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In March 2012, David Nicholson, Chief Executive of NHS England, issued a letter containing new deadlines by which retrospective claims for NHS Continuing Healthcare funding (CHC) had to be submitted to the relevant Primary Care Trusts (PCT). In short, the clock has started to tick again in connection with care fees refunds for loved ones who have paid for their care. The rationale behind such measures is to ‘clear the decks’ for the new Clinical Commissioning Groups when they replace PCTs with effect from 1 April 2013.

The first of these periods expired on 30 September 2012 and it related to unassessed periods of care between 1 April 2004 and 31 March 2011. For the purposes of this article, the next deadline expires on 31 March 2013 for care received between 1 April 2011 and 31 March 2012.

NHS care fees

If you have a primary healthcare need, then the NHS should fund any associated care costs because it is a service that is free at the point of delivery. It is a common misconception that such funding can only be received in nursing homes. It can also be awarded to those in a residential setting or at home.

What is a primary healthcare need?

The term ‘primary healthcare need’ is not defined by the Department of Health. However, there are certain key indicators that, when considered alone or in combination, are illustrative of a primary health need. These are:

  • Nature – which describes the characteristics of an individual’s needs and the quality of interventions required to manage them;
  • Complexity – which means the interaction between different care needs and the level of skill required to address an individual’s needs;
  • Unpredictability – which describes the extent to which needs fluctuate;
  • Intensity – which relates to the quantity and severity of the individual’s needs and the support required to meet them.

The Needs Portrayal (for retrospective claims only) will look at twelve care domains, including behaviour, cognition, psychological and emotional needs, and communication, which are then sub-divided into low, moderate, high, severe or priority levels of need. Generally speaking, the score of one ‘priority’ or two ‘severes’ will be indicative of a primary health need and, as a consequence, eligibility for CHC funding will be likely.

Continuing Healthcare Funding

While the 30 September (2012) care fees refunds deadline for has long since passed, the NHS may still consider retrospective CHC claims if there are “exceptional circumstances”. Again, the Department of Health has been unclear as to what constitutes an “exceptional circumstance”. However, looking at the previous 2007 cut-off point, an exceptional circumstance could arise where a health professional was involved and it should have been reasonably apparent that an individual should have been assessed for CHC funding but was not.

So, if you have relatives who are receiving care at home or in a nursing or residential care home and they have a health need or you would like to find out more about care fees refunds, contact the Private Client Services steam or call 0117 904 6000.