assessment #

Five Reasons You May Be Entitled To a Refund of Care Fees

You can claim a refund of care fees for periods during which you or a loved one was eligible for NHS Continuing Healthcare but did not receive it. Do any of the following apply to you? If so you may have a claim.

You or a loved one have paid care fees in England because of complex and/or unpredictable care needs

These could be home care, residential care or nursing home fees. To qualify, the care fees must have arisen from a primary health need, whether diagnosed or undiagnosed. They may have been the result of, for example:

a severe illness such as Alzheimer’s, other form of dementia, multiple sclerosis, chronic obstructive pulmonary disease, cancer, or Parkinsons;
a physical or learning disability;
the effects of stroke;
an accident that caused injury;
a severe mental illness.

If so, the person may have been eligible for NHS Continuing Healthcare. This is personal health and social care arranged and funded by NHS Clinical Commissioning Groups (CCGs). It is not means-tested and must cater for all assessed care needs.

You have been been told you/they were not eligible without an assessment being carried out

The CCG must assess someone for NHS Continuing Healthcare if it seems they may need it. Usually they should carry out an initial checklist assessment, which will help them decide quickly if the person should undergo a full assessment. The exception is for urgent care needs – usually due to a terminal illness – in which case the assessment should be a fast-track one. If the checklist suggests they need a full assessment, this should be carried out by a team of trained health and social care professionals. If you think there should have been an assessment, you can ask for one retrospectively.

You disagree with the outcome of an NHS Continuing Healthcare assessment

You may believe the assessment did not accurately reflect the person’s care needs, for example around behaviour, cognition or mobility or other domains. The NHS Continuing Healthcare assessment should have taken into account the views of the person receiving care, their family and carers where appropriate. It should not have happened behind closed doors. If you believe the assessment did not give a true picture of care needs, you may be able to challenge this with evidence of your own.

You have had NHS Continuing Healthcare funding withdrawn following a review

This will probably have been on the grounds of a reduction in care needs. Were you told the condition had “improved” or “stabilised”, even though you believe this was purely down to good care? Do you believe overall care needs are just as intense, complex and unpredictable as before? You may be able to challenge a review with evidence of your own.

You have been “topping up” NHS Continuing Healthcare to meet the needs of the care plan

While the legislation governing local authority social care expressly provides for “topping up” care fees (though only in specific circumstances) the NHS are not permitted to ask for NHS Continuing Healthcare top-ups for assessed needs. (You can, however, pay for additional private services over and above those you need – in certain circumstances.) Yet we know many recipients of NHS Continuing Healthcare are paying “top-ups”. You may be able to claim these back.

If any of the above apply to you, you may be able to claim a refund of care fees. You may even be able to claim on behalf of someone who has died as long as you have the legal authority to do so. However, because of Government rules you cannot now claim for a refund of care fees paid in England before 31st March 2012. In Wales, retrospective claims can cover no longer than 12 months back from the date of application for review.

Do you think you may be entitled to a refund of care fees? If so fill in our initial online questionnaire and Just Caring Legal will advise you further.

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Five Key Questions to Ask About Your NHS Continuing Healthcare Review

Have you or a loved one had your care funding withdrawn following an NHS Continuing Healthcare review? Here at Just Caring Legal, we are hearing of more and more cases like this. A review of NHS Continuing Healthcare takes place after the first three months, then at least once a year thereafter. Of course, there will be times when the withdrawal of funding is justified, if the intensity or complexity of care needs have genuinely reduced. However in some cases, even those with long-term, degenerative conditions such as Alzheimer’s, other forms of dementia and Parkinsons, are losing much needed support. This often means the loss of trusted and familiar carers, or even a move to a different (cheaper) care home.

However, you may be able to challenge a decision to withdraw funding following an NHS Continuing Healthcare review. The key is whether the most recent assessment has followed the correct procedures. Here are five key questions to ask.

How have care needs reduced since the previous assessment?

Before withdrawing funding following an NHS Continuing Healthcare reassessment, the Clinical Commissioning Group (CCG) should be able to demonstrate how care needs have reduced. This should be with reference to the previous assessment based on the Decision Support Tool. But we know that this doesn’t always happen. In fact we find some people have never even seen their previous Decision Support Tool document. And it is never fully explained to them why they are no longer eligible for NHS Continuing Healthcare.

Who has given their input to the review?

The National Framework on NHS Continuing Healthcare is clear. Any review should take place in consultation with the person receiving care and “any other relevant people who know the person who are present”. In short, an NHS Continuing Healthcare reassessment should never take place behind closed doors or by an unqualified member of staff.

Has the review followed the correct processes?

An NHS Continuing Healthcare review should not just look at previous care needs. Often as conditions progress, needs change. Each case is unique and requires a thorough and detailed assessment. Has the review considered the full medical and care records? Has it taken into account the carers’ and family’s views? In short, has it examined overall care needs? Does it establish whether they are any less intense, complex or unpredictable than before? The review should give a complete picture across all the NHS Continuing Healthcare “domains”.

What would happen if current care was withdrawn?

A well-managed need is still a need. Nevertheless, we know people sometimes have their NHS Continuing Healthcare withdrawn on the grounds their condition has “improved” or “stabilised”, even though this is actually a reversible phenomenon purely down to the interventions of skilled carers. Ask what would happen if the same level of care was no longer provided? Would they remain stable or would they deteriorate?

Has the review also assessed whether current care is good enough?

The review should not just focus on continuing eligibility for NHS Continuing Healthcare. It should also address the question of whether the care provided is appropriate and adequate. If you have any concerns about the level of care provided, now is the time to raise it.