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3 January 2018 | Comment | Article by Lisa Morgan

Is the diagnosis of dementia sufficient for NHS continuing healthcare eligibility?

The majority of residents in a care homes suffer with dementia and have to pay the full cost of their care home fees. However, if a resident is found eligible for NHS continuing healthcare funding the NHS is responsible for full payment of that resident’s care home fees.

Often in our Nursing Care Department, new and existing clients ask whether the diagnosis of dementia is sufficient for NHS continuing healthcare funding to be awarded. The simple answer is that unfortunately, the diagnosis of any condition, including dementia, is not enough for NHS continuing healthcare funding to be awarded.

Eligibility for NHS continuing healthcare funding is person centred and awarded based on the level and type of care required by an individual and not a specific diagnosis. However, the diagnosis of dementia is an important factor which is taken into account because of the impact the condition has on an individual’s mental functionality and their needs as a whole.

Assessing a patient’s healthcare needs

To be found eligible for NHS continuing healthcare funding, an individual’s needs must meet the eligibility criteria. There is a two stage assessment process which must be completed. Firstly, a checklist assessment is completed. A checklist assessment is an initial screening tool to determine whether an individual’s need may qualify for NHS continuing healthcare funding. If this stage is passed, a Decision Support Tool (DST) will be completed. The DST is a full assessment which is more critical when considering a Patient’s needs.

You can read more about the two stages of the assessment in our previous blog post NHScontinuing healthcare: What makes someone eligible.

How dementia affects a patient’s needs

Dementia obviously has an impact on an individual’s mental functionality which results in episodes of confusion, disorientation, short-term and long-term memory loss. However, depending on the severity of the condition, dementia may also affect other aspects of an individual’s needs. I’ve listed a number of examples of how dementia can interact with other aspects of an individual’s care, however, the effect of dementia is not limited to these examples and is of course different for everybody.

  • Dementia often has an impact on a Patient’s communication abilities. For example, a dementia sufferer may become forgetful during a conversation and may become repetitive or struggle to find their words. They may therefore rely on carers to anticipate their needs.
  • Limited communication can also have an impact on an individual’s psychological and emotional state. If someone is unable to communicate or participate in group activities within the care home, they may be at risk of social isolation. This could cause loneliness. Confusion may also result in hallucinations, further impacting on a dementia sufferer’s emotional state.
  • Dementia often causes an increase in challenging behaviour, a key care domain in assessing NHS continuing healthcare eligibility. For example, a dementia sufferer may not understand the nature of their needs, and may therefore lash out during care interventions. This may result in a higher number of falls when carers are assisting with mobility. If they require mobility aids such as a Zimmer frame or wheelchair, they may forget their mobility is limited and attempt to walk unaided resulting in falls.
  • Challenging behaviour may also prevent someone from getting essential care in terms of their nutritional intake or medication. They may not recognise that the care given by carers is essential, and they may therefore refuse the assistance offered.
  • Further, an individual’s behaviour could prevent carers from providing personal hygiene care, or prevent the treatment of skin related concerns. This would result in a higher risk of pressure damage or pressure sores.
  • In addition to refusing care interventions, a dementia sufferer may believe that something belonging to another resident is in fact their property. It is difficult to predict how the owner of that property will respond or whether that response will be violent. Their poor memory may therefore place them at risk of displaying challenging behaviour due to their misconception of an item of property.
  • A dementia sufferer may also forget how to swallow and may therefore require prompting and encouragement from carers.

You can see from the above that dementia therefore has an impact on an individual’s care needs. The nature of the condition adds additional layers of complexity to an individual’s care. The overlap between needs may require a higher level of support from professionals such as a GP or the community mental health team to manage, also providing evidence that their care is intense.

In summary, the diagnosis of dementia alone does not result in NHS continuing healthcare funding, but the impact the condition has on an individual’s care requirements should be discussed in detail during an assessment.

How we can help

The Hugh James Nursing Care department has extensive knowledge and expertise regarding NHS continuing healthcare funding; we deal with both retrospective and on-going claims for funding.

Our lawyers are capable of assisting you from the start of your claim, right to the end. If you are considering registering a claim for NHS continuing healthcare funding on behalf of a relative, we can ensure that the process takes place as quickly as possible and that any assessments completed are procedurally fair. If you have already registered a claim for NHS continuing healthcare funding, we are able to step in and assist you for the remainder of the process. We are trained in evaluating unfavourable assessments and analysing essential information from medical records which may result in a positive decision for your relative.

In most cases, we are able to take instructions under a “no win, no fee” agreement. This means that you are only required to meet our costs if your case is successful. In this event, our costs would be deducted from any reimbursement that you receive from the NHS. However, the availability of this agreement is dependent on your relative’s needs.

Please get in touch with the Hugh James Nursing Department for more information by calling 0800 988 2373, or get in touch with the form below

Author bio

Lisa Morgan


Lisa Morgan is a Partner and Head of the Nursing Care department. She is regarded as an experienced and specialist solicitor leading in the niche area of continuing healthcare.

She has been instrumental in developing a niche legal department in Hugh James, which comprises of 40 fee earners who solely act for the elderly and families in recovering wrongly paid nursing fees.

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