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Introduction

This Factsheet is about Continuing NHS Healthcare funding. It should be read together with our general information booklet about our service.

People living in care homes or receiving care at home may be entitled to receive Continuing NHS Healthcare funding to meet the cost of their care needs if their physical and/or mental healthcare needs meet the eligibility criteria. Health Boards, to whom all requests for funding should be made in the first instance, will need to consider each person’s care needs in detail to determine whether or not their ‘primary need’ is for healthcare. If a ‘primary healthcare need’ exists the Health Board is required to meet the costs of that person’s care
and/or make suitable arrangements for their healthcare needs to be met. Continuing NHS Healthcare funding is not means tested.

You can ask your local Health Board to assess the needs of a person currently receiving care and/or request a retrospective assessment of past care needs. However, there is now a one year rolling cut off period for retrospective claims (for example, claims relating to the period 1 October 2015 to 30 October 2016 will need to be submitted to the Health Board by 31 October 2017; claims for care before that period will no longer be considered). Currently, there is high demand in Wales for Continuing NHS Healthcare assessments and reviews. You may have to wait some time for your claim to be considered, particularly if it was submitted in one of the windows for earlier retrospective claim periods. The Ombudsman is aware of the delays some people have experienced in relation to retrospective claims and is satisfied that they are now being addressed. He will not normally therefore consider complaints about delay in relation to historic retrospective claims. More details about the relevant time-frames for submitting a claim and other useful information can be found at web links on the next page.

 

What the Ombudsman can do

If you think that a decision by the Health Board to refuse Continuing NHS Healthcare funding for you, your relative or a person you look after, is flawed, the Ombudsman may be able to help you. He can usually look at your complaint if:

  • A request for an assessment or review was unreasonably refused or has been unreasonably delayed (see also note above);
  • The process of assessment of your claim was significantly flawed;
  • The reason for refusing funding was illogical, flawed, or not based on evidence and that those flaws are likely to have made the decision unreasonable.

 

What the Ombudsman cannot do

He cannot:

  • Undertake his own assessment of health care needs;
  • Help you make a claim for Continuing NHS Healthcare funding (there are other organisations who may do this – see ‘further information’ below);
  • Tell you whether, or not, Continuing NHS Healthcare funding should have been granted or replace the Health Board’s decision and direct them to pay Continuing NHS Healthcare funding.

 

Issues to bear in mind

If the Ombudsman upholds your complaint he may make recommendations to the Health Board about what they should do. This may include a request to carry out a new assessment of healthcare needs, or to hold a new panel to consider your appeal. You do not need to make your complaint to the Ombudsman using a solicitor or any other advocate; his service is free and impartial and we aim to make the process as easy to follow
for complainants as possible.

 

Further information

You may like to consider contacting the following organisations for advice:

Age Cymru can provide information and advice. You can contact them by phone on 0800 169 65 65 or on the internet – www.agecymru.org.uk

MIND can provide help and advice on a range of mental health issues contact by phone on 02920 395123 or on the internet www.mind.org.uk

The Alzheimer’s Society can provide help and support. You can contact them on 02920 480593 (S. Wales), 01248 671137 (N.Wales) or on the internet www.alzheimers.org.uk

Your local Community Health Council (CHC) can provide advice and support with making a complaint. Contact details for your local CHC can be obtained via your local telephone directory or via the Board of Community Health Councils in Wales’ website at www.patienthelp.wales.nhs.uk or their helpline on 0845 6447814.

Details of your local Health Board can be found at www.wales.nhs.uk/directory.cfm

Details of the process for claiming continuing NHS healthcare can be found at http://www.cciss.org.uk/home

The Ombudsman is independent and impartial; he cannot order public bodies to do what he recommends – but, in practice, they almost always do. Examples of cases that the Ombudsman has looked at can be found on our website. Please see www.ombudsmanwales.org.uk

 

Contact us

If you are unsure whether the Ombudsman would be able to look into your complaint, please contact us.