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Is there an upper limit to amount NHS continuing healthcare funding will cover?

The untruths, misunderstanding and myths surrounding NHS continuing healthcare continue to astound us and cause distress to our clients, here we clarify a recent funding related query.

Recently, a person enquiring about continuing healthcare funding challenged our statement that the funding pays 100% of the cost of care; they were adamant that their family had been told there was an upper care limit of £575 a week (leaving relatives to ‘top-up’ the outstanding amount because, as she correctly identified, there are very few care homes with weekly fees as low as £575).

The information she had been supplied, either by the care home or by her local Clinical Commissioning Group was categorially incorrect and is another example of why the NHS continuing healthcare funding process is so complex and confusing for clients and patients alike.

Not only does NHS continuing healthcare pay 100% of the fees associated with an assessed and established primary healthcare need, there is no financial limit of any kind and the National Framework explicitly prohibits patients paying ‘top-up’ fees.

Tim Davies, Managing Director and non-practicing solicitor at Compass CHC explains, “where it is established that a patient is entitled to NHS continuing healthcare funding the local Clinical Commissioning Group is obligated to pay – in full – the cost of the care package required to meet the health needs of the particular individual. It is not the case that a generalised cap can be placed on this amount.

In fact, page 116 of the NHS National Framework, paragraph 99.1, states “The funding provided by CCGs in NHS continuing healthcare packages should be sufficient to meet the needs identified in the care plan, based on the CCG’s knowledge of the costs of services for the relevant needs in the locality where they are to be provided. It is also important that the models of support and the provider used are appropriate to the individual’s needs and have the confidence of the person receiving the services“. Clearly this cannot be achieved by applying a set maximum figure if no appropriate private care home can meet the needs of the individual at the set level. By way of a working example, in one case recently, we secured an ongoing package of care for an individual with complex care needs at a cost of £3000 a week.

Further, the National Framework specifically states that topping-up of fees is not allowed. Page 117, paragraph 99.3 “…. ‘Topping-up’ is legally permissible under legislation governing LA social care but is not permissible under NHS legislation“. Unfortunately, this type of confusion surrounding the National Framework is a clear example of the misinformation provided to people which can result in individuals being denied the continuing healthcare funding they are entitled to.”

Others have told our specialist advisors that they feel the National Framework is open to interpretation by the Clinical Commissioning Groups who seem to choose which parts to adhere to and which sections to ignore.

Tim Davies clarifies, “the National framework is absolutely not open to interpretation or cherry picking by different Clinical Commissioning Groups. However, I know first-hand that left unchallenged this can occur which is why I always encourage clients to use a reputable continuing healthcare expert when navigating the often-complex funding process.”
How can Compass CHC help?

If you have encountered problems with your Clinical Commissioning Group or feel you have been given incorrect or conflicting information we, at Compass CHC, can help.

Before any instructions are accepted on a case a full, detailed, free and confidential assessment of the specific circumstances relating to the patient will be undertaken. Only at this stage – and when the expert assessor from Compass CHC is of the view that the evidence relating to the patient’s condition indicates that there is a reasonable prospect of success in securing funding – would we accept instructions to act on a patient’s behalf.

Our team of continuing healthcare experts, comprising lawyers (non-practising) and clinicians (including nurses, tissue viability specialists and pharmacists) will then review and consider all the evidence from a clinical perspective before drafting reasoned arguments to your Clinical Commissioning Group which identify an individual’s entitlement to the funding by cross-referring the medical evidence to the National Framework for continuing healthcare criteria

Should you, or a relative, have any concerns regarding NHS Continuing Healthcare funding, our expert advisors can assist by explaining the ins and outs of what can be a perplexing and complicated process. There is no time limit placed on this free, no obligation consultation. Should you wish to discuss matters further, do not hesitate to contact us directly on 0121 227 8940.

Author: Tim Davies LLB

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