Easing the cost of care

Thousands more people should have their care homes fees paid in full under new rules which start this month. The new guidance sets out when the NHS should pay for care home fees in England. In the past each Strategic Health Authority (SHA) has set its own rules, leading to a postcode lottery of who got their care paid for and who did not. The new guidance will apply throughout England (but not in Scotland, Wales or Northern Ireland) and should make decisions more consistent. The Government says the change will cost £219 million a year and should mean that 5500 more people get their fees paid in full. But campaigners say that is an underestimate and up to 20,000 extra should move onto full NHS funding.

The changes follow a court ruling last year that one SHA’s guidance about when the NHS should pay care home fees in full was "fatally flawed". They were part of the great confusion about when the NHS should pay and when it should not. In a hospital all care and accommodation is free. But in the past the NHS has discharged patients straight into a care home and then refused to pay towards the costs of those ex-patients. That has led to several court challenges and, finally, the new national guidance.

From 1 October 2007 people in care homes are divided into three categories of need.

• Those who require continuing health care. The NHS will pay the full cost of their place in a care home, including all their nursing, care and accommodation costs just as if they were in hospital.

• Those who require only social care. Their care is the responsibility of the local council social services department. Residents are subject to means-testing. Some people will get the bulk of the fees paid by the council though most will have to pay something from their income or capital towards the cost. Others who have a high income or capital will have to pay the whole cost of their care.

• Those who require some care from a registered nurse. The NHS will pay a flat-rate of £101 a week, towards their nursing costs. If they pay in full for their own care they will get this as a reduction in the cost of their fees. If they do not pay their fees in full then the contribution will reduce the amount Social Services pays towards their fees.

Anyone who goes into a care home either straight from hospital or from their own home, will be assessed jointly by the NHS Primary Care Trust (PCT) and the local council’s Social Services Department using the new National Framework to assess their needs in 11 areas such as behaviour, mobility, continence, and breathing. Each area is assessed on a six point scale from priority, through severe and moderate to none. One priority need or two severe or a number of high and or moderate needs mean that continuing health care is required and the NHS will pay the whole cost. If the person does not have sufficient needs for that then the same framework is used to assess if they need some nursing care. If they do, that will trigger the flat-rate nursing payment.

Transition
Before 1 October nursing care was paid for in three bands at £40, £87, and £139 a week depending on the degree of nursing required. People on the two lower bands should move up to the new standard rate from 1 October. People on the higher band will continue to get £139 until their case is re-assessed. Most of them should probably be moved to continuing care and get their fees paid in full by the NHS. However, some may not and they will see a cut in the contribution towards the cost of the nursing care. The Government estimates that up to 20,000 people currently get the highest band of nursing care but only 5500 extra will move to full NHS funding. Campaigners say that anyone on the highest band who is reassessed and does not get full NHS funding should appeal against that decision.

Appeals
A resident who thinks that a decision on continuing NHS care or nursing care is wrong can appeal against it to the Strategic Health Authority on the grounds that the proper procedures have not been followed or that the eligibility criteria have been wrongly applied. The SHA will try to resolve the appeal informally but may refer it to a formal Review Panel. Its decision can be appealed further to the Health Service Ombudsman. An appeal against a care decision which was made before April 2004 must be made to the SHA before 30 November this year. Appeals relating to time before April 2004 will not normally be considered if they are made after that date.

Paying for care
People who do not get their care paid for in full by the NHS will be means-tested to see what contribution they have to make themselves. The means test looks at capital assets and income. Normally people will be allowed to keep £20.45 a week from their income but the rest will be taken as a contribution towards the cost of the fees.

If their capital is £13,000 or less then it is ignored completely and so is any income it earns. If capital is above £21,500 then no help with fees is normally given. The person is expected to spend their capital until it falls below that level. If capital is between the two limits, a contribution of between £1 and £34 a week has to be made from it.

The value of the resident’s home does not count as part of their capital if their spouse or partner continues to live in it or if another relative who is either aged 60 or is disabled lives there as their home. Even if no-one lives there the value is ignored for the first twelve weeks in the care home. After that its value is counted as part of the resident’s capital. That will normally mean that the resident has to pay the whole cost of their care themselves. But it does not mean that the home has to be sold.

Instead, the Social Services Department will make a ‘deferred payment agreement’. It continues to provide the care and the cost of the fees accumulates as a debt. Only when the resident eventually dies will the home have to be sold and the debt paid. The advantages are that the debt builds up interest free while the resident is alive and for 56 days after their death. It may be possible to rent out the home to help pay for the cost of the care. And the value of their home will rise while they are in the care home. As a result the there will probably still be money left for the heirs.

Attendance Allowance
People who do pay all their own fees may be able to claim a benefit called Attendance Allowance which is worth up to £64.50 a week. Almost everyone ill enough to be in a home will be entitled to it. It can be claimed even if a contribution towards the nursing care is being paid by the NHS (but not in Scotland). And it can be claimed even if the resident has made a deferred payment agreement on their home. Staff at the Department for Work and Pensions sometimes misunderstand these complex rules and wrongly refuse claims for attendance allowance to people in care homes in these two groups. If that happens the resident can ask for the decision to be revised or of that does not work go to appeal. Citizen’s Advice can help with appeals.

Scotland, Wales, Northern Ireland
These three countries have different rules from England.