Complex Needs Nursing Team

Children and Young people’s Continuing Care

Type of service provided:

A Continuing care package will be required when a child or young person has needs arising from disability, accident, or illness that cannot be met by existing universal or specialist services alone.
Children and Young people’s Continuing Care is a National NHS Framework and comprises of three phases


  1.   Assessment – led by the Continuing Care Nurse. This may include a pre assessment. The continuing care nurse will meet with the child and parents/carers either in hospital or home. Reports and assessments will be collated from the multidisciplinary teams involved in the child’s care.
  2.   Decision making – This involves a panel of professionals made up of the Clinical Commissioning Group (CCG), Education, Health, Social Care and the Continuing Care Nurse. The panel will consider all information and will reach a decision as to whether or not the child or young person has a continuing care need.
  3.   Development of a care package – The panel will decide how the continuing care will be provided based on the child and young person’s health need. The Local Authority will consider the social care needs of the child and young person, and may agree funding towards a joint package of care with health. The CCG will identify care providers in order to deliver the care package as soon as possible. The care package will be reviewed at regular intervals.

An alternative to a care package is a Personal Health Budget.

A Personal Health Budget is NHS money that the CCG’s would spend on individuals with assessed Continuing Care Needs. It is an alternative method of care delivery which enables flexibly, allowing individuals and families to have more control over the funding to meet health and wellbeing needs in way that works for them.

Useful links:
https://www.gov.uk/government/publications/national-framework-for-nhs-continuing-healthcare-and-nhs-funded-nursing-care

https://www.gov.uk/government/publications/send-code-of-practice-0-to-5

Children with Complex Needs may also require support from other services; they may have special educational needs and need support from social care, children with disabilities (CWD) and Special Educational Need and Disability (SEND) All agencies will work together to gain a collaborative approach to your child’s care.


Age Range:

From Birth to 19 years

The Service:

  • Experienced paediatric nurses, supported by the Manager of the Complex Needs Nursing Service, Evelina London Children’s Healthcare
  • We provide a Continuing Care service for children, young people, their families and carers who reside within Southwark and Lambeth. We're based in the community, when you have to visit the hospital, we will work closely with the specialists, your GP and community paediatricians to ensure a continued supportive service.
  • Continuing care nurses work closely with families to assess their needs and organise care packages when they are required.
  • We support children and young people with complex health needs to be cared for at home.
  • To work in partnership with Children and Young people, their families, carers to prevent unnecessary hospital admission
  • To work in partnership with Clinical Commissioning Groups (CCGs), care providers, GP, community paediatricians, paediatric specialists, Dieticians, Therapists, Head Teacher, Social Care or Special Educational Needs and Disability (SEND)
  • To signpost and facilitate vital respite for families with local organisations.
  • Support children requiring Non Invasive ventilation with consumables and arranging servicing of equipment.
  • A key contact for families enabling signposting to other available services.
  • Information and advice is available from school nurse or the Team Leader.

Who is the service for?

The service is available for children with complex health needs who are registered with a GP in Southwark or Lambeth.

Criteria for access to service

Any parent/carer of a Child or Young person, with a complex health need may access this service. This may be for advice or a referral.

Accessibility of this service

Once a referral has been received the continuing care nurses will arrange to meet with the family. This could be in the hospital, home, or respite setting.

How this is provided:

Continuing care nurses will complete a face to face assessment with the family of the child and will also contact appropriate healthcare professionals involved in the child’s care. Advice or signposting maybe given by telephone.

How can I access this service?

You can refer your child to our service or ask your specialist, Social worker or GP to do this for you.

Email: gst-tr.evelinacommunityreferrals@nhs.net

How is this service funded?

The service is funded by CCG's.

Do you need to pay for this service?

The service is free if you are entitled to NHS care and are registered
with a GP practice in Lambeth or Southwark.

Confidentiality and Impartiality

All contacts with children and their families are treated in a confidential way as per Trust policy.

Useful to know

The Continuing Care service is available 9am – 5pm Monday- Friday
The office is closed on weekends and Bank Holidays. You can send an email or leave a message on the answer phone and we will contact you within 2 working days. If you visit the centre it is located within the congestion charge zone.