This piece first appeared in Saga Magazine in June 2012
The text here may not be identical to the published text  

Will the NHS pay care home fees?

If the main reason you're there is medical the answer is 'yes'

Thousands of people in a care or nursing home could get their fees paid in full by the NHS regardless of their income or assets. The NHS already pays all the fees for more than 26,000 elderly people in care or nursing homes. Thousands more could join them if they applied for this help. But many have no idea the NHS will even consider paying.  

The NHS has an obligation to pay for the cost of long term care if the primary need of the person in the care or nursing home is medical. It calls that having a high level of ‘primary health needs’ as opposed to social care needs. And with fees often topping £30,000 a year getting the NHS to pay would be a welcome relief for many families.

Very often though the option is not offered. As soon as person needs to go into a care or nursing home the local authority social services department gets involved, assesses care needs and immediately starts asking about income and assets. The NHS – which does not apply a means-test – is often not mentioned.

Similar schemes operate throughout the UK. But in England the rules will change later this year and anyone who applies after the end of September will get very limited backdating of the payments. At the moment the NHS payment can pay future fees and refund those already paid as far back as 1 April 2004. But the new rules mean that any money due from 1 April 2004 to 31 March 2011 will be lost forever if a claim is not made by 30 September. Claims relating to 1 April 2011 to 31 March 2012 must be made by 31 March 2013. In Scotland backdating a claim is already difficult. But in Wales claims can be backdated to 1 April 2003 and that is not changing.

Who can claim?
Assessing whether you or your relative has a ‘primary health need’ can be difficult. Guidance published in April 2010 by the Department for Health explains it like this:

“An individual has a primary health need if, having taken account of all their needs, it can be said that the main aspects or majority part of the care they require is focused on addressing and/or preventing health needs.” 

If you pass that test then the NHS should pay. Solicitors Hugh James specialises in appeals against PCTs which refuse to pay for continuing care. Lisa Morgan is the partner responsible for 2000 clients.

“The primary need has to be a health need. If the main reason why you're in the home is a health need then the NHS should pay. You don’t need to show highly specialist or complex medical conditions as some Primary Care Trusts will say. That is just wrong.”

Since October 2007 the decision (in England) about whether you are eligible is made by the Primary Care Trust using two questionnaires. They take account of the types of need you have, the extent and severity of those needs, the skills needed to deal with them and how unpredictable they may be.

Altogether there are twelve categories (called ‘domains’) which are assessed. They include mobility, communication, nutrition, continence, breathing, and medication as well as mental factors such as behaviour and cognition. These should cover many common complaints such as stroke, heart and breathing problems and various forms of dementia – including Alzheimer’s Disease. Many people who successfully claim continuing care fees from the NHS – or challenge a refusal – have deteriorating mental conditions caused by some form of dementia.

To qualify you need to reach certain level in a certain number of categories. Although the rules seem very precise, assessing the need in each category can be subjective and different PCTs will make different decisions on similar cases.

Your needs should be assessed on discharge from hospital or when the first question of going into a nursing or care home arises. Once you are in a nursing home your needs should be re-assessed at least once a year and you can ask for a re-assessment at any time if your condition deteriorates or seems to be terminal. Talk to the staff at your care home and ask them to use what is called the ‘continuing care checklist tool’ available from the NHS to assess your needs. If that indicates you may be eligible for the NHS to pay for your care then you should apply in England to your local Primary Care Trust. It will use a more thorough ‘decision making tool’ to assess your eligibility. If refused you can ask for a review and, if that fails, appeal to the Strategic Health Authority.

Well worth doing
The process may take a long time but it could save you – and your heirs - £30,000 a year or more. Lisa Morgan’s team has recovered several hundred thousand pounds for some of their clients. Initial assessment of the case is free but if they take it on they will represent the client through the whole process. The typical case will take two to three years and any money recovered can be paid to the estate if the person dies during the process. The firm charges 18% (+ VAT) of the fees the NHS refunds.

Lisa Morgan says she is very concerned about the new deadline for cases in England.

“Lots of families don’t know about continuing care so they are even less aware of the new deadline.” She urges anyone who thinks they or their relative is in a home primarily because of their health to consider putting in a claim. And in England to make sure that happens before the end of September.

From 1 April next year the Primary Care Trusts in England will be replaced by Clinical Commissioning Groups partly run by GPs and the ten Strategic Health Authorities will be replaced by an independent NHS Commissioning Board. They will take over assessment and reviews under the National Framework. In Scotland and Wales the decision is made by the local Health Board and in Northern Ireland by the Health and Social Care Board. The overall rules in those countries are similar but backdating rules and the terminology will differ.  

Get Help
You should always avoid the non-legal firms that have sprung up recently claiming to help people in nursing homes get their fees paid in full by the NHS. These firms simply fill in the forms and make the application you could make yourself. But they can charge a third of the fees saved. Carers UK can offer help and advice on getting the NHS to care for someone in a care or nursing home. Age UK produces a very comprehensive Factsheet about the assessment and how to go about applying. The information from the NHS itself is more difficult – both to understand and use – but the ‘decision tool’, ‘practice guidance’ and checklists are very helpful.

If you need help or you come up against a blank refusal you should go to a specialist lawyer like Hugh James or contact Solicitors for the Elderly which will put you in touch with one.

More information and for continuing care checklist tool.
AgeUK, search for ‘Factsheet 20’ or ‘AM083’
Carers UK 0808 808 7777
Solicitors for the Elderly 029 2022 4871


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