Although the Multi-Disciplinary Team assessors are supposed to be impartial and simply gather facts objectively to be able to complete the Decision Support Tool, we have heard anecdotally from families that on occasion they perceive that the assessors come with a pre-conceived outcome in mind ie that the individual’s health needs do not meet the eligibility criteria for NHS Continuing Healthcare funding. That is clearly not in the spirit of the National Framework. One family told us that the MDT meeting was conducted without even seeing their relative who was in the next room!
If the assessor has never met your relative or has had no involvement in their care, you should raise concerns at that point and ask them to be noted by the assessors – as this alone could be good grounds for raising an appeal if the expected outcome does not go in your favour.
In practical terms, it may be a pointless exercise going through the motions and continuing with the MDT meeting with assessors who are not actually familiar with your relative’s day-to-day health needs. How can they possibly complete the DST accurately?
So, consider requesting an adjournment at that stage if the NHS National Framework has not been adhered to and ensure that the assessors note your reasons, and that you are not being difficult for the sake of it. You just want a fair and robust assessment, that’s all – conducted by assessors who are familiar with your relative’s health care needs.
The MDT should review the individual’s health needs and score them against the 12 Care Domains in the Decision Support Tool. Some of the scoring can be subjective and therefore it is important that you state your case if you believe they have misunderstood or under-played any element of need.
This your chance as an advocate to have your say in the assessment of your relative’s needs and to put your points across.
The Decision Support Tool is intended to be a document that records health needs, risks and scores based on information gathered by and supplied to a Multi-Disciplinary Team. The MDT is the forum within which to discuss all the evidence. The MDT’s assessment simply makes a recommendation with its reasoning (rationale) to the CCG as to whether or not they believe the individual has a primary health need and is therefore eligible for NHS Continuing Healthcare Funding.
IMPORTANT: The MDT is not the actual decision-maker. It is the CCG that ultimately makes the final Decision as to whether to approve NHS Continuing Healthcare funding.
Sometimes the MDT assessors seem to be very supportive, and may even tell you that they are going to make a positive recommendation for CHC funding, only for that recommendation to be overturned by the time it gets to Clinical Commissioning Group for ratification. This can be immensely disappointing and frustrating! Practice Guidance Note 40 of the 2012 NHS National Framework states that the role of CCG is to verify and confirm the recommendations on eligibility made by the MDT – without “financial gatekeeping” (ie independent of budget constraints), “completing/altering DSTs” or “overturning recommendations”.
The MDT’s recommendation should therefore be followed.
You can quote – Practice Guidance Note 28.1 which says that, “The recommendation should then be presented to the CCG who should accept this, except in exceptional circumstances. These circumstances could for example include, insufficient evidence to make a recommendation or incomplete domains”. See also Practice Guidance Note 39.1. The reasons for rejection should be clearly articulated.
Our TIP: If the recommendation is for CHC funding is rejected by the CCG you really have to question why, as it goes against the NHS National Framework, and you should consider appealing.
What families always find difficult to understand is that: the MDT assessors have actually had input into your relative’s care needs, and have actually met with you and your relative, taken time to assess their health needs and then complete the DST, but are then overruled by someone who has never had that level of input and is merely carrying out a ‘desk-top’ review of the DST. To a lay person, this can seem somewhat bewildering (even perverse) and does raise the question as to what is the point of having an MDT at all if positive recommendations for CHC funding are going to be overturned higher up the ladder. Some might sceptically be drawn to the conclusion (whether rightly or wrongly) this is a form of “financial gatekeeping” to protect the NHS budgets.
We would be interested to know if there has been a case where the MDT has not recommended CHC funding, but the CCG have intervened and overruled it in favour of the individual, and granted funding?
6 Essential tips:
- Get to the MDT meeting early.
- Ask for access to the care home or nursing home records in advance, as you will be best placed to know whether there are any missing gaps; whether the records accurately reflect the day-to-day care needs of the individual or are lacking in detail, or paint a ‘rosy’ picture which couldn’t be further from the actual position. Often the care home records are incomplete or do not actually accurately record the person’s needs in sufficient detail – but that is another subject. Nursing staff are under pressure to look after numerous patients all with different needs and wants, and therefore it is not uncommon for entries to be missed out or not fully particularised so as to be meaningful (or indeed accurate). For example, saying, “Mr X had a good day today”, is somewhat meaningless and tells you nothing about their health needs.
- Ask if the assessors have made a start before you got there? It can happen that the MDT actually takes place before you even arrive. We have come across situations where families have said as they got there in plenty of time for the meeting, but the MDT had already taken place separately and the family were presented with the (negative) recommendation without any prior input. Who knows how the assessment was conducted, who the assessor spoke to and what questions they asked of the carers or the individual and how they responded, or what picture the assessors gleaned.
- Ask to see what the assessors are writing. It is a good idea to try and sit next to the Assessor when they are making notes to see what they are writing.
- Don’t sign! We would generally advise against signing any document provided to confirm the outcome of the meeting. You cannot be certain what documents have been reviewed, and in how much detail and whether they are accurately recorded. It could be that the assessors have seen various records, but inadvertently omitted various key entries which could affect the scoring dramatically. Therefore by signing off the DST document, you may effectively be prejudicing your claim in case the MDT have made mistakes. There is only a limited time the assessors can spend with your relative and looking at the various health records and things can be missed or misinterpreted. So, what may seem an innocuous comment to you in the DST, might have adverse implications further down the line when the recommendation is reviewed by the CCG.
Therefore it is better not to sign your agreement to anything and don’t be bullied into doing so! Otherwise your signature could later be interpreted as having agreed with the eligibility decision, and it will be difficult to appeal later on if you disagree with the outcome.
TIP: don’t commit yourself at this stage; but if you do, then simply write saying you attended the assessment and do not agree to the outcome nor that the assessment was necessarily comprehensive.
- Make notes at the meeting. You should definitely try and make a contemporaneous note of things discussed.
Common question: Can I record the meeting? You can mention to the MDT that you would like to record the meeting as an aide-memoire, even though this reasonable request is likely to be refused. The National Framework offers no guidance here, but in our experience, assessors do not like generally like to be held accountable on record – even though they are supposed to be impartial and objective. However, whether you decide to record the meeting is ultimately a matter for you, and we can offer no advice here as this is really a legal issue. There will be a lot of information to take in so it could be useful to have evidence of the assessment, even for your own records, but particularly so if you need to show an abuse of process.
What happens next?
The CCG should send you a copy of the DST outcome as soon as possible afterwards. There is no prescribed timescale according to the National Framework. If you disagree with the CCGs findings, then you only have 6 months to appeal from the date you receive their letter. It is important to diarise this so as not to miss the deadline, otherwise you will be out of time. You may consider getting professional help with your appeal. For more information on appeals, read our blog on Appealing the Decision not to Grant or Withdraw CHC Funding.
Share your experience of MDT Panel Meetings. Tell us f you’ve had a positive MDT recommendation which has then been rejected by the CCG?