Battling NHS delays – join the queue!

Battling NHS delays – join the queue!

If you represent a living relative or friend who has applied for NHS Continuing Healthcare Funding (‘CHC’) but has been turned down following assessment, or else has had their existing package of CHC Funding withdrawn following a review, then consider appealing the decision if you disagree with it or if the assessment was fundamentally flawed.

The full assessment for CHC Funding is carried out by a Multi- Disciplinary Team (‘MDT’) appointed by the local Clinical Commissioning Group (CCG). The purpose of the assessment is to assess eligibility for CHC by matching health needs against certain fixed criteria set out in the Decision Support Tool (‘DST’).

However, this assessment is often only as good as the CHC assessors appointed to carry it out; how well they have been trained in the National Framework for NHS Continuing Healthcare Funding; how well they know your relative and have been involved in their daily care. The subjective nature of the whole assessment process leads to inconsistencies across the county when trying to match health needs against the prescribed descriptors in the DST. The outcome varies widely throughout the country as to who is more likely to get CHC Funding depending on where you live. This is often referred to as the ‘postcode lottery’.

When can the CCG carry out a reassessment?

Individuals in receipt of CHC should undergo a reassessment after an initial 3 month period, and then again every 12 months thereafter, to check that the package of care is still required at that level, and if so, is adequate to meet your relative’s ongoing care healthcare needs.  See paragraph 189 of the National Framework.

Read this informative blog on the subject:

Beware! Annual Reviews can lead to CHC Funded Care being withdrawn

Similarly, if your relative has a rapidly deteriorating condition that may be entering a terminal phase and has been awarded Fast Track Funding, that, too, may be reviewed and withdrawn if your relative lives longer than expected. This is becoming a common scenario as more individuals are readily being granted Fast Track funding just to get them out of hospital. Families are delighted, knowing that their relative’s care will be funded by the NHS, thinking that this is going to endure for the foreseeable future. However, most are not told that their relative will be reviewed again in 3 months and that Fast Track funding is likely to pulled from under their relative’s feet, leaving them to pay for their own care.

Read these blogs on the subject of Fast Track funding:

Let’s Talk Fast Track! Vital NHS Funding Withdrawn After 3 Months – The Latest NHS Controversy

How To Fast Track The Continuing Healthcare Funding Process

Sadly, due to delays in CCGs undertaking full assessments (and reassessments) promptly, some reviews for living patients turn into retrospective reviews instead.

Alternatively, you may be applying (or appealing) retrospectively to recover care home fees that have wrongly been paid for a departed relative who should have been entitled to CHC had the CCG carried out a fair and robust assessment at the outset.

Delays when Appealing

Whether alive or deceased, the appeal process will follow the same route. It’s just a question of which point you are at when you start the process.

If your relative has been found ineligible for CHC Funding by the MDT, then they have 6 months to appeal the decision to a Local Resolution Panel, conducted by the local Clinical Commissioning Group.

This is a two stage process:

Stage 1 (optional) – is an informal case review to go through the DST and rationale (reasons) for rejection. Often a waste of time as the decision is unlikely to be overturned.

Stage 2 – a formal written appeal to the Local Resolution Panel.

For further information, read our blogs below:

Rejected for CHC Funding? Part 1: How To Appeal The MDT Decision

Relief as 6 Month Time Limit To Appeal MDT Decision Is Reinstated

If unsuccessful in your appeal to the Local Resolution Panel, you then have 6 months to appeal to an independent appeal body, conducted by NHS England.

Read our blog:

Rejected for CHC Funding? Part 2: How to appeal the Local Resolution Decision

If dissatisfied with the process (rather than the result), you have up to 12 months to appeal to the Parliamentary and Health Service Ombudsman.

The purpose of the National Framework is to provide consistency and certainty throughout the country for CCG practitioners and lay claimants alike. CCGs are supposed to adhere strictly to their own guidance as set out in the National Framework when performing their duties, assessments and appeals. However, from what contributors post on our website, and from our own experience, some CCGs are ‘selective’ in how they interpret and apply the National Framework to suit the circumstances!

In practice, most CCGs will inevitably prioritise living patients when dealing with assessment and appeals to the detriment of retrospective appellants. But, even these timescales can go by-the-by and become unduly prolonged.

Retrospective reviews are even worse! Don’t expect your relative’s retrospective appeal to be dealt with within a matter of weeks or months. Realistically, for most areas of the country, you are looking at years!

Families throughout the UK have been frustrated and angered by the inordinate delays (and incompetence!) created by CCGs (and those appointed by them) when processing retrospective reviews or appeals. Such is the chaos that some appeals dating back to 2012 are only now being dealt with. It is an absolute disgrace and a national scandal, for those families who have wrongly been denied CHC funding and then made to endure many stressful and anxious years whilst their appeal is languishing in a backlog.

To try and cope, some CCGs have appointed Project Teams to try and tackle their backlog. Others have simply buried their heads in the sand, adding further misery to families who believe that they have wrongly been deprived of CHC Funding, and are now made to sit in lengthy queues waiting for their case to be dealt with.

We know one CCG that is currently trying to clear almost 100 retrospective cases, but with so few resources available, we anticipate that it will be several years before some cases reach a final satisfactory outcome.

Worse still, the delay in processing these retrospective reviews and appeals is simply accruing wasted interest which the CCGs are obliged to pay to families in addition to the restitution sum, in the event of a successful claim. Even at current RPI rates, the interest payable on some historic appeals can be very considerable. This is a truly scandalous waste of valuable NHS resources.

Rather than paying interest, it would be a far more efficient use of NHS budgets if CCGs allocated more resources throughout the assessment and appeal process. If they ensured their appointed assessors were better trained in the National Framework, CCGs could apply the eligibility criteria competently and consistently. Robust and transparent decision-making would significantly reduce the number of cases going to appeal and speed up the process, leaving families less inclined to believe that the NHS system is slanted against them at every step.

Most CCGs will deal with retrospective appeals in the order they are received – oldest first. So, although you may have six months to lodge your appeal to a Local Resolution Panel (or NHS England), the sooner you get it in the better, and the higher it will rank in the queue.

Here are a 5 handy tips:

Tip 1: Don’t leave your appeal to the last minute, otherwise you run the risk of being out of time. For example: if, in error, you send it to the wrong address and the CCG doesn’t receive it in time.

Tip 2: Early preparation of your appeal submissions is essential. Leaving things to the last minute could be to own detriment!

Tip 3: You must be able to prove you’ve lodged your appeal and that it has been received in time. Use Recorded Delivery to track and trace your appeal, rather than trust ordinary post.

Tip 4: If deadline is imminent, check whether the CCG will accept email or fax. In any event, use next day Special Delivery to post the original so that it arrives in time (and remember to keep a copy of your appeal submissions for your records and later reference!).

Tip 5: Good preparation is the key. A well drafted appeal could make the difference between your relative receiving full CHC Funding for their care and paying nothing, or having to use private savings or selling assets (such as their home) to pay for their own care.

You don’t have to fight this battle alone. Remember, if you need professional help then don’t delay, otherwise you may lose the opportunity to get timely help.

Complain

When faced with delays, you must complain to your local CCG.

Do not delay or wait! You must get on with this and drive the case forward, but do so in a polite and professional manner.  Being overly assertive will not usually assist your cause, however frustrated you may be.

Too many families sit back and accept the CCG’s delays as inevitable. It is unacceptable for them to do nothing for months on end and fob you off with a holding reply. Be persistent! Keep chasing and press for action.

Read our helpful blog on some ‘do’s’ and ‘don’ts’ when complaining.

Frustrated with CCG delays? Here’s how to complain

Don’t Give Up When Faced With Ongoing Delays

Know your rights – Appealing the CCG’s refusal to grant CHC funding.

3 Comments

  1. Michelle Wetherall 4 weeks ago

    Hi Andy,
    You’re probably right!
    The disgusting behaviour of some NHS Managers who sell care grant advice (The Daily Telegraph) gives credance to your comment, but I would like to believe it’s more a case of assessors that are inept and time constrained. From my own experience our assessors were registered nurses who quite honestly didn’t seem to be that knowledgeable about the NF or indeed the key indicators.
    The MDT was totally unprofessional and it was clear that they could only tick boxes! Ask them questions or indeed quote the NF and they were like rabbits in headlights.
    The process of CHC has to start with assessors who are better qualified. Yes they need to have a nursing qualification but they need to have a skill set that reaches far wider.
    It is such a complex process to navigate and I don’t think nurses or indeed social workers are the right people to carry out these assessments alone. You almost need a legal qualification to complete the process. These nurses aren’t lawyers! When I think of the law firms/industry that has grown up around CHC and the specialist nursing/legal teams that scrutinize appeals and set the evidence against the criteria, is it any wonder that so many assessments fail when they are completed by assessors who lack the necessary skills to carry out a fair and robust assessment using the NF and the Law!
    You’ve every right to be cynical about the decisions made by those higher up, but from my own experience the poor assessors were the ones responsible for setting of a chain reaction!
    I was one of the fortunate ones to have been successful at IRP but that hasn’t stopped me from submitting a 12 page complaint about the handling of my father’s case to CCG.
    Probably a waste of time, but like Admiral Matthias …..to do nothing is not an option.
    I’m not sure how far you have come through the process but don’t give up!

  2. Michelle Wetherall 1 month ago

    Another article that resonates and something that I have already commented on, in respect of the lengthy wait for cases to be heard and the inevitable cost to the NHS in terms of the interest accrued on restitution and the administrative costs of dealing with hearings.
    If you are successful with your appeal, restitution can take many many months to conclude as evidence of fees etc have to be verified, again all the time accruing interest on the sum to be restored.
    The amount of different departments/workforce that is involved in the process of CHC becomes wider as you journey through it and all at a cost to the NHS/Tax payer!
    This is a shocking waste of public money. Money that could be better spent on ensuring that the beginning of the process of CHC is administered correctly/fairly/robustly by properly trained Assessors who know how to apply the National Framework, thus preventing the huge amount of appeals because of the ineptitude and maladministration of these individuals, who in many cases really haven’t the expertise to handle them.
    I believe many assessors have only nursing qualifications and whilst this is necessary, many of them haven’t the analytical skills of applying legislation that is the National Framework to a case. Until there is recruitment of assessors who have this ability and can make good, well evidenced and well thought out decisions then we will continue to have years and years of appeals. Assessors, who know how to evidence, Nature, Intensity, Complexity and Unpredictability in more than just 6 sentences!!!
    We are stuck with the National Framework, until something better replaces it, but in the meantime we should all campaign for better trained assessors in the hope that the service will be improved. Even though we experienced ineptitude and malpractice, I have to remain hopeful!

    • Andy 4 weeks ago

      From my experience so far, my impression is that nurse assessors are trained specifically to convincingly play out the charade that is the MDT and LRP. I also don’t think they have any power in the eligibility decisions. Their strings are being pulled by their superiors.

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