CCG

Where Is the Meaningful Data on NHS Continuing Healthcare Assessments

What do we really know about the experiences of those going through NHS Continuing Healthcare eligibility assessments?

If someone is eligible for NHS Continuing Healthcare this should cover both their health and social care costs. If the NHS Continuing Healthcare assessment finds they are not eligible, the individual may have to pay some or all of their social care costs. However, this depends upon their assets, savings and income.

At Just Caring Legal, we hear anecdotal evidence every day about how the assessment process is working – and not working – for people. But what do the statistics tell us? Sadly, not enough.

NHS England published its latest data this month, covering April to June 2017. It told us the total number of people receiving assessments for NHS Continuing Healthcare was 35,654. Of these, 14,668 were via the Standard NHS Continuing Healthcare assessment route and 20,986 via the Fast Track assessment route. Less than a third (31%) of standard assessments resulted in eligibility. Yet, most applicants would have undergone an initial screening process to assess their likelihood of success before a full assessment.

On the other hand, nearly all (99%) of those receiving Fast Track assessments were successful. Fast Track assessments are designed for those who require end of life care.

What the NHS England figures can’t tell us is why there are such huge variations nationwide in both the number of assessments and the proportion of applicants qualifying for NHS Continuing Healthcare funding.

How different local bodies are applying national guidelines.

The National Audit Office found that in 2015-16, the proportion of people referred for an assessment who were subsequently deemed eligible for NHS Continuing Healthcare funding ranged from 41% in some local Clinical Commissioning Groups, to 86% in others.

NHS England itself admits it cannot explain the variation in so-called “conversion rates”. There must be significant differences in the way local bodies are applying the national guidelines on NHS Continuing Healthcare assessments.

Where is the meaningful data that might help shed light on this? It simply isn’t there. The independent Continuing Healthcare Alliance put it in a nutshell:

“At the moment…we know nothing about all of those who were unsuccessful. We don’t know how long they waited for an assessment, why they were unsuccessful, or if they appealed. Healthcare professionals have huge demands on their time, but it is essential that accurate information around NHS Continuing Healthcare is recorded so the system can be improved, and problematic areas can be tackled.”

We need to fill in these blanks so we can make sure the NHS Continuing Healthcare system works justly and efficiently for everyone. Their postcode should not be a factor.

We find that if our client’s seek our help earlier in the process, there is usually a greater chance of success in a shorter period of time. If you have queries about your family’s situation then contact us today.

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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.

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Many NHS CHC Assessments Are Flawed, Reports Reveals

The Continuing to Care report, which came out last week, is a reminder of the difficulties facing many of those who apply for NHS Continuing Health Care (NHS CHC) funding. NHS CHC pays care fees in full for those with a ‘primary health need’. However, many NHS CHC assessments are flawed, the report found.

How are NHS CHC assessments carried out?

Someone is eligible for NHS CHC if healthcare is more than ‘incidental or ancillary’ to their care needs. The National Framework on NHS CHC provides detailed guidance to local health boards (CCGs) on how to conduct NHS CHC assessments. Yet the Continuing to Care report suggests some CCGs do not apply the guidance correctly.

NHS CHC assessments rely heavily on the “Decision Support Tool” (DST). This detailed document separates the person’s care needs into 12 broad “domains”. It should be used by a multi-disciplinary team of professionals to grade how severe the person’s care needs are for each domain. Using their expert judgement, the team should then consider the overall nature, intensity, complexity and unpredictability of needs.

However, 73% of respondents to the report who had applied for NHS CHC felt the DST did not “enable an accurate impression of the person’s situation”.

Here is an extract outlining Alison’s story.

“It was very clear to me that the assessment was a sham”, Alison told researchers

At 96 Tom, a former teacher, had developed vascular dementia. So his daughter-in-law Alison, a nurse for 40 years, applied for NHS CHC.

Alison said: “I believe the team assessing Tom manipulated some of the information. For example, when assessing his mobility they decided that because he could shuffle about in bed, he was mobile and therefore did not qualify. What’s their definition of mobility? He couldn’t walk, stand or even turn over in bed, which I think means he was immobile. It was very clear to me that the assessment was a sham. It was awful to watch… I felt the assessors seriously downplayed most of his problems.”

What to do if an NHS CHC assessment goes against you

The good news is you can challenge an NHS CHC ineligibility decision. The first step is to use the local complaints procedure. If this fails, you can take the case to an Independent Review Panel. And, if all else fails, you can go to the Parliamentary and Health Service Ombudsman. However, the report found many people were “too distressed and exhausted to go through the complex appeals process”.

As the Head of Just Caring Legal I echo a lot of the views from this vital report. Which is why I felt compelled to start my own business, challenging the NHS CHC assessment process on behalf of vulnerable people.

Because it does take a great deal of perseverance, knowledge and hard evidence to successfully appeal an NHS CHC decision. But it can be done! For further inspiration, read Don’s story.

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Postcode Lottery in NHS CHC – New Report Sheds Light on Why it Exists

Cash for care.

Here at Just Caring Legal we are dedicated to fighting the postcode lottery in NHS Continuing Health Care. This is the funding that exists to meet the care costs of those with a “primary health need”.

Some local health boards (known as CCGs) are three times more likely to grant NHS CHC than others. (See Just Caring Legal’s story in the South Shields Gazette on this). Even allowing for local health variations, how can this be right? After all, there is a National Framework designed to ensure all CCGs follow the same process. Now a new report from the Continuing Healthcare Alliance has shed light on why this postcode lottery exists. A coalition of leading charities, the alliance has gathered evidence from hundreds of professionals as well as NHS CHC applicants.

The report finds some CCGs are not following the National Framework on NHS CHC

Flawed processes mean many people who are eligible for NHS CHC are failing to get this much needed support. The researchers found the system is “complicated, confusing and intimidating” for individuals and families. As for the National Framework, “some local decision makers appear to be choosing which bits they intend to follow.” Around a third of respondents said their NHS CHC assessment was not carried out by a multi-disciplinary panel. Very worrying, since this is a basic requirement under the Framework.

The report suggests some NHS CHC decisions are based on “financial ulterior motives”

One NHS worker, Kathy, explained to the CHC alliance why she thinks the postcode lottery exists. “I really believe decisions are being based on financial ulterior motives and not on the patient’s needs,” she says.

This is how it goes in Kathy’s area. In order to complete a decision on NHS CHC, the CCG asks relevant professionals and care providers for evidence of need. They usually give 28 days to respond. If no information is forthcoming, or if some reports miss the deadline, the case is closed. Thus many patients never even make it to the assessment stage, Kathy explained.

Even where the CCG does receive evidence, however, Kathy says the decision-makers do not always take it into account. “They cherry pick bits from the professionals which gives a distorted reflection of the patient – this seldom results in eligibility.”

The report says some decision-makers “rarely find anyone eligible” for NHS CHC

Kathy continues: “I’ve also seen panels come together and downgrade the [original] findings – despite the fact they’ve never seen the person…My CCG rarely find anyone eligible.

“Some local areas have someone whose job it is to co-ordinate the assessments. That person is a health professional, usually a nurse, but shouldn’t form part of the [decision-making panel]. They are supposed to be an impartial resource. But in my area this person gives the patient a score, and sometimes even has their opinion rated more important than others. I have been in situations where the [panel] members recommend someone is eligible, and the co-ordinator says no.”

Kathy doesn’t know where to turn any more. Despite raising her concerns with NHS England, nothing has changed.

Her testimony is shocking. But unfortunately, in our experience, not unusual. The good news is you can challenge NHS CHC decisions. You can get the funding you deserve – but you will need time, perseverance and lots of hard evidence.

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Do you Recognise Don’s Story About his Battle to Secure NHS Continuing HealthCare funding? If so get in touch

A battle for healthcare funding.

“It has been a long, arduous, frustrating struggle. There are many others who are being unlawfully denied NHS Continuing Healthcare Funding, feel impotent in the face of intransigence from the health service and are in despair. Hopefully my victory will inspire them.”

Don Keiller, a university lecturer, spoke to The Times after the NHS was forced to pay nearly £94,000 to his mother. His mother isa 90-year-old woman with dementia, who was wrongly denied funding for her care for two years.

Don, 60, fought long and hard to prove his mother was entitled to receive NHS Continuing HealthCare Funding (NHS CHC) to meet the full costs of her care. He showed that Cambridgeshire and Peterborough clinical commissioning group (CCG) repeatedly misrepresented the evidence to deny Vicki rightful access to these funds. NHS England is now looking into the case to see what lessons can be shared.

A common situation.

At Just Caring Legal, it is common to hear stories like Don’s. We are a specialist firm dedicated to recovering wrongly paid care fees. We help families who have been denied the NHS CHC funding their loved ones are entitled to.

Many people don’t realise that the full cost of care fees should be paid by the NHS where the person eligible for care has a ‘primary health need’. A large number of people also don’t realise that savings or owning your own home is irrelevant in this case.

The NHS is responsible for paying NHS CHC where the applicant has specific needs. These are described as ‘relating to the treatment, control or prevention of a disease, illness, injury or disability and the care and after care of a person with those needs’. The Court of Appeal case of ‘Coughlan’ clarified the law. Additionally, since 2007, there has also been a National Framework in place that provides further guidance on these cases.

Across the country.

Despite this, figures from the NHS’s own data provider reveal huge variations in how local CCGs are prepared to pay NHS CHC. There has been a downward trend in the numbers receiving the funding over the past few years. This is despite the reality of the UK’s rapidly ageing population.

In our experience, many CCGs are failing to apply the rules on NHS CHC correctly. As can be seen by Don’s case. They delay decisions, misapply the eligibility criteria and ignore evidence. In so doing, they avoid paying what is needed to meet severe and complex care needs.

Finding support.

Do you recognise your own struggles in Don’s story? Perhaps you have been told your loved one won’t qualify for CHC. Or, that an assessment has been carried out – without your knowledge or involvement. This may have found that your loved one is not eligible. Don too was told all of these things.

We have specialist experience in pursuing these complex cases. Just Caring Legal are a strong and persuasive voice for families. We construct robust legal arguments to challenge ineligibility decisions and recover the funding they are entitled to.

If you have a story like Don’s, get in touch with us today on 01915 561 078 or email us at [email protected].

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