CARE HOME FEES - will the NHS pay?

A resident in a care home is now likely to be paying care fees of around £1000 a week, if not more – that is over £52,000 a year. Many people are aware that they can request a financial assessment by their local Social Services Department to see if they are eligible for their care fees to be paid by their local authority. There needs to be a social care need - that is one that is focused on providing help with the activities of daily living, maintaining independence and social interaction. Eligibility for this funded social care takes into account capital, savings and income. Following an assessment, contributions may be required from income and the present position is that no financial assistance will be available if an individual’s capital exceeds £23,250. For many people they are therefore required to use life savings and the capital value of their interest in their home to pay for their care.

However many people and their families are unaware, or have been misinformed, about their right to make an application to their local Clinical Commissioning Group (CCG) for an assessment which may lead to their care fees being paid for by the NHS, if they have a primary health need. The significance of having a primary health need is hugely important because if that can be established, an individual’s care fees, including accommodation costs in a nursing home, will be funded by the NHS regardless of an individual’s means. This Continuing Healthcare (CHC) funding is not means tested and does not involve the local authority. The care can be provided in a residential or nursing care home or in a person’s own home. If granted, an individual will not be required to fund their care or accommodation costs out of income, savings or capital.

An application for CHC funding involves a screening or checklist assessment and then, if appropriate the completion of a detailed decision support tool (DST) which should involve the individual, their family or representatives and healthcare professionals – this is a full Multi-Disciplinary Team (MDT) assessment. 12 care domains will be considered. These cover areas such as mobility, nutrition, continence and cognition. There will be a consideration of four key indicators or characteristics of the individuals need – the nature, complexity, intensity and unpredictability of need.

A National Framework of guidelines must be applied, along with case law. Strict time limits apply for various steps in the process, particularly for assessments and decisions.

If an application is successful and CHC funding is granted ex gratia payments can be made if there has been unreasonable delay in reaching the decision. If an original application is unsuccessful a request can be made for a Local Review and if that is unsuccessful for an independent review by NHS England. Successful reviews or appeals will generally lead to care fees being backdated, and refunded with interest.

Where a period of care has been previously unassessed, an application for a retrospective review can also be made in appropriate cases and if successful care fees paid by an individual or their family will be repaid.

There are many misconceptions, myths and misunderstandings in relation to NHS funding of care fees due to the process, the complexity of the rules and how they are applied. It is an area where expert legal advice can be essential.

For further assistance and to discuss your particular circumstances, please contact Richard Gregory our Litigation Partner on 01264 325811, alternatively, email your enquiry to:  rgregory@bsandi.co.uk or go to our website:  www.bsandi.co.uk and complete our no obligation enquiry form.  We will be happy to help you with your enquiry.