NHS Continuing Healthcare (NHS CHC) is a package of care for adults aged 18 or over which is arranged and funded solely by the NHS. In order to receive NHS CHC funding individuals have to be assessed by Clinical Commissioning Groups (CCGs) according to a legally prescribed decision making process to determine whether the individual has a ‘primary health need’.
This process is set out in the National Framework for NHS Continuing Healthcare and NHS funded Nursing Care (Revised 2012), underpinned by the NHS Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) Regulations 2012 as amended by The National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) (Amendment) Regulations 2013).
The Department of Health has produced a helpful public information leaflet.
NHS England’s Role and Statutory Function
NHS England is required to establish arrangements for the independent review of Clinical Commissioning Groups (CCGs) decisions on eligibility for NHS Continuing Healthcare funding. The right to request an independent review from NHS England rests with individuals and/or their representatives. CCGs should notify the individual and/or their representative of this right when sending the final decision letter.
Before an independent review is set up it is particularly important that all appropriate steps have been taken by the relevant CCG to resolve the case informally. If the case cannot be resolved by local resolution the applicant or their representative may ask NHS England to arrange an independent review.
The independent review process is co-ordinated by the NHS Continuing Healthcare teams in each of the four regions of NHS England.
Once it has been determined that a case is ready for independent review, the Chair (seeking independent clinical advice if required) will look at the case to determine whether a full panel will proceed.
If the case falls well outside the eligibility criteria the chair and clinical advisor will review the case and a letter and report will be produced and sent to the applicant and the CCG. In cases where the chair determines that a full panel is required, this will then proceed.
This approach is detailed in Annex E Paragraph 14 of the National Framework for NHS Continuing Healthcare and NHS funded Nursing Care.
In all cases should the applicant remain dissatisfied with the outcome they will be informed in writing of their right to use the NHS complaints procedure.
NHS England has been testing this process from 1 December 2015 for requests for review of Previously Unassessed Periods of Care cases.
As of 11 July 2016, NHS England has decided to extend the testing of this process to include ALL requests for Independent Review.
The testing period of this process will continue until 31 December 2016. NHS England has decided to further extend the testing period until 31 March 2017
This is to ensure the best possible use of staff resource to focus on reviews for individuals in need of long term care. It should also support timely independent reviews for all cases.
Independent Review Panel
An Independent Review Panel is made up of:
- an independent chair
- a representative nominated by a Clinical Commissioning Group (not involved in the case);
- a representative from a Local Authority (not involved in the case); and
- at times there is also a clinical advisor in attendance.
Here are the contact details for the four regional teams:
- London: email@example.com, 0113 807 08166
- North: firstname.lastname@example.org, 0113 825 2950
- Midlands and East: email@example.com, 0113 825 3175
- South: firstname.lastname@example.org, 0113 825 5083
NHS Continuing Healthcare Operating Model
The Operating Model for NHS Continuing Healthcare (NHS CHC) sets out the strategic importance of NHS CHC not only as a vehicle for the delivery of long term care, but also its importance as it interfaces with a number of care pathways across health and social care. The associated Assurance Framework and Improvement Tool set out the arrangements for NHS England to be assured of compliance with the National Framework for NHS CHC.
The establishment of NHS England has given us the opportunity to bring together the overall approach to NHS CHC, to refocus on achieving the best possible assessment and care pathways and on being assured that these are delivered locally in a fair, efficient and cost effective manner.
The Operating Model has been developed in discussion with the NHS CHC Stakeholder Group, Regional teams, Clinical Commissioning Groups (CCGs) and the Association of Directors of Adult Social Services (ADASS) since its launch in March 2014.