NHS-funded Nursing Care Procedure (FNC)

1. The NHS-funded Nursing Care Practice Guide

The NHS-funded Nursing Care Practice Guide is a document that sets out the process for the consideration of NHS-funded Nursing Care (FNC).

The practice guide is supplementary to the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care, and practitioners carrying out any action in relation to NHS-funded Nursing Care funding must have regard for both documents.

2. An Introduction to Funded Nursing Care

Defining NHS-funded Nursing Care

NHS-funded Nursing Care (sometimes called Funded Nursing Care or FNC) is a weekly financial contribution made by the NHS towards the cost of registered nursing care provided in a care home setting.

FNC is available for people who:

1. Live in a nursing home / care home with nursing provided; or
2. Stay short term in such a placement (for example respite).

Eligibility for NHS-funded Nursing Care

NHS-funded Nursing Care is only available for people:

1. From the age of 18; who
2. Are not eligible for NHS Continuing Healthcare; but
3. Who have eligible nursing needs; and
4. Those needs are most appropriately met by a Registered nurse in a care home environment.

The local Integrated Care Board (ICB) must determine if a person is eligible for NHS-funded Nursing Care.

In most cases, people should be considered for NHS Continuing Healthcare before being considered for NHS-funded Nursing Care (see Section 3, Funded Nursing Care and NHS Continuing Healthcare).

Eligible nursing needs

Eligible nursing needs are those needs with interventions that have to be:

1. Carried by a Registered nurse;
2. Planned and reviewed by a Registered nurse;
3. Monitored by a Registered nurse; or
4. Supervised by a Registered nurse.

Only a Registered nurse can carry out the assessment to determine whether the person has eligible nursing needs.

The Funded Nursing Care contribution

The FNC contribution is provided at a flat rate set by central government. It does not change depending on the cost of the placement, or the complexity of the person's eligible nursing needs.

The FNC contribution is paid directly by the ICB to the nursing/care home providing the registered nursing care, unless there is an agreement in place for this to be paid via a third party (e.g. a local authority).

As the FNC contribution does not cover the total cost of the placement, the remaining costs will need to be paid by:

1. The person (if they are self funding); or
2. The Local Authority.

3. Funded Nursing Care and NHS Continuing Healthcare

Unless all the following apply, a person must be considered for NHS Continuing Healthcare before being considered for NHS-funded Nursing Care:

1. They will be staying short term in a nursing home / care home with nursing provided; and
2. They have nursing needs that have been assessed by a Registered nurse; and
3. That Registered nurse has made a recommendation that the person is eligible.

Note: Eligibility for NHS-funded Nursing Care can be considered based on available evidence, and does not require the full assessment and DST process to be carried out.

4. Roles and Responsibilities

The role of the Integrated Care Board (ICB)

When a NHS Continuing Healthcare checklist has been completed

The ICB should consider a person's eligibility for NHS-funded Nursing Care when:

1. A full assessment to determine eligibility for NHS Continuing Healthcare is not required; or
2. A full assessment has determined the person is not eligible for NHS Continuing Healthcare and the practitioner coordinating the CHC process has recommended so.

When considering eligibility for NHS-funded Nursing Care the ICB must use any available nursing needs assessment completed as part of the NHS Continuing Healthcare process. If such an assessment is not available they must appoint a Registered Nurse to complete one.

After considering eligibility for NHS-funded Nursing Care the ICB must make a decision about eligibility.

When there is no NHS Continuing Healthcare checklist

The ICB can only consider eligibility for NHS-funded Nursing Care without a NHS Continuing Healthcare Checklist when:

1. A Registered Nurse has completed a nursing needs assessment; and
2. The Registered Nurse recommends that the person is eligible for NHS-funded Nursing Care.

The role of the Local Authority

Practitioners carrying out Local Authority functions should, through any assessment or review process:

1. Identify when a person may be eligible for NHS-funded Nursing Care; and
2. Provide information to the person (and their family) about NHS-funded Nursing Care and the NHS Continuing Healthcare process (whenever it is requested or would be beneficial); and
3. Seek the person's consent to complete the NHS Continuing Healthcare checklist (of if they lack capacity decide whether it is in their Best Interests to continue); and
4. Complete the NHS Continuing Healthcare checklist; and
5. If the need for a full assessment is indicated, make a referral to the ICB.

Note: Unlike a Registered Nurse, the Local Authority cannot ask the ICB to determine eligibility for NHS-funded Nursing Care. Eligibility for NHS Continuing Healthcare must always be considered first.

The role of the NHS Continuing Healthcare coordinating practitioner

During a full assessment of eligibility for NHS Continuing Healthcare

When the MDT recommends that the person is not eligible for NHS Continuing Healthcare the coordinator appointed to manage the assessment process should make a recommendation to the ICB about the person's eligibility for NHS-funded Nursing Care or a joint package of health and social care.

The role of a Registered Nurse

Eligibility for NHS-funded Nursing Care can only be considered by the ICB when a Registered Nurse has:

1. Completed a nursing needs assessment; and
2. Recommends that the person is eligible for NHS-funded Nursing Care.

A Registered Nurse should complete a nursing needs assessment and make a recommendation to the ICB when:

1. The ICB appoints them to do so;
2. They have been part of an MDT that has made a 'not eligible' recommendation in regards to NHS Continuing Healthcare;
3. Whenever they believe a person has needs that are eligible.

Note: Registered nurses are the only practitioners who can make a direct request to the ICB to consider eligibility for NHS-funded Nursing Care without first completing an NHS Continuing Healthcare Checklist.

Maximising participation of the person

A core value and principle of the National Framework for NHS Continuing Healthcare and NHS-Funded Nursing Care is to ensure the involvement and participation of the person at all stages of the process, from completing the checklist to the point where a decision is made about eligibility and beyond.

As a minimum the MDT should:

1. Ensure that the person and/or their representative is fully and directly involved in the process and any decision making (to the extent that it is possible to do so);
2. Take full account of the person's own views and wishes, ensuring that their perspective is the starting point of every part of the process;
3. Address communication and language needs;
4. Seek consent to assessment and sharing of records;
5. Deal openly with issues of risk; and
6. Keep the person (and/or their representative) fully informed.

Practitioner skills and knowledge

The Framework requires that practitioners involved in the process have received the necessary training to fulfil their role and meet their responsibilities.

You should speak with a line manager if you are concerned about your skills or knowledge around the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care.

5. Identifying a Possible Eligible Nursing Need

Why it is important to identify possible eligible nursing needs

As a social care practitioner it is important that you understand when a person may have eligible nursing needs, for both person centred and statutory reasons.

Person centred benefits

It is unlikely that practitioners based in the Local Authority will:

1. Understand how best to meet nursing needs; or
2. Be able to assess the appropriateness of a placement to meet the person's nursing needs.

Statutory implications

Under Section 22 of the Care Act the Local Authority is not permitted to provide services and support to people when it is the legal duty of the NHS to provide them unless:

1. The support being provided is merely incidental or ancillary (secondary) to doing something else to meet Care and Support needs; or
2. The support is of a nature that the Local Authority could be expected to provide.

People that may have an eligible nursing need

It is important that no assumptions or generalisations are made about a person's possible eligible nursing need. However, where a person’s needs appear to include significant health needs, they may be eligible, and steps should be taken to consider eligibility.

Identifying when a person may have eligible nursing needs

Consideration of possible eligible nursing needs should, wherever possible take place as part of the Care and Support planning process, as a way to:

1. Confirm a person's need for a nursing /care home with nursing provided placement; and
2. Support the Local Authority to identify the most appropriate placement to meet their specific nursing needs.

Consideration should only take place after a person has moved into a nursing/care home with nursing provided when:

1. They arranged their own placement; or
2. Their needs have changed and you feel they may now be eligible (when previously they were not).

If you are not sure of a person's possible eligibility you should seek the support and advice of your line manager.

When a possible eligible nursing need is identified

When you have identified that a person may have an eligible nursing need you should:

1. Provide information to them (or their representative) about NHS Continuing Healthcare and NHS-funded Nursing Care; and
2. Seek their consent to complete the NHS Continuing Healthcare checklist; and
3. Complete the checklist to determine whether a full referral for an assessment of eligibility by the ICB is indicated.

6. Providing Information and Advice

You are expected to be able to provide accessible information and advice about NHS Continuing Healthcare and NHS-funded Nursing Care whenever:

1. A person/carer asks for it; or
2. You have identified that a person may have an eligible nursing need.

The following is a list of the information that you should be able to provide:

1. What NHS Continuing Healthcare is;
2. What NHS-funded Nursing Care is;
3. What factors might make a person eligible for NHS Continuing Healthcare;
4. What factors might make a person eligible for Funded Nursing Care;
5. The process of completing a NHS Continuing Healthcare checklist;
6. What happens following a checklist;
7. Who is responsible for making decisions about eligibility;
8. How decisions about eligibility are made;
9. The implications of an 'eligible' decision; and
10. The implications of an 'ineligible' decision.

For information about the process of determining NHS Continuing Healthcare, see the NHS Continuing Healthcare Procedure.

You should speak with a line manager if you are concerned about your skills or knowledge around the NHS Continuing Healthcare framework or the NHS-funded Nursing Care process before providing advice about it.

7. Consent

See Consent, which is part of the NHS Continuing Healthcare Procedure.

8. Completing the NHS Continuing Healthcare Checklist

See: Completing the NHS Continuing Healthcare Checklist, which is part of the NHS Continuing Healthcare Procedure.

9. Making a Referral to the ICB

See: Making a Referral to the ICB, which is part of the NHS Continuing Healthcare procedure.

10. Agreeing Eligibility for NHS-funded Nursing Care

The responsibility of agreeing eligibility

It is the responsibility of the ICB, based on the recommendations of the Registered nurse, to make a decision about eligibility for Funded Nursing Care.

The recommendation of the Registered nurse

To support their recommendation the Registered nurse is required to:

1. Complete a nursing needs assessment; and
2. Consider whether or not a nursing home / care home with nursing provided placement is required (see below); and
3. If so, develop a Care Plan setting out how nursing needs will be met; unless
4. This information has already been provided as part of the NHS Continuing Healthcare assessment process.

When completing a nursing needs assessment and Care Plan the Registered nurse should ensure they only consider interventions that are (or would be):

1. Planned and reviewed by a Registered nurse;
2. Monitored by a Registered nurse; or
3. Supervised by a Registered nurse.

Determining whether a placement with nursing is required

The Registered nurse should consider the following questions:

1. Could the person's eligible nursing needs be met by a community nurse in their own home?
2. Does the level or nature of the eligible nursing needs require a nursing home placement / care home with nursing provided placement, or could a non-nursing placement meet the need?
3. Does the person want to be in a residential setting?
4. Are there any safeguarding concerns relating to the person, or to any proposed placement that must be considered.

Note: If a nursing home / care home with nursing provided placement is not required the nurse cannot recommend NHS-funded Nursing Care.

Notification of the outcome

As part of the NHS Continuing Healthcare process

Regardless of your involvement in the multidisciplinary team, if you made the referral the coordinating practitioner should notify you of the outcome as soon as possible after a decision has been made. You should:

1. Record the outcome on the person's electronic file; and
2. Answer any questions that the person may ask of you regarding the outcome or implications.

The coordinating practitioner is responsible for formally notifying the person of the outcome in writing, explaining the implications of the outcome to them and letting them know how they can make a complaint about the decision.

Outside the NHS Continuing Healthcare Process

If a Registered Nurse made a direct request to the ICB for NHS-funded Nursing Care to be considered the Local Authority may not be aware, but should be notified if the ICB have deemed them eligible.

In this case it is the responsibility of the Registered Nurse to notify the person.

If the person is eligible

See: Section 11, Arranging Services and Recording NHS-funded Nursing Care Contributions.

If the person is not eligible

If the person is not eligible for NHS-funded Nursing Care the Local Authority must provide a Personal Budget that is sufficient to meet all of the person's eligible needs for Care and Support, which can include support provided by a health professional when:

1. It is merely incidental or ancillary (secondary) to doing something else to meet Care and Support needs; or
2. It is of a nature that the Local Authority could be expected to provide.

Complaints and challenges to the decision

Challenges to the decision

If you are concerned about the decision of the ICB you should discuss any action that may (or may not) be needed to challenge the decision with your line manager. Challenges should be made in line with the local dispute resolution process.

Complaints about the decision

If the person (or their representative) is unhappy with the decision of the ICB they should complain about it directly to the ICB, and the ICB is required to review their decision.

11. Arranging Services and Recording NHS-funded Nursing Care Contributions

Arranging services

When arranging a nursing home/care home with nursing provided placement (either permanently or for respite) you must:

1. Use any available nursing needs assessment to understand the nursing needs that the person has; and
2. Work jointly as required with the Registered nurse that completed the assessment in order to ensure that an appropriate placement is identified.

Guidance about effective joint working can be found in the Joint Work Procedure.

When the person moves into the placement

When the person who is eligible for NHS-funded Nursing Care moves into a nursing/care home with nursing provided placement the Registered nurse responsible for reviewing the FNC must ensure that they have access to all of the health services that they require when they move. This can include:

1. Tissue viability services;
2. Occupational Therapy;
3. Speech and Language Therapy;
4. Physiotherapy; and
5. Palliative Care.

Self Funders

The Local Authority should consider the benefit in arranging and managing services for a self-funder if they are eligible for NHS-funded Nursing Care.

This is because their needs are likely to be:

1. Complex;
2. Likely to change; or
3. Unstable (or at risk of becoming unstable).

Recording NHS-funded Nursing Care contributions

NHS-funded Nursing Care contributions should be recorded in line with local requirements.

12. Reviewing Eligibility

The Integrated Care Board (ICB)

The ICB has a statutory responsibility to review the person's eligible nursing needs 3 months after NHS-funded Nursing Care was first agreed, and then every 12 months after that.

When reviewing the need for NHS-funded Nursing Care, potential eligibility for NHS Continuing Healthcare must always be considered. In order to determine whether there has been a material change in need, if applicable, the previously completed Checklist or DST should be available at the NHS–funded Nursing Care review.

The Local Authority

The Local Authority should consider completing a further NHS Continuing Healthcare checklist if they believe there to be a change in the person's needs or circumstances in the future, and that they:

1. May now be eligible for NHS-funded Nursing Care; or
2. May now be eligible for NHS Continuing Healthcare.

Joint reviews

Wherever possible statutory Care and Support Plan reviews should be carried out at the same time as the ICB carries out its review of the NHS-funded Nursing Care to:

1. Prevent duplication for the person; and
2. To ensure a multidisciplinary approach to agreeing the response to any change in need or circumstances of the person.

Guidance about effective joint working can be found in the Joint Work Procedure.

If a joint review is not possible the Local Authority practitioner and the Registered nurse must make arrangements to share relevant information, having regard for confidentiality and consent.

Withdrawing NHS-funded Nursing Care

If there is any evidence to suggest that the person may no longer be eligible for NHS-funded Nursing Care the ICB must carry out an appropriate reassessment of the person's nursing needs to confirm this to be the case.

NHS-funded Nursing Care can be withdrawn by the ICB if:

1. The person no longer has eligible nursing needs; or
2. The person no longer requires registered nursing care; or
3. They become eligible for NHS Continuing Healthcare.

If the ICB intends to withdraw NHS-funded Nursing Care the Local Authority should be informed in writing of:

1. Their intention to do so;
2. The date that they intend to stop providing funding; and
3. The rationale for the decision.

If the Local Authority is managing the placement they should:

1. Consider whether the nursing / care home with nursing provided placement remains the most appropriate way to meet the person's eligible Care and Support needs; and
2. If so arrange to increase the person's Personal Budget accordingly so that the full cost of the placement is met; and
3. If not, agree and make alternative arrangements for Care and Support.

If the Local Authority is not managing the placement because the person is self funding, the person must make suitable arrangements to pay the full cost of the placement.

13. Hospital Admissions

The ICB is not permitted to continue paying NHS-funded Nursing Care contributions to a nursing home if the person is receiving registered nursing care in an acute hospital (or other NHS setting).

However, the ICB is permitted to pay a retainer fee to the nursing home / care home with nursing provided at the FNC rate in order to hold the placement.

Where available local NHS-funded Nursing Care policy should set out:

1. The circumstances when the ICB will/will not pay the nursing home / care home with nursing provided a retainer fee to cover the shortfall;
2. The circumstances when the Local Authority must pay the difference in cost in order to retain the placement; and
3. The circumstances when the person must make suitable arrangements to pay (if self funding).