NHS-funded Nursing Care Procedure (FNC)

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 placement; or
2. Stay short term in a nursing placement (for example respite).

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 Clinical Commissioning Group (CCG) must determine if a person is eligible for NHS-funded Nursing Care.

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

The FNC contribution is paid directly by the CCG to the care home providing the registered nursing care.

The FNC contribution and will not cover the total cost of a nursing home and the remaining costs will need to be paid by:

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

When a NHS Continuing Healthcare checklist has been completed

The CCG 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 CCG 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 CCG must make a decision about eligibility.

When there is no NHS Continuing Healthcare checklist

The CCG 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.

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. Obtain 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 a full assessment is required, make a referral to the CCG.

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

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 CCG about the person's eligibility for NHS-funded Nursing Care or a joint package of health and social care.

Eligibility for NHS-funded Nursing Care can only be considered by the CCG 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 CCG when:

1. The CCG 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 CCG to consider eligibility for NHS-funded Nursing Care without first completing an NHS Continuing Healthcare Checklist.

A core value and principle of the National Framework for NHS Continuing Healthcare and NHS-Funded Nursing Care is to maximise 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;
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. Obtain 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.

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.

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 by a health professional 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.

It is important that no assumptions or generalisations are ever made about a person's possible eligible nursing need. However people with the following health conditions that may require (or already live in) a nursing home placement may have needs that are complex enough to require the care of a Registered nurse.

1. Advanced Dementia;
2. Parkinson's Disease;
3. Cancers;
4. Acquired brain injury;
5. Severe learning disability;
6. Complex personality disorders; or
7. Enduring mental health illness
8. Needs that are complex, intense and unpredictable.

The Care and Support Planning process

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 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 home 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).

How to identify possible eligible needs

Possible eligible nursing needs can be identified by considering the person's needs in the context of their:

1. Nature;
2. Intensity;
3. Complexity; and
4. Unpredictability.

If you are not sure of a person's possible eligible nursing need you should seek the support and advice of your line manager:

If 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. Obtain 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 CCG is required.

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

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 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.

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, or could a non-nursing home 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 placement is not required the nurse cannot recommend NHS-funded Nursing Care.

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 CCG for NHS-funded Nursing Care to be considered the Local Authority may not be aware, but should be notified if the CCG have deemed them eligible.

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

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

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.

Challenges to the decision

If you are concerned about the decision of the CCG you should discuss any action that may (or may not) be needed to challenge the decision with your line manager.

Complaints about the decision

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

The Local Authority is not able to manage any complaints relating NHS-funded Nursing Care.

When arranging a nursing home 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 who is eligible for NHS-funded Nursing Care moves into a nursing 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.

The Local Authority should consider the benefit in arranging and manage 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).

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

The CCG have a statutory responsibility to review how the nursing placement is meeting the person's eligible nursing needs 3 months after NHS-funded Nursing Care was first agreed, and then every 12 months after that.

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

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.

Wherever possible statutory Care and Support Plan reviews should be carried out at the same time as the CCG 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.

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

1. The person no longer has eligible nursing needs; or
2. The person no longer require a nursing home placement; or
3. The person no longer requires respite in a nursing home.

If the CCG 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 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.