Alzheimer's Society

People with dementia living in nursing homes should have their nursing care provided free of charge by the NHS, through funding known as the registered nursing care contribution (RNCC). This factsheet applies to people receiving care in England. Different arrangements apply in Wales, Northern Ireland and Scotland.

A brief history

Before 2001, most care homes registered to provide nursing were maintained by social services, rather than by the NHS. Unlike NHS services, which are free at the point of delivery, support from social services is means-tested. Many residents therefore paid their own costs, including those relating to the nursing side of their care.

In 1999 the Royal Commission recommended that all personal care − both social care and nursing care − should be free.

The government response, in the form of the NHS Plan, stated that the NHS should be responsible for providing all nursing care free of charge wherever it was delivered. However, social care would continue to be means tested.
 
Section 49 of the Health and Social Care Act 2001 removed from local authority social services departments the responsibility for paying for nursing care in care homes. Instead, the NHS became responsible for providing nursing care.

In 2001, a new assessment process was introduced for people receiving nursing care in care homes. The assessment calculates the proportion of the care someone receives in a care home that can be classed as 'nursing care' and therefore provided free of charge by the NHS rather than means tested by social services. The money paid by the NHS for the nursing care component of a person's care package is known as the registered nursing care contribution (RNCC). Until 30 September 2007, nursing care funding was divided into three bands − high, medium and low.

Since 1 October 2007, the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care has been implemented. The national framework simplifies the interaction between the process for the assessment of NHS continuing healthcare and the assessment of NHS-funded nursing care. In all cases, a decision about eligibility for NHS continuing healthcare must be made before considering the need for NHS-funded nursing care.

If a person does not qualify for NHS continuing healthcare, the need for care from a registered nurse should be considered. The assessment should consider whether the person's needs would be most appropriately met in a care home providing nursing care (and, therefore, if they are eligible for NHS-funded nursing care).

Legislation change in 2007

Since October 2007, a single rate of payment for NHS-funded nursing care has replaced the three bands.

People who were categorised in low and medium bands prior to 1 October 2007 were moved immediately onto the standard weekly payment. Any resident who was receiving high-band funding continues to receive this higher level of payment until their case is fully reviewed in line with the national framework. If, on review, the person:

• is not eligible for NHS continuing healthcare, but their needs are still such that they would have been granted the high-band payment, payment should continue at the high rate
• has needs that would have been medium or low, they move on to the new, flat-rate payment
• is eligible for NHS continuing healthcare then NHS-funded nursing care payments cease.

Frequently asked questions

What is the difference between NHS continuing healthcare and NHS-funded nursing care?

NHS continuing healthcare is a package of continuing care arranged and funded solely by the health service for a person aged 18 or over to meet physical or mental health needs which have arisen as a result of illness.

NHS-funded nursing care, introduced in October 2001, is the funding provided by the NHS to homes providing nursing, to support the provision of nursing care by a registered nurse for those assessed as eligible.

How is a decision made about NHS-funded nursing care?
The starting point for decisions about NHS continuing healthcare and NHS-funded nursing care could be one of a number of different triggers, in a number of different settings. Possible situations include where a person is cared for in the community and their needs change, where they are being discharged from hospital, or where they are resident in a care home and their needs are being reviewed.

Whatever the outcome of the consideration for NHS continuing healthcare, the person's needs have to be met. Where it is decided that the person is not eligible for NHS continuing healthcare, the need for care from a registered nurse should be considered, and the decision made as to whether registered nursing care in a care home providing nursing is the best option. This will involve an assessment by a registered nurse.

What are the registered nurse assessments for?

A registered nurse involved in this decision should try to answer the following questions:

• Does the person have registered nursing needs at a level where they require a care home providing nursing care environment?
• Do they want or need to be in residential setting, or is another option more appropriate?

A nurse making this decision should take into account all the individual's nursing needs, based on what is known about their condition and their usual behaviour over the course of a week, or a number of weeks. They should also consider the potential outcomes if support were not provided, or were provided in different ways, and should focus on the impact of any decisions on the person's independence, and risks involved for the person, their family and others close to them.

Since 1 October 2007, registered nursing care needs may be recorded in the form of a care plan, using the same comprehensive care domains as those used in the Decision Support Tool and the NHS Continuing Healthcare Needs Checklist.

What is the difference between a care home registered to provide personal care and a care home registered to provide nursing care?

Care homes registered to provide nursing have a registered nurse present at all times. Ask the manager of the home what kind of care they are registered to provide. Dual-registered homes no longer exist, but homes registered to provide nursing may accept people with personal care needs who may need nursing care in the future.

The nursing care assessments are not carried out in care homes registered to provide personal care only, because people in these homes should have their nursing needs met by the NHS through a visiting district or community nurse.

How is 'nursing care' defined?

Rather narrowly. It is defined as 'care provided, delegated, monitored or supervised by a registered nurse'. This does not include the care provided by a nursing or care assistant, even if that care is delegated or supervised by the registered nurse. In this context, it is the act of supervision or delegation that is classed as 'nursing', rather than the care itself. Personal care is not defined as nursing care.

What impact does this assessment have on attendance allowance and other benefits?

None. The introduction of NHS care in care homes does not affect the level of attendance allowance or benefits received by residents.

Will anything else be taken into account when assessing the registered nursing care contribution?

Yes. The results of other assessments and the care plan will be taken into account, and the nurse carrying out the assessment may also talk to other professionals involved.

Do I have to arrange the assessment?

No. The health authority will automatically arrange an assessment. The money will be paid straight to the care home.

Will I see a reduction in my fee if I am self-funding?

Care homes registered to provide nursing receive the money for assessed nursing needs from the NHS. You may see this reflected in your fees or the home may continue to charge you a full fee, in which case they should refund you the money at a later date. However, in many situations this does not seem to happen. If you receive neither a reduction in your fees nor a refund, ask the home for a breakdown of your fees. If you are not happy with this breakdown, call the Alzheimer's Society legal and welfare helpline for further advice (details at the end of this factsheet).

What if I am partly self-funding?

Very few people who are partly self-funding are likely to see a reduction in their fee. Where the fee is split between the resident and social services it is likely that social services, and not the resident, will have its fee reduced.

The exception to this is in situations where the contribution by social services is less than the sum it has been decided that the NHS should pay. For example, if a resident has been assessed as being in the lower band, and social services' contribution to the weekly care costs is less than the lower band, the resident is clearly paying something towards their nursing care costs and their contribution should be reduced accordingly.

What if I'm unhappy with the assessment of the registered nursing care contribution for my care?

If the person is dissatisfied with the outcome of a decision relating to eligibility for NHS continuing healthcare, they are entitled to ask for a review of that decision as set out in the national framework. Challenges to decisions about eligibility for NHS-funded nursing care will be dealt with by the local primary care trust according to their local disputes process in the first instance. The individual's rights under the existing NHS complaints procedure remain unaltered.

Your local Alzheimer's Society branch will always be willing to talk to you and offer advice and information to support your needs.

For more information, Dementia Catalogue, our specialist dementia information resources is available on the website at alzheimers.org.uk/dementiacatalogue

Factsheet 452

Last updated: April 2008
Last reviewed: April 2008

Reviewed by: Louise Lakey, Policy Officer, Alzheimer's Society