Many people with a retrospective claim for care fees (NHS Continuing Healthcare funding) are now finally receiving the outcome – but the funding decisions being made are not always correct.
If you’ve submitted a retrospective claim for NHS Continuing Healthcare, you may have had a long wait for any progress to be made. You may still be waiting. When you do eventually receive the funding decision, it may not necessarily be correct.
You may be told that your relative is ineligible for retrospective NHS Continuing Healthcare funding. We’ve noticed, however, that these decisions often contain serious flaws. This article highlights some of the things to be aware of if you’re in this situation.
In a retrospective claim for care fees these steps should be taken:
- Your claim should have been reviewed by an NHS nurse reviewer, who should have looked thoroughly at all the relevant care notes, health reports and records, risk assessments, etc. for your relative – plus any information you submitted yourself.
- The reviewer will have applied the principles of an initial Checklist assessment for NHS Continuing Healthcare to ascertain whether or not your claim warrants further investigation. Assuming it does, the reviewer will complete a document called a Needs Portrayal and should then apply to your case the eligibility criteria contained in the Decision Support Tool form. This is the form used in all full assessments for NHS Continuing Healthcare funding.
- The reviewer will then make a recommendation about eligibility. Note – this is a recommendation, not a final decision. The final decision is made by a Clinical Commissioning Group (CCG) panel. When you receive the actual funding eligibility decision, and you find your retrospective claim for care fees has been rejected, be sure to request copies of the Needs Portrayal and Decision Support Tool – so that you can check that all relevant health and nursing care needs were properly considered.
- Also, ask the CCG (reply to the person who sent you the letter) to send you information on every piece of evidence and information the reviewer looked at and everything the panel saw prior to making their decision. For the process to be open and transparent, you should see what evidence was actually put before the panel. If they say there’s nothing else to send you, and you feel that what you have been sent is not a true representation of needs and/or an incorrect decision, you can appeal.
- If you believe your relative’s care needs have been played down or overlooked, write straight back to the Continuing Healthcare team at the CCG and state that you disagree with the outcome and will be appealing. State that you would like immediate action to rectify the situation.
- If it becomes clear that the nurse reviewer did actually recommend retrospective funding, and yet this was then rejected by the panel – which means the CCG has overturned Continuing Healthcare eligibility and denied funding – you probably also have grounds to appeal. The panel should only overturn such a recommendation in exceptional circumstance. Again, write to complain. The CCGs decision will almost certainly be motivated by budgets, and yet that should play no part whatsoever in this process.
- Unless you see the actual recommendation made by the reviewer (in the Decision Support Tool), you will not know if the panel has simply disregarded it.
- If you’ve had a claim rejected, the whole review process may also contain the following three fundamental flaws:
1. The reviewer has assessed the ability of the care home to provide care, instead of looking at your relative’s actual care needs. This contravenes all guidelines. CCGs also often say that if carers are ‘competent’ then the care needs count for less. Again, this is completely flawed. The degree of competence of a carer does not in any way negate the health needs in question. Indeed, one would hope that the carers are competent! A Continuing Healthcare review is not about the ability of the care provider to provide care; it is about a person’s day-to-day care needs.
2. The reviewer has looked at ‘managed needs’ only (care needs as they appear once care is in place), and has ignored the underlying health and care needs (care needs as they would appear if no care were in place). This contravenes all guidelines.
3. The reviewer has written that care is ‘routine’ and so doesn’t qualify for funding. Again, this is completely wrong. Care can be ‘routine’ and still involve serious health issues. For example, care in an Intensive Care Unit is often ‘routine’ for the people working in it, and yet this doesn’t negate the severity of health needs for the people in that unit. The same principle applies in NHS Continuing Healthcare assessments.
Keep all these points in mind if your retrospective claim for care fees if rejected.
If you need to appeal, you’ll find information on the different stages of NHS Continuing Healthcare assessment and appeal here.
How long have you been waiting for the outcome of your retrospective claim for care fees?