Care Home Fees Who Pays?
Understandably, families who are watching their inheritance disappear whilst an elderly relative is paying for care home fees are keen to put the burden on the NHS and reclaim care home fees wherever possible. This is an extremely important topic to which there is rarely a clear-cut answer to the question – care home fees who pays?
There are three distinct categories of long-term care patients, as follows:
- Those who are suffering from the ravages of time in terms of the diminution of their mental or bodily faculties and need care and accommodation. These patients are in need of Social Care and are either funded by themselves if they fail the means-test or by themselves and their local council if they have less than the lower capital threshold – see the separate article entitled Paying for Care.
- Those who are mainly suffering from the ravages of time, but who also have a nursing need for a medical condition. In these circumstances, because the NHS is still responsible for “cradle-to-grave” medical care, the patient is eligible for what is known as NHS-funded Nursing Care. This is a fixed contribution determined by the Government from time to time – £183.92 per week (2020/21) – for nursing care fees. The NHS is not responsible, however, for care and accommodation for these patients so the individual and/or the Local Authority remain responsible for that.
- Those for whom the need for care is overwhelmingly as a result of a medical condition. In these cases, the NHS is responsible for all three elements, nursing care fees, care fees and accommodation costs, with no contribution from the patient themselves or the Local Authority. This is known as NHS Continuing Healthcare.
Clearly, if care is needed, from a financial point of view, it is desirable to be placed in the third category. However, many of the ailments that afflict the elderly and which cause them to seek care are conveniently not considered to be eligible for NHS Continuing Health Care – Dementia, including Alzheimer’s Disease, Arthritis, Osteoporosis and Osteogenesis Imperfecta (Brittle Bone Disease), etc.
The patient will be eligible for NHS Continuing Healthcare if it is established that they have a Primary Health need based on their physical and mental needs. This is determined by following the principles and processes set out in the National Framework.
Eligibility for NHS Continuing Healthcare may vary from time to time during a patient’s life. Consequently, eligibility should be considered, or reconsidered:
- if the patient has a rapidly deteriorating condition,
- before or immediately after discharge from hospital, particularly if it is apparent that a permanent place in a care home is going to be necessary.
- at a patient’s annual care needs review
- if the patient’s physical or mental health deteriorates significantly, in the period between regular reviews.
To determine whether a patient is eligible for NHS Continuing Healthcare the Clinical Commissioning Group (CCG) must undertake an assessment. Before an assessment is carried out the consent of the patient should be obtained and the views of patient, family and carers taken into account.
The assessment itself is carried out using one of more of the three assessment tools namely:
- Fast Track Tool
- Checklist Tool
- Decision Support Tool (DST)
The Fast Track Tool is used for patients who have a rapidly deteriorating position and/or who appear to be entering the final phase of life and therefore need urgent consideration.
The Checklist Tool is used once it is agreed that fast-tracking is unnecessary. Its purpose is to encourage assessments appropriate to need and to help health and care professionals identify who is most likely to be eligible for NHS Continuing Healthcare to facilitate full consideration of their case.
The DST has 11 areas of need (described as “domains”). The patient is assessed and each domain is given an appropriate priority level ranging from “no need” through low, moderate, high and severe to “priority”.
The domains in the decision support tool include the following descriptions for the most severe manifestations:
- ‘Challenging’ behaviour of a severity and/or frequency and/or unpredictability that presents an immediate and serious risk to self and/or others. The risks are so serious that they require access to an immediate and skilled response at all times for safe care.
- Cognitive impairment that may include, in addition to any short-term memory issues, problems with long-term memory or severe disorientation. The individual is unable to assess basic risks even with supervision, prompting or assistance, and is dependent on others to anticipate even basic needs and to protect them from harm, neglect or health deterioration.
- Mood disturbance, hallucinations or anxiety symptoms, or periods of distress, that have a severe impact on the individual’s health and/or well-being. OR Withdrawn from any attempts to engage them in care planning, support and/ or daily activities.
- Unable to reliably communicate their needs at any time and in any way, even when all practicable steps to do so have been taken. The person has to have most of their needs anticipated because of their inability to communicate them.
- Completely immobile and/or clinical condition such that, in either case, on movement or transfer there is a high risk of serious physical harm and where the positioning is critical.
- Unable to take food and drink by mouth. All nutritional requirements taken by artificial means requiring ongoing skilled professional intervention or monitoring over a 24 hour period to ensure nutrition/hydration, for example intravenous fluids. OR Unable to take food and drink by mouth, intervention inappropriate or impossible.
- Continence care is problematic and requires timely and skilled intervention, beyond routine care.
- Open wound(s), pressure ulcer(s) with ‘full thickness skin loss involving damage or necrosis to subcutaneous tissue, but not extending to underlying bone, tendon or joint capsule’ which are not responding to treatment and require a minimum of daily monitoring/reassessment. OR Open wound(s), pressure ulcer(s) with ‘full thickness skin loss with extensive destruction and tissue necrosis extending to underlying bone, tendon or joint capsule’ or above OR Multiple wounds which are not responding to treatment.
- Unable to breathe independently, requires invasive mechanical ventilation.
- Has a drug regime that requires daily monitoring by a registered nurse to ensure effective symptom and pain management associated with a rapidly changing and/or deteriorating condition. OR Unremitting and overwhelming pain despite all efforts to control pain effectively.
- Coma. OR Altered State of Consciousness that occur on most days, do not respond to preventative treatment, and result in a severe risk of harm.
It is basically a “points make prizes” situation; the greater number of high, severe and priority areas the patient scores the more likely it is that they will qualify for NHS Continuing Care.
After the assessment process has been completed the CCG should tell the patient verbally and in writing what decision has been reached. Typically this will be within two weeks of referral. Whatever the outcome of the assessment the decision is not necessarily permanent and may alter as the patient’s condition changes.
What if I don’t agree?
If the patient is unhappy with the decision of the CCG this can be challenged. The patient may be unhappy that the CCG has not followed the correct procedure to reach the decision; alternatively the patient may feel that the evidence collected and the application of the guidance has not been properly interpreted.
In the first instance the CCG will usually have a local resolution process to be followed. If local procedures have been exhausted and the patient is still not happy with the outcome the patient can ask that the case be referred to appeal.
The National Framework referred to earlier was only introduced in October 2007 and, prior to that, each health authority used a different set of criteria to assess the funding a patient was eligible for. So it is quite possible that a patient was denied NHS Continuing Care unfairly in the past.
If you believe a patient was wrongly assessed, then the first port-of-call is the patient’s own GP for a continuing care review or a retrospective assessment from when they first entered the nursing home, if that was no longer ago that 01 April lat year – backdated claims before then are now time-barred.
If it is decided the patient was wrongly assessed, then they could reclaim care home fees, including accommodation costs. This applies even if the patient is no longer in the nursing home or even dead. In England, for the period 1 April 2014 to 31 March 2015, the deadline will be the 31 March 2016.
Can I get help?
If you want professional help with an application or appeal for NHS Continuing Healthcare, see my further blog.
If you need help with any aspect of care fees planning, please contact me using the form below.