By Rosalind Hughes, founder, Just Caring Legal
Do you believe your relative has been wrongly assessed as ineligible for NHS Continuing Healthcare? Have they recently “failed” at either the checklist or the full assessment stage of the process? A staggering two thirds of applicants find themselves in this position. The good news is that even under the temporary Coronavirus Act rules, you can still appeal an ineligibility decision for NHS Continuing Healthcare. The bad news is that many Clinical Commissioning Groups (CCGs) have temporarily relaxed their timeframes for dealing with requests. And as regular readers of my blog will know, the appeal process was often too slow in the first place. Nevertheless, even if you have to pay care fees for now, you should be entitled to a sizeable refund if your appeal is eventually successful.
How do you appeal an ineligibility decision for NHS Continuing Healthcare?
The appeal process normally consists of three stages:
- The local resolution procedure. This can vary from area to area but should involve an informal stage such as a meeting, followed by a panel review if necessary.
- An Independent Review convened by NHS England. This is a formal review by an independent panel of experienced health and social care professionals and a lay Chair. You would normally be invited to attend part of the panel hearing.
- Referral to the Parliamentary and Health Service Ombudsman for a full independent investigation. After stopping all complaints work in March because of the Coronavirus crisis, the ombudsman is to restart this work on July 1. While there is a 12-month time limit for complaints, if this ran out between 26 March and 30 June the PSHO will treat it as in time as long as it is brought within two months of the service resuming.
How long do you have to request an appeal?
You should have six months to request local resolution from the date of your ineligibility decision. But in practice, some Clinical Commissioning Groups (CCGs) impose much shorter deadlines. If yours does, and the deadline has already passed, don’t give up. You may be able to challenge this citing the National Framework. Where necessary, CCGs have been allowed under the emergency legislation to redeploy CHC staff to support the discharge and care planning of COVID-19 patients. So there are likely to be even more delays than before in processing appeals. Obviously, face to face meetings may also not be possible yet.
So is it worth appealing an ineligibility decision for NHS Continuing Healthcare?
It most definitely is – as long as you have clear grounds to do so. Was your relative’s assessment carried out in line with the NHS CHC national framework? Was the multidisciplinary team (MDT) made up of the requisite health and social care professionals? Did representatives of the family get to attend the meeting? Did the assessors take your oral evidence into account? Perhaps you feel important evidence of complex and unpredictable care needs was downplayed or simply ignored. Or perhaps the MDT recommended a finding of eligibility and the CCG overruled it. If so, did they justify this by reference to exceptional circumstances?
There are many possible grounds for appealing an NHS CHC ineligibility decision. Seeking legal representation can help maximise the chances of your appeal being successful – and completed within a reasonable time frame. Just Caring Legal specialises in NHS Continuing Healthcare. Our job is to carry out detailed, forensic analysis of CCG decision-making processes. If there are holes, we will find them. And then, if you need us to, we will do the talking at any meetings or hearings that take place. In the past, we have secured NHS CHC refunds within weeks for clients who have been waiting years for an outcome.
We may be able to help you too to get the right decision for your family member. And, in some cases, a sizeable refund of care fees. So if you have had an ineligibility decision and you think it is unjustified, give us a call or email us today.