currently receiving their care, whether than be a care home, hostel or their own home.

Evidence gathering

If they are successful at this stage, before moving forward to the full assessment, the NHS requires you to provide evidence. This evidence will include care home notes, medical records, behaviour charts, risk assessments and anything else that can make their case. The more evidence you have, the stronger your application. Our specialist team will be able to guide you through this process and advise on what evidence you should and shouldn’t include in your application.

Decision Support Tool (DST) meeting (full assessment)

If your loved one passes the Checklist assessment and you are able to provide the proper evidence, you will be invited to a Decision Support Tool meeting which is the full assessment. At this meeting, a Multidisciplinary Team (MDT) will meet with you to discuss your loved one’s needs. They will use the DST to assess your loved one’s needs against the four criteria and 12 domains. You can correct or challenge anything that you think does not reflect the reality of your loved one’s situation. This can be an emotional situation. If you would like representation at your DST meeting, we can attend with you to make sure your loved one’s needs are properly represented.

ICB decision

The ICB will review the Decision Support Tool and then will issue a final decision letter. If CHC funding is approved, the NHS will arrange and fund a bespoke care package. They will review eligibility at the 3-month mark and then annually thereafter.

If the CHC funding is denied, you have the right to request the assessment documents and proceed with an appeal. Many families succeed on appeal. If you are denied, we encourage you to get in touch with us at your earliest convenience so that we can work with you to develop an appeal plan.

How we can help (our services)

You do not require legal support with an NHS CHC application, however seeking early advice will significantly improve your chances of success and prevent you from wasting any time if you do not have a viable case. We offer a range of services to help with your CHC funding application, from your initial assessment right through to approval or appeal.

Initial CHC Consultation

Your journey with us starts with an initial CHC consultation. This consultation is completely free of charge and allows us to discuss your loved one’s situation, explore your options and let you know if you have a viable case. Where people are successful in these applications, the cost and time it requires is absolutely worth it. We will not advise you to proceed and pay for legal support if we don’t think you have a chance of success.

If you’re thinking you might be eligible, we encourage you to reach out to schedule your consultation at your earliest convenience. The earlier you speak with us, the sooner you have peace of mind and can plan for the future.

If you require a further consultation, this will be billed at an hourly rate.

Comprehensive Care Needs Assessment & NHS CHC Checklist

With a lacking legal definition for ‘primary health care need’ combined with complex criteria that are often open to interpretation, it is not uncommon to seek a second opinion on the Checklist assessment.

We offer our own comprehensive assessment of your loved one’s health care needs cross referenced against the Care Act 2014 to ensure your loved one’s full needs are taken into account according to legislation. With this service you receive:

• Thorough Care Act 2014 needs assessment: A full, domain-by-domain review providing a clear picture of current care needs.
• Professionally completed prospective NHS CHC Checklist: Conducted by qualified experts to help you understand your potential pathway to Continuing Healthcare funding.
• Evidence-based documentation: Detailed written findings outlining the level, nature, and complexity of care required.
• Expert recommendations: Clear professional guidance on the likelihood of CHC eligibility and next steps.

This service is charged at a fixed fee of £1,800 +VAT, not much more than the cost of one week of care.

DST Representation

Prior to your DST meeting, we offer a full DST preparation and representation service. You are allowed to take representation with you to the meeting, and in fact many people choose to. The meeting can be emotional, and it is incredibly important to make sure the MDT understand the full extent of your loved one’s needs.

 We offer: 

• A review of your evidence and care records
• Guidance for strengthen your evidence
• Help with preparing for your DST meeting
• Representation at the meeting to professionally argue your case

DST Review

You will at this stage receive a decision letter from the ICB based on the DST meeting. If your application is not successful, we offer a full review or your DST outcome to determine how that decision was made. We will hep you acquire the decision documentation that you are entitled to and guide you on whether you have grounds to appeal. Many families are unsuccessful in their initial application but are able to secure the funding package at the appeal stage. We will:

• Help you acquire the DST decision documentation
• Complete a full legal review of the documentation to understand how the decision was made
• Identify any errors, gaps or issues in how the case was assessed.
• Advice on whether you have grounds to challenge the decision and whether you will be likely to succeed.

Appeal

There are three stages of appeal during this process:

1. Stage One: Local Resolution
2. Stage Two Independent Review Panel
3. Stage Three: Ombudsman

If your application has been denied but we believe the decision is wrong, we can support you with each stage of the appeals process. Data suggests that as many as 25% of rejected applications are then awarded NHS CHC funding following a stage one appeal.

We offer appeal support at an hourly rate. If your application has been rejected and you think you have a viable case, schedule your 30-minute free consultation below.

Do you need a lawyer for NHS CHC?

No, you do not legally require legal support for an NHS CHC funding application. You are able to request the Checklist assessment and go through that process independently. However, seeking legal support at an early stage has many benefits, including: 

Careful planning

Planning your application is arguably the most important part. Without careful planning, your chances of a successful application are lower. When you seek advice from us, as experts in this process we will share our expertise and help you formulate a plan for your application.

Process clarity

There are many parts of this process that are incredibly confusing. Particularly, making sure you fully understand your loved one’s health care needs and how they measure against the four criteria and their level of need against the 12 domains is key for fighting their case. We provide that clarity so that you aren’t going into your DST meeting blind.

Strengthened applications

From evidence gathering to written reports, we can assist you with acquiring the necessary information and documentation to strengthen your loved one’s application and give you the highest chance of success the first-time round.

Independent assessments

When so much of this process is open to interpretation, it’s important to seek a second opinion if at any stage you think the ICB or MDT have made the wrong decision. We offer independent assessments of your loved one’s case using the Care Act 2014 to make sure your case is legally sound.

Representation

Facing the DST meeting and appeal meetings can be difficult and highly emotional. These are also the most important parts of the process as they are what determine whether your loved one’s application is accepted or not. We offer representation to ensure your case is properly fought.

If you’d like to discuss your loved one’s situation, check your eligibility and get in touch today.

We’re Here For You

If you’re unsure whether your loved one might qualify for NHS Continuing Healthcare, or you’re feeling overwhelmed by the process, you don’t have to face it alone. The right guidance can save you significant time, stress, and potentially thousands of pounds in care costs.

Reach out to us today for your free 30-minute consultation, and let us help you understand your options, strengthen your application, and take the next step with confidence. Together, we can make sure your loved one receives the care and support they deserve.