Will the NHS pay care home fees?

September, 2012 TSG_PTIMG_0011_20pounds

If the main reason you’re in a home is medical, the answer’s yes to the above question. What’s more, the fees can be backdated for years. But the rules are changing, so you need to claim now.

Thousands of people in care or nursing homes 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 to pay for long-term care if the primary need of the person in the care or nursing home is medical. To qualify one has to have a high level of ‘primary health needs’ as opposed to ‘social care needs’. With fees topping £30,000 a year, getting the NHS to pay would be a welcome relief.

Frequently though, the option is not offered. As soon as a person needs to go into a care or nursing home the local social services department gets involved, assesses care needs and starts asking about income and assets. The NHS – which does not apply a means-test – may not be 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 can pay future fees and refund those already paid as far back as April 1, 2004. But the new rules mean that any money due from April 1, 2004 to March 31, 2011 will be lost for ever if a claim is not made by September 30. Claims relating to April 1, 2011 to March 31, 2012 must be made by March 31, 2013. In Scotland, backdating a claim is already difficult. In Wales, claims can be backdated to April 1, 2003 and that is not changing.

Who can claim?

Assessing a ‘primary health need’ can be difficult. Guidance published 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 Primary Care Trusts (PCTs) that refuse to pay. Lisa Morgan, the partner responsible for 2,000 clients, says: ‘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 PCTs will say. That is just wrong.’

Since October 2007, the PCTs in England have had a ‘National Framework’ to decide if you are eligible for NHS-funded ‘continuing care’. It uses two questionnaires that 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 12 categories (called ‘domains’) 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.

To qualify you need to reach a certain level in a set 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 when you are discharged from hospital or when the question of going into a nursing or care home first arises. Once you are in a home, your needs should be reassessed at least once a year. You can ask for a reassessment if your condition deteriorates or seems to be terminal.

Ask staff at the care home 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, in England you should apply to your local PCT. It will use a more detailed ‘decision-making tool’ to assess your eligibility. If refused you can ask for a review and, if that fails, you can appeal to the Strategic Health Authority.

Well worth doing

The process may take a long time but 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, if the person dies during the process, any money recovered can be paid to the estate. The firm charges 18% (plus 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,’ she says, ‘so they are even less aware of the new deadline.’ She urges anyone who thinks that they or their relative is in a home primarily because of their health to put in a claim. In England, you should do it before the end of September.

From April 1 next year, PCTs 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.

Getting help

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 do 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 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 helpful.

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

More information

Visit or call 0800 096 8703; go to (or use Google) and search for Continuing Healthcare Checklist; get Factsheet 20 from (0800 169 6565); visit (0808 808 7777); visit (0844 567 6173); or see (029 2022 4871).

* Read Paul Lewis’s money articles every month in Saga Magazine.

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