Care system in the UK Archives - Care to be Different

Can CCGs Use Annual Reviews to Ration Care Funding?

We know that certain parts of the country are more likely to award NHS Continuing Healthcare (CHC) than others. This is often referred to as the ‘postcode’ lottery. Where you live can increase or decrease your chances of receiving CHC Funding from the NHS.

CHC Funding is assessed and paid for by the NHS, via its local Clinical Commissioning Groups (CCGs). CHC Funding is free of charge and is not-means tested. If you are 18 years or older, have had an accident, disability or illness, CHC will pay for your all your long-term assessed healthcare and social care needs as well as your accommodation – providing, of course, that you meet the eligibility criteria. Those criteria and guidance are set out in the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care.

Don’t make the mistake of confusing healthcare needs and social care needs! Social care needs are paid for by the local authority and are subject to means-testing, whereas healthcare needs are paid in full by the NHS, are not means-tested, and are free at the ‘point of delivery’ (ie need). Specifically, the National Framework, states:

35. Where individuals receive care, treatment or support from the NHS this is normally under the provisions of the National Health Service Act 2006, referred to from this point onwards as the NHS Act. This support is provided free at the point of delivery to the individual.

180. NHS care is free at the point of delivery. The funding provided by CCGs in NHS Continuing Healthcare packages should be sufficient to meet the needs identified in the care plan.

For more information read: Part 1. Explaining The Vital Difference Between Social Needs vs Healthcare Needs.

Families ask us…Why?

Why is the bar to obtaining CHC Funding set very high and why is the whole application process so tortuous, subjective and complex?

Why do so many families struggle to get this vital long-term CHC Funding for their relative in need of care? And more critically, once they have it, how do they keep it?

Why do we hear so many stories of funding being withdrawn following a review – causing untold anxiety, anger and frustration?

The most likely answer is perhaps due to a combination of:

a) budgetary constraints and money ie rationing care and/or;

b) incompetent or inadequately trained assessors, and;

c) being able to recruit highly proficient quality assessors due to a high staff turnover.

If correct, it is hardly surprising that so many individuals who are absolutely entitled to CHC Funding are being failed by the system and the application of the National Framework guidance which is designed to protect them.

No wonder there is an obvious anomaly, that despite an ageing population, so few people by comparison qualify for CHC funding. Read our blog: “Care crisis fear as over 85s to double by 2043”.

The NHS are under pressure to save £855m by 2021. Although paragraphs 37 and 41 of the National Framework categorically state that ‘financial gatekeeping’ should never be a factor when determining eligibility for CHC Funding – in the absence of other explanations, it is hard to find a plausible reason why so many individuals are not awarded CHC funding, or those that are, can have it wrongly withdrawn without robust justification. The National Framework states:

37.3. CCG decision-making processes should not have the function of:

financial gatekeeping

41.2. CCGs do not have to use a panel arrangement as part of their process for ratifying eligibility recommendations, but if they do the panel should not be used for financial gatekeeping.

Contrary to the guidance, it appears that some CCGs are more aggressive in seeking to withdraw existing CHC funding than others. But again, perhaps that could be a symptom of the ‘postcode lottery’ rather than any calculated policy on protecting funds.

Yet, when an individual is perfectly entitled to receive CHC funding (and has been receiving it for many years to help with their long-term care needs), it is hard to understand how it can possibly be withdrawn – especially, if due to the nature of their illness or injury, there is no possibility of a reduction in the level of need over time, or their needs have remained constant since the last assessment, if not increased!

Annual Reviews – an opportunity to withdraw funding:

Paragraph 181 of the National Framework provides that CCGs are obliged to carry out reviews of CHC funded care packages, initially after 3 months from when the eligibility decision is made, and then every 12 months thereafter. According to the National Framework:

183. These reviews should primarily focus on whether the care plan or arrangements remain appropriate to meet the individual’s needs. It is expected that in the majority of cases there will be no need to reassess for eligibility.

142. The decision-making rationale should not marginalise a need just because it is successfully managed: well-managed needs are still needs. Only where the successful management of a healthcare need has permanently reduced or removed an ongoing need, such that the active management of this need is reduced or no longer required, will this have a bearing on NHS Continuing Healthcare eligibility.

In short, the 3 month or annual review is a safety mechanism to ensure that the individual’s needs are still being met by the care package in place. If their needs remain as before, then the care should continue unabated. However, if they have increased, the CHC care package should also be enhanced to meet those higher demands. However, unless there has been a substantial reduction in the individual’s needs, there should be no need to reconsider their eligibility for CHC funding at the annual review: review and reassessment are separate entities and one does not naturally follow the other in every case. Of course, where the need has been permanently removed and no longer exists, then the CHC Funding should be withdrawn upon reassessment.

However, what is clear is that CCGs should not try to use the 3 month or annual review as an opportunity to remove an individual’s CHC Funding when, in fact, their eligibility should never have been in question. This is entirely in contravention of the National Framework and there is no justification for it. What is more galling for families, is when their relative has obvious ongoing continuing care needs – which have not significantly changed – but face the daunting prospect of them being referred to a reassessment and funding being withdrawn.

It is no wonder that families going through the application or review process become so stressed. The fear of vital funding being withdrawn could throw their relative into the open arms of the local authority and subject them to a means-tested assessment for social care funding. If they don’t meet the local authority assessment criteria, they will then have to pay for their own care out of private funds and savings. Families will then be forced to appeal and join the back of the queue, and potentially face years of delay whilst having to finance their relative’s care.

Unjustified reassessment:

Here are some examples where it would be unjustified for a CCG to conduct a reassessment of CHC eligibility following an annual review, eg where there has been:

Failure to review the care arrangements;
Failure to conduct annual reviews;
Conflated annual review combined with reassessment where there is no justification to do so;
Failure to identify any significant change in needs to justify full reassessment;
Failure to make any comparison with the most recently completed Decision Support Tool (DST);
Failure to apply the ‘well-managed need’ principle;
Failure to accurately summarise the patient’s needs;
Too much reliance on written records, over verbal staff testimony, despite being aware that the care home records were not reflective of needs;
Minimising and marginalising the patient’s needs;
Improperly analysing the four Key Indicators (Characteristics);
Failure to ensure consistency of assessment;
Failure to provide adequate procedural and clinical training for its staff;
Failure to take the family’s or patient’s view of needs into account;
Failure to recognise/correct clinical failings in its assessment when informed by the staff/family;
Expressing the view that it doesn’t matter if CHC is withdrawn because the individual will be funded by the local authority anyway!

Justified reassessment:

There are various ways a CCG can go about the annual review, but here’s an example where it would be justified to conduct a reassessment of CHC eligibility following an annual review:

Scenario: The CCG’s Nurse Assessor visits Mr A to conduct a review of his care package. The DST or CHC review template is completed and, when compared with the DST from the previous review/assessment, Mr A’s needs are evidenced to have reduced in a number of key domains. For example: Mr A, who was assessed as meeting the CHC criteria on the basis of the complexity and intensity of his behaviour, has subsequently fractured his hip and is now bedbound; his dementia has advanced and he no longer resists necessary care or presents as distressed; all psychotropic medications have been withdrawn with no negative effect on his behaviour, psychological state or presentation; Mr A has been discharged by the Community Mental Health Team and is no longer under the care of the Community Psychiatric Nurse.

In this scenario, the CCG would be justified in proceeding to a full reassessment of CHC eligibility. The Nurse Assessor should make a recommendation to the CCG that Mr A’s needs have changed and a full MDT, with a local authority representative, should be convened to reconsider CHC eligibility.

Remember, if your relative’s CHC funding is withdrawn, they are most likely to be passed over from the NHS to their local authority and with it, the financial burden. Your relative with then be subjected to a local authority means-tested assessment, and if they have assets or capital (including a home) valued in excess of £23,250, they will end up self-funding and having to pay for their own care privately.

We applaud Admiral Philip Mathias’ pioneering public campaign to bring the NHS to task and create a fairer and more transparent process. For more information watch his recent TV interview with Victoria Derbyshire https://www.youtube.com/watch?v=Fc3fsSEnEBo and visit his website here: www.nhschcscandal.co.uk

Here are some other useful blogs for additional reading around the subject:

Rationing NHS Continuing Healthcare Funding – The ‘NHS’s Best Kept Secret’

Is your relative waiting for a review of their CHC care package?

Should you pay care fees if your NHS Continuing Healthcare Funding is refused or withdrawn?

Over the years, we have been contacted by many families facing the worry and anxiety of an annual review, especially as they are already aware that critical CHC Funding for their relative could be referred for reassessment and possibly withdrawn. If you need specialist advocacy help visit our 1-2-1 Support page.

If you feel your relative has been the victim of a poor or biased review and has then had CHC Funding unfairly or wrongly withdrawn, share your details below and let others know how you went about getting it reinstated, whether you were successful, and how long it took…

November 19, 2020/5 Comments/by Care To Be Different

Where is your retrospective CHC claim up to? If you’re frustrated by delays, read on…

You can make a retrospective claim to recover care fees that were incorrectly charged if your relative meets the eligibility criteria for NHS Continuing Healthcare Funding (CHC) as set out in the National Framework for NHS Continuing Healthcare Funding and NHS-funded Nursing Care (2018).

Background history

To draw a line under its pipeline of retrospective review cases and manage the scale of the issue, the Department of Health introduced an arbitrary deadline to register any retrospective claim for wrongly paid care fees (paid between 01/04/2004 – 31/03/2011) by 30^th September 2012. This was shortly followed by a second deadline of 31st March 2013 to register any retrospective claim for funding between 01/04/2011 to 31/03/12. If you missed the deadline, you can now only retrospectively claim for care fees going back to 1^st April 2012.

However, the NHS could not have anticipated that it would be inundated with nearly 60,000 new retrospective claims for NHS Continuing Healthcare Funding as a result of their own instigation to get a grip on the number of current and prospective pending retrospective claims.

The result was to create administrative chaos, more red tape and bureaucracy, and a plethora of wrong decisions as to eligibility for CHC. Whether this was due to maladministration or sheer incompetence of those assessors appointed to carry out reviews or CCG Local Resolution Panel appeals, or perhaps some deliberate financial gatekeeping policy to turn down claims, remains open to debate. But, the lack of successful claimants magnified the administrative headache for CCGs as many appeals were kicked down the road and left to languish in the ether.

Whilst the underlying principle of our much-admired NHS is that “NHS care is free at the point of delivery” in practice, accessing CHC funding quickly, just when you need it, can be an entirely different proposition! Readers comment that the CHC review and appeal’s process is full of ‘minefields’, ‘hurdles’, ‘complexities’ and is ‘overwhelming’, ‘daunting’, ‘stressful’ and ‘challenging’.

The backlog created by the deadlines for registering retrospective claims backfired and clogged up the retrospective review pipeline for many years to follow. Perhaps this was a desired outcome? Regardless, most CCGs, without exception, demonstrably failed to absorb the huge influx of retrospective cases efficiently and allocate adequate resources to cope. The backlash has been felt ever since, and indeed, some cases registered in 2012/13 still have not been finalised and remain under appeal!

Whilst apologising for the delays, the best most CCGs could do in the early years was to issue holding updates when chased, advising that your case was (say no. ‘56’) in the queue – with no commitment or timescale as to when it would be looked at. And, just when you thought your it was moving to the top of the list for review, the case could then be reallocated to a Commissioning Support Unit (CSU) and get downgraded again. Most CSUs were notoriously hard to communicate with (not to mention administratively incompetent) and inevitably you would be fobbed by someone who had no idea what was going on (assuming that they could actually trace your papers!). All these delays and bureaucratic hurdles left families and their representatives feeling angry and frustrated.

Some might say this was all part of a brilliant strategy by CCGs to ration payments by delaying progress of cases – and hence, ultimately payment – in the hope that claimants would just give up and abandon their retrospective claim. After all, in many cases, it was money their deceased relative had paid, not them, and to recover anything was a ‘bonus’. However, for most, it was a point of absolute and resolute principle. Their spouse, relative, friend or those for whom they had a professional duty to protect, saw this as their moral duty and obligation to pursue recovery of care fees that had wrongly been charged by care homes. These fees should have been paid for in full by the NHS (ie free of charge), had they undertaken a correct assessment for CHC funding diligently, fairly and robustly. Instead, some of the most vulnerable in our society have been forced to use hard-earned life savings set aside for a rainy day in their old age or sell their assets or home to pay for their care, quite needlessly.

So, no matter how long the delays or what obstacles are thrown in the way to slow down or delay retrospective claims, nor whatever farcical bureaucratic red tape and maladministration families have had to endure, for most, this was and still is, a matter of principle and CCGs must be held to account.

You only have to read what our contributors to the Care To Be Different website and our Facebook page say about their personal experiences when battling for their relative’s rights for CHC funding, to get an immediate sense of the delays, anxiety, worry, and frustration caused at the hands of the CCGs – sometimes referred to as ‘judge, jury and executioner!’

Admiral Philip Mathias, who undertook his own retrospective claim and successfully recovered £200,000 for care fees on behalf of his late mother said that the “CCG did everything possible to avoid making an eligibility decision. This included ignoring and grossly distorting the evidence contained in her care records.” You can read more from Admiral Mathias in our blog: Rationing NHS Continuing Healthcare Funding – The ‘NHS’s Best Kept Secret’.

CCGs can, of course, take their time processing retrospective reviews and appeals, as there is no set timescale to adhere to. They’ll work at their own pace, probably in chronological order, with the oldest cases being dealt with first. Nor is there any proverbial ‘stick’ to beat them with in the event of delay. Your only option is to be patient or else keep chasing for progress or lodge a formal complaint, for what it’s worth. Conversely, in return, little leeway is often afforded to families who can be made to jump through arbitrary hoops to meet unrealistic and unreasonable CCG deadlines.

Families who successfully reclaim care fees that were wrongly charged are, of course, entitled as of right to receive additional interest on their restitution award as a consequence of the CCG’s ‘maladministration’ (ie delays or unsound decisions). Since 1^st April 2015, the revised Redress Guidance provides CCGs should pay interest at RPI rates – which are relatively low. CCGs might see the trade-off between delaying cases and holding on to their NHS budgets as a price worth paying if they have to pay out some interest if they lose at appeal.

What’s happened since?

We are hoping that these historic practices will be eroded by the new Government Guidelines which came into effect from 1^st September 2020.

CCGs have been mandated by the Government to progress assessments and appeals with all speed. That said, it is up to each CCG how to manage and progress its own caseload. Some are likely to cut corners in an effort to try and catch up. It is too early to tell whether that is a good or bad thing, but speed should not be a substitute for poor decision-making that will only add to the pile of pending appeals. But for others, we fear delay may be part of the fabric and has become ‘institutionalised’ after many years of practice since 2012. For more information, read our blog: Are you ready for 1st September 2020? CHC Funding Gets Back to Business

Here’s what you can do…

Whether you are waiting for a Multi-Disciplinary Team Meeting or Local Resolution Appeal or the outcome decisions from these panels to be notified to you, here are some quick tips to help you counter delays:

Be persistent. Try and establish a point of contact with whom you can liaise regularly at the CCG. Sounds obvious, but not so easy in practice!
Set diary reminders and don’t be afraid of chasing the CCG or CSU regularly for updates.
Don’t be fobbed off, and press for progress.
Keep emailing or calling until you are satisfied that your claim is receiving the CCG’s attention.
Remember to get hold of and keep safe your proof of payment. If you win your appeal, you will need to satisfy the CCG as to the amount of care fees to be reimbursed. Keep safe all bank statements, invoices, statements of account from the care home and any correspondence relating to fees. If you don’t have them, do your best to get copies as quickly as you can.
If waiting for an appeal date, prepare your written arguments in advance. Early preparation is essential. Too many people leave the matter to the last minute. Get hold of all relevant notes and records from your relative’s GP, hospital, and care home notes so you can draft your retrospective appeal. This process can take weeks, especially in the current COVID climate, where administration might be much slower (regardless of GDPR allowing them one calendar month to comply). Our website features lots of helpful information here. Search for terms surrounding the ‘4 Key Indicators’).
Check whether you have legal authority to act for your relative, friend or client. Do you have a valid Lasting Power of Attorney or Deputyship Order (for living patients) or a Grant of Probate (deceased patients)? Correct authority will be required by the CCG before they will process your restitution award.
Don’t be afraid to raise a formal complaint to the CCG if you’re getting nowhere. You should be able to find their details online.
Even though the interest payable by the CCG may not be significant compared to the overall amount of reimbursement due, this is still costing the CCG money. You can remind them that delay is a waste of resources which could be put to better use.
Read our book, How To Get The NHS To Pay For Care.
Above all, when communicating with the CCG, remember to be polite – however frustrated you may feel. The NHS staff deserve respect. In our experience, you will get better results with a courteous approach.
Remember that you don’t have to fight this battle alone. There is professional help and advocacy support available if you need it. We only recommend that you don’t leave it to the last minute or you might miss out.

We’ve added a selection of blogs around the subject to get you started, but there are dozens more on our website. Browse our Articles page or use the search box to find what you’re looking for.

Confused? Read This Before You Start Your Retrospective Appeal for CHC Funding…

Perseverance and stubbornness pays off, so don’t give up!

Don’t Give Up When Faced With Ongoing Delays

Frustrated with CCG delays? Here’s how to complain

Essential: Have You Got A Power Of Attorney?

Retrospective Reviews for past periods of care – avoiding fatal mistakes

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

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

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

An exclusive Q & A interview with an IRP Chair – a rare insight into conducting your appeal and knowing what to expect on the day.

November 5, 2020/3 Comments/by Care To Be Different

Care system in the UK, NHS Continuing Healthcare, Personal stories - care fees

Sick pensioners threaten to sue Health Secretary Matt Hancock and the NHS for £5BILLION

If you missed this article in last week’s Daily Express (26th October), you can read it in full below:

Sick pensioners threaten to sue Health Secretary Matt Hancock and the NHS for £5BILLION

“Legal documents have been sent to Health Secretary Matt Hancock and the NHS giving them 14 days to give very sick pensioners the free healthcare they have a right to or face a £5bn lawsuit. The move is the first in a campaign fighting to overturn the unfairness which sees elderly people bankrupted to pay for NHS care – which they have paid for via their taxes all their lives.

The notices – known as a Judicial Review pre-action protocol pre-claim letter – were sent to Mr Hancock and the NHS by Rear Admiral Philip Mathias, who is leading the fight after winning back £200,000 wrongly charged by the NHS for the care of his late mother. The Department of Health and Social Care and the NHS now have two weeks to promise a new fairer plan or the Judicial Review in the High Court will go ahead.

And if successful, the action could cost the health service £5bn in paid-back medical fees.

The lawfulness of the Continuing Healthcare National Framework is being challenged as the scandal of NHS Continuing Healthcare (CHC) rationing grows.

Tens of thousands of eligible pensioners – and other sick and disabled adults – are being rejected by their local Clinical Commissioning Groups for healthcare costs despite suffering from awful health problems.

Many of these people are suffering from dementia or Alzheimers and the vast majority of them are homeowners – so they can be forced to sell their properties to pay the bills.

Former submariner Admiral Mathias, who was in charge of Britain’s nuclear policy at the Ministry of Defence before his retirement, said: “In terms of the sheer scale of this scandal, measured by the significant number of old, ill and vulnerable people adversely affected and the huge level of unlawful financial deprivation, this is very possibly one of the biggest government scandals of modern times.

“The aim of this legal action is to force the Government and NHS England to stop Clinical Commissioning Groups breaking the law and to make sure redress is provided to those who have been unlawfully denied CHC funding.”

On his Crowd Justice page, Admiral Mathias highlights the plight of an elderly patient plagued with health conditions who was denied CHC funding.

The severely ill man suffered from Parkinson’s disease, ulcerative colitis, double incontinence, chronic kidney disease and was unable to move or feed himself.

But his healthcare needs were deemed insufficient to qualify for CHC payments.

The day after that decision was confirmed at an appeal, he died weighing 45kg.

Caroline Abrahams, the charity director at Age UK said: “It’s very sad that things that have reached the point at which administration of the Continuing Health Care scheme is being legally challenged.

“But at Age UK we too have heard too many stories of older people seemingly denied their rights and they and their families having to battle for months or even years to obtain redress.”

“Continuing Health Care exists to help older people with the most serious needs and that’s why it is especially important that it is properly resourced and operates in a transparent and fair way.

“We really do hope that this legal action leads to improvements, so that older people living with complex health problems can be confident of getting the support they desperately need, and so they and their loved ones are not faced with sky high care bills that legally ought to be being met by the NHS.”

Under national CHC rules, elderly people with significant health problems should have their care and nursing fees paid in full by the NHS, provided their condition is the main reason they need help.

This is different to the means-tested adult social care funded by councils.

But the process is complicated, bureaucratic and local clinical commissioning groups (CCG) have been accused of “rationing” successful applications so they do not have to pay out.

There is a 20-fold variation in the chances of securing CHC funding between different NHS clinical commissioning groups, recent research found.

The Daily Express has led a crusade against the refusal to fund the costs which leave elderly people with “catastrophic” bills.

The first £30,000 needed for the court action was raised in a matter of days.

Campaigners are now raising £250,000 for the rest of the legal fees.

The total was boosted earlier this month by a £1,000 anonymous donation from a supporter who wrote; ‘shame on the liars and cheats, who tried to swindle an old man, so ill, he could do NOTHING for himself….. The system, and more so the supposed “caring professionals ” concerned, are corrupt to the core….

Dan Harbour, the managing director of the independent advice group Beacon CHC, said: “The public support for Philip Mathias’ campaign reflects the strong feelings about the CHC system that we encounter every day from clients who turn to us for help.

“Rear Admiral Mathias is passionate about this issue, and I have no doubt he’ll be an effective representative for those who’ve already donated to support the legal challenge.”

To get NHS CHC, you must have “a complex medical condition with substantial, ongoing care needs”, and you have to be assessed as needing it.

In England & Wales, this assessment is carried out by the local CCG.

But worried families complain that the criteria is too strict and often changed.

They say obviously very sick people – especially if they are homeowners – are rejected by a NHS they have paid into all their lives.

The papers – drawn up by top law firm Hopkin Murray Beskine and delivered to the Government’s legal department in Westminster – say the evidence is overwhelming that consistent and lawful CHC funding decisions are not being made.

They describe the postcode lottery of positive eligibility decisions as “startling”.

And despite a growing older population, since 2015 there has also been a sharp decline in the number of people qualifying for the payments.

This “defies any logical explanation save for a desire to save money which cannot be a lawful reason to deny a person the free NHS care to which they are entitled”, the papers say.

The Department of Health and Social Care would not comment on the legal action.

COMMENT By Andrew Farley

There is almost a complete lack of awareness of the existence of CHC and for those who have heard about it an inability to navigate the complexities of the process alone.

Clinical Commissioning Groups at local hospitals are often very inconsistent in their interpretation of the CHC regulations.

This leads to an unacceptable level of subjectivity in the way in which the National Framework is applied and often there is a complete disregard for the law.

There is also considerable evidence of a “postcode lottery” where the eligibility criteria is applied more harshly in some areas than others.

The fact that the NHS are judge, jury and gatekeeper is blatantly wrong – a lot more independence is required.

In any other legal situation, this would be considered to be a clear conflict of interest.

We know that many thousands of people have been inappropriately denied NHS CHC Funding.

The Government has provided significant support to those who have been discharged from hospital requiring ongoing care during the current pandemic.

But there are now 25,000 people who all need to be assessed for care funding and the delays and process issues which are already endemic in the system will be further compounded by the situation.

Many reviews have been found to be inadequate due to a failure by the Assessors to consider available evidence either properly at all.

There are a significant number of appeals presented to NHS England each year resulting in long delays to have cases reviewed by an Independent Review Panel, the success rate at which is very low.

The Health Service Ombudsman also seems to have very limited scope in relation to complaints about CHC funding.

As long as the CCG has followed the correct process, there is a reluctance to uphold a complaint even when the clinical decision is deeply flawed.

And the Ombudsman’s Clinical Advisors are generally individuals employed by the NHS Continuing Healthcare teams, being the very organisations against whom complaints are being made.

The NHS has been told that it has to make £855m worth of efficiency savings in relation to CHC by 2021.

The only way of achieving this is to reduce people’s packages of care and/or to withdraw funding from those who continue to be entitled to it.

This is further compounded by arbitrary caps on care fees which are imposed by various CCGs.

This requires families to top up the shortfall between what is funded and what is being charged by the care provider and is illegal.

Many of the families we speak to have relatives who have been funded for several years, but are now being reassessed and funding is withdrawn.

This is despite the fact that they continue to deteriorate and there has been no improvement in their condition, or reduction in the care required.

Families understandably struggle to rationalise the justification for this which in many cases is blatantly wrong.

The whole CHC system is unlawful and not fit for purpose.

• Andrew Farley is a lawyer and the founder of Continuing Healthcare support group Care to be Different

Case study

On the day of her mother’s funeral, Margaret Kemp received a bill for £63,178.20p – this was on top of £110,000 already paid for supposedly free NHS care.

The 95-year-old mother of two, also called Margaret, was a former district nurse but died penniless after working for and paying into the NHS all her life.

Despite suffering from dementia and host of other severe health problems, the Surrey Clinical Commissioning Group did not class her needs as ‘primary’.

This meant her daughters were left with no choice but to sell the home their mum loved to pay the nursing home and healthcare bills.

Miss Kemp, who lives in Osgathorpe, Leicester, said: “It’s criminal, unlawful and immoral the way they treat dementia sufferers and other elderly people whose poor health means they need care and treatment.

“Dementia robs a person of their dignity; the State rapes them of their assets.

“My mum did the right thing all her life. My father was a veteran of the D-Day landings and they were typical of their generation as they lived within their means.

“They never had a credit card, didn’t go on foreign holidays or went to restaurants and always ‘made do and mended’.

“They scrimped and saved and eventually bought their council house which was their pride and joy.

“My dad died in 2013, he had prostate cancer and mum nursed him at home for as long as possible and then he spent his final days in a hospice. All this was covered by the NHS.”

In 2016, aged 92, Mrs Kemp senior fell and broke her hip. She was admitted to hospital but never walked again.

There was also a diagnosis of dementia which was exacerbated by the anaesthetic and it became clear she could not live alone anymore.

“When the care professionals got involved, one of the first questions I was asked was ‘is your mum a homeowner’,” said Miss Kemp.

“My mum could not stand, could not walk, did not know where she was, where her husband was and was distressed and highly anxious.

“Added to this, she could not remember she could not walk so kept trying to stand up and more falls ensued. She needed 24/7 care as she was a danger to herself.

“But every single Continuing Healthcare assessment minimised her problems, every “need” was ignored.

“The CHC Assessors would spend a couple of minutes with her and decide she was mildly confused.

“This was despite being in front of a woman who thought she was on a farm in Ireland, could not recognise her daughters, had to be hoisted everywhere, could not move due to a risk of falls and was on all kinds of medication.

“Her skin was like tissue paper, she weighed seven stone and was covered in bruises.

She was awarded Funded Nursing Care at £717.43 per month, but the Surrey nursing home fees were £5,300.

“Then in March 2019, mum was diagnosed with pneumonia and we were told to expect the worse.

“We were asked whether we wanted her to be transferred to the hospital but we wanted her to pass away peacefully in her nursing home, not in a busy A&E and her doctor agreed.

“I asked for a Fast Track CHC to be initiated on March 2 and asked again on Monday 4.

“On March 5, I bumped into a CHC Assessor at the home. Mum had pneumonia, not eating or drinking, we were at a vigil at her bedside and she weighed 6½ stone.

“A report came back to say she only needed social care.

Apparently the assessor thought she was “responding to antibiotics” which meant she could open her eyes slightly.

“I can’t express my anger and frustration. They hadn’t reached the limit of what her house would give them when it would be sold, and they just disregarded her needs.

“I complained and they did another Decisional Support Tool a few months later, she qualified but when the report went to Surrey Clinical Commissioning Group her scores were lowered and there was to be no other help.”

If you are in the process of seeking NHS Continuing Healthcare Funding for your relative, you don’t have to fight this battle alone. Read our book for lots of handy tips and help.

October 29, 2020/1 Comment/by Care To Be Different

Care homes, Care system in the UK

Problems with care home records? Mind your language…

It is quite common for care home records to be in a jumbled and disorganised mess, containing incomplete and inaccurate information with lots of missing critical information. Good record keeping is essential for any resident in a care home or other care facility.

Logically, how can a care home responsibly care for its residents without an accurate description and record of each individual’s daily events and healthcare needs. What did they do in the day? Did they exhibit any challenging or inappropriate behaviours? What medication was administered, when and by whom? What did they eat and how much fluid intake did they have? Are they at risk of weight loss or malnutrition? Were they able to mobilise safely or need carers to assist with transfers? Did they fall? Were they left in bed or sitting too long, putting them at risk of skin damage and pressure sores? How was their continence and toileting managed etc? All these issues and more should form part of a resident’s daily care records.

You put your trust in the care home and believe that they will do their absolute best to look after your relative and keep them safe and well. But, how often are the records incomplete or inaccurate and simply not reflective of the resident’s actual care needs? So much so, that you may wonder if they’re actually talking about your own relative!

Good records are vital to supporting a successful application for CHC Funding.

All these daily records are, of course, not only vital for monitoring the individual’s well-being and for staff handover, but also form a very important part of the NHS Continuing Healthcare assessment process. The care home records should be considered and referred to by the appointed Clinical Commissioning Group’s assessors when conducting their assessment of the individual’s eligibility for NHS Continuing Healthcare Funding (CHC). The same records will also be an essential reference point at any subsequent appeal, whether conducted at a Local Resolution Meeting or by NHS England.

However, care home records will often be completed by staff with a poor grasp of the English language, which might account for some misdescription (or lack of description) of key events and errors in the notes.

Other difficulties arise due to a lack of training as to the quality and level of detail required for good note keeping.

Staff may become case-hardened and used to some challenging behaviours that become the ‘norm’ for that individual, and so may not necessarily think to record them in the care records.

Most commonly, however, the problem is caused by the sheer lack of time, with too few staff having to cope with too many residents.

If a contemporaneous note does get written up, it is quite likely to contain minimal content as staff have to keep moving and there will be other residents in need of their attention. Due to daily pressures of working, it is common for notes to be written up at the end of a shift when staff are tired and anxious to get home, or else by night staff.

Care home staff are there to provide care – they are not administrative record keepers. Missing entries recording key events and episodes are common. Some events might recur frequently during the day e.g. pad changes due to incontinence, but only get recorded as one single event to save time. Other entries can be so meaningless as to be worthless. For example, ‘Dorothy ate a cheese sandwich today’; or lots of repeated daily entries saying, ‘no daily change’. The latter sounds like a tick box exercise or a ‘cut and paste’ job. It is of absolutely no help to anyone and suggests that the author of the note just couldn’t be bothered to write what actually happened, or thought this will suffice as they’re far too busy – without realising the wider implications.

You need to know far more detail, such as their actual Waterlow score, whether they were incontinent, and if so, how often? Were they resistive to care and product changes? What is their weight so you can monitor any fluctuations? Did they experience any breathing problems etc? Where is the Care Plan? Is it being adhered to? When was it last updated? Do the entries in the care records meet or contradict the Care Plan? Ask yourself, do the daily records reflect this sort of detail, and if not, why not?

We often see records that paint a rosy picture or ’blue sky’ the resident’s needs and write entries in nice ‘fluffy’ language, apparently, so as not to distress the family by describing the real state of their relative’s condition. However, beware! Playing down needs does not assist you and will undoubtedly count against the individual at any pending CHC assessment or appeal.

We hear from families who tell us that the records they have seen are totally inaccurate e.g. referring to their father having a healthy appetite and enjoying a roast pork lunch, when in fact they have lost several kilos and are at nutritional risk, and have such an acute intolerance and aversion to pork that they haven’t eaten it since childhood! It’s as if the records are fabricated, or else the author is thinking of an entirely different person! But, unless spotted and challenged, this type of erroneous entry will be a fixture in the records and could be referred to at a CHC assessment or appeal to your relative’s detriment.

Watch out for the language being used in the records as this can be misleading and distort the gravity of the individual’s health needs. Here are some real examples we’ve encountered:

“…pleasantly confused…” – this was used to describe someone with significant cognitive impairment on account of dementia.

“…eats well and finishes her meals…” – this elderly lady would eat just a few spoonfuls of food at mealtimes and was rapidly losing weight.

“…enjoys watching his favourite TV programmes…” – this gentleman could not engage in any way with people or with his environment; the TV was simply switched on and he was placed in front of it.

“…responds well to reassurance in due course…” – this lady had continual suicidal thoughts on account of her severe paralysis and she was deeply distressed by her situation.

“…speaks clearly and can communicate her needs…” – this person’s speech was impaired and further complicated by mental confusion; assessors attributed her ‘clear speech’ to the fact that her carers were used to her. This is in no way a valid argument in an assessment.

“…inconsistency in bowel action…” – this lady had serious problems on account of her double incontinence combined with other major health problems, which together were causing immense distress. The word ‘inconsistency’ here doesn’t come close to describing the real situation.

“…uses a wheelchair for distance…” – this lady was completely immobile and the only way she could be moved from one place to another was by someone pushing her in a wheelchair.

The cynic would say that it is not generally in a care home’s interest to keep good daily records because that could assist the resident achieve CHC Funding. It is better if needs are played down in an attempt (one would assume) to render the elderly person ineligible for CHC Funding. Otherwise, it can create a cash-flow problem for the care home and leave them substantially out of pocket. For example, let’s assume a care home usually charges £1,500 per week for a standard room, but the NHS agreed CHC bed rate with the care home is only £825 – that leaves a shortfall of £675 per week. Multiply that by 50 – 100 residents in a large care facility and they could be losing between £33,750 to £67,000 a week! That is a big loss to absorb when you have high standards, lots of staff, big overheads and manicured grounds to maintain. No wonder, few care homes are rushing to encourage residents to seek CHC Funding. This scenario was portrayed in the harrowing BBC drama, ‘Care’ featured in a previous blog. You can read more about it here: BBC Drama, “Care”, Shines A Spotlight On NHS Continuing Healthcare

Inadequate records can make the CCG’s task much easier to reject or withdraw existing CHC Funding at an MDT, especially if their assessors are dismissive of the family’s representations to fill in the missing gaps or correct information in the care records.

Also, don’t forget, that the appeal panels will not have seen the resident. All they have are the oral and written submissions presented to them. The CCG’s representatives will point to the lack of entries in the care records as justification for arguing reduced or low needs when opposing CHC Funding. Faced with poor records, the family will have a much tougher job persuading the CCG that their relative’s daily needs are complex, intense and unpredictable. That can be hugely frustrating, but unfortunately, quite common. Although family representatives can give evidence that those needs exist, without independent corroborative evidence in black and white print, it can make the adjudicators’ decision far easier to decline funding. Of course, when reaching an outcome as to eligibility for CHC Funding, there is an element of skill required to read between the lines and think about what level of care would have been required to meet the individual’s needs. But, the job is so much easier if the care records are up-to-date, complete and accurate. Otherwise, if it’s not there in print, then the MDT or appeal panel might conclude that if the care records are silent, it didn’t happen.

Read our blog: PART 3 – Looking At The Four Key Indicators: Completing the Jigsaw

So, be alert! Regularly check the minor detail in the care records carefully and look for any inconsistencies and contradictions. Do the contents accurately match your knowledge of your relative’s daily needs and how they are being cared for? Are they doing the things that the records portray? Be willing to challenge meaningless or inaccurate records, or records which are simply not true, or which seem designed to diminish or underplay their healthcare needs.

Beware of the care home’s reluctance or delay in sharing the records with you. They may have something to hide or reflect the home’s inefficiency in completing them on a daily basis. There may be huge gaps for their staff to complete.

Failure to address the records and keep on top of them could end up adversely affecting not only your relative’s well-being, but also their prospects of getting (or retaining) CHC Funding.

Keep a diary

When you or a family member are visiting a relative, it’s a good idea to keep your own diary or a daily log of events as a contemporaneous aide memoire and evidence of their daily needs, should it ever be required at an assessment or appeal.

Take an elderly and vulnerable resident with poor mobility who is at high risk of falling. Too many falls go unwitnessed and/or unreported, which can be indicative of an inadequate Falls Risk assessment and a general lack of care and supervision (ie neglect). However, it is vital that the care records record each and every falling incident or near miss, as it builds up a picture of need. If an individual has numerous falls within a short space of time, they shouldn’t be ‘swept under the carpet’ as ‘just one of those things’, because it happens frequently, or more worryingly, as a cover-up. You should be notified of each and every fall, and the care records should reflect the incident and not trivialise it. Keep your own records of any new fall, bruise or injury as this evidence may be vital (and be corroborated by records following hospital admission) even if the care home records don’t tell the whole story!

Encourage other family members to write in it if you’re not there. Include things like:

How your relative was – think of their pain, mobility (note any falls, new bruises), nutrition (weight loss or gain), cognition, behaviour, skin issues (new sores or patches developing) breathing, communication, medication, continence (accidents) etc.
Records dates and times of any relevant medical or healthcare appointments, eg physiotherapy, GP or Consultant visits, and other meetings to do with your relative’s health needs, declining health or general provision of care.
Any relevant conversations with staff and therapists (e.g. physiotherapy, occupational therapy, speech and language therapy, nutrition, etc) – and write down what was discussed.
Notes on anything that doesn’t seem right to you about the care being administered or errors in the notes and records.

From a family’s point of view this type of detailed information is required to build up a picture of their relative’s overall healthcare needs. Without it, they will face an uphill struggle to convince any Multi-Disciplinary Team or appeal panel to award CHC Funding.

For more reading around the subject, look at these blogs:

“So will you be self-funding?”

Ongoing conflicts of interest in NHS Continuing Healthcare

Why is it important to check your relative’s care home records?

Focus: Falling at the care home

If you have noticed bizarre, misleading or incorrect entries in your relative’s care home records, then let us know and provide details below (remember not to name the care home)…

June 26, 2020/4 Comments/by Care To Be Different

Care system in the UK, NHS Continuing Healthcare

COVID: How Will Backlogs Impact on NHS Continuing Healthcare Funding?

Whilst care providers still have restrictions in place to deter visitors and protect their vulnerable residents, it is inevitable that in time, those restrictions will continue to ease slowly. Indeed, some care homes are already allowing non-essential visitors. We know of one company which has been able to arrange for its external nurse assessors (wearing full PPE) to visit a patient at a care home and undertake a preliminary assessment as to their potential eligibility for NHS Continuing Healthcare (CHC).

Clearing the backlog: What is the future for Assessments?

NHS Clinical Commissioning Groups (CCGs) were already behind and flooded with pending assessments (and appeals) before coronavirus. How much more so will the backlog be felt once care homes can reopen their doors to facilitate CHC assessments and MDT hearings can fully resume face-to-face in due course?

CCGs are generally under-resourced and couldn’t cope before COVID, and in all likelihood, they will struggle again, but only to a greater degree. It is, of course, too early to predict the level of that degree until life returns to some sort of ‘normality’. However, we expect that most CCGs will take a long time to regain control and make inroads into clearing their huge backlogs and undertaking new patient assessments (as well as completing appeals).

Those whose CHC assessment is still on hold or else postponed by COVID, may well be feeling the financial strain of paying for their ongoing care. If savings or assets, such as a home, need to be sold to release funds, this is not the right financial market to do so. These are indeed worrying times.

Yet, knowing of the backlogs, some families may be feeling complacent, thinking that their relative’s existing CHC package of NHS fully-funded care (FREE) is ‘safe’ and going to remain in place indefinitely post-COVID.

Those waiting for an assessment or appeal which has been postponed by CCGs, can probably expect lengthy delays unless the NHS put their house in order to address the looming problem. It is expected that CCGs will be inundated and unable to cope as furloughed staff, and other key staff deployed to the frontline to fight COVID, return to their previous CHC duties. We would expect CCGs to recruit more staff to meet the increasing demand of an ageing population and clear the backlogs; but that will have a financial cost, too.

The alternative is for CCGs to outsource its backlog of CHC assessments as a quick fix to catch up, but again, this has a financial implication. Will the quality of the assessments be adversely affected? Does the CCG’s CHC Department have the time to check the quality and standard of assessments undertaken by their appointed outsourced provider? Just because an outsourced resource has been used before, it doesn’t necessarily follow that they are still up to the job, even if they have managed to retain their most experienced staff, post COVID. Will families lose out as a result of shoddy and inadequately prepared assessments?

Will stretched NHS Continuing Healthcare Departments have the time and resources to train new staff to an acceptable standard, such that both they and families can trust their decision-making process and outcome rationale?

Will the mistakes of previous poorly trained assessors and flawed NHS Local Resolution appeal outcomes be perpetuated post-COVID?

Will families be squeezed into rushed assessments merely to clear backlogs, but in doing so, create another long-term problem instead – making wrong decisions due to lack of time and careful consideration, just to tick a box and get the job done? The result may be to knock out lots of assessments quickly, and simply defer those found ineligible for reconsideration at appeal, should the family have the gumption and staying power to fight on.

We shall have to wait and see how all these ‘unknowns’ play out. The Government will have to make huge resources available to CCGs to deal with the backlog of assessments and help patch up a CHC system that some argue has not been fit for purpose for some time.

What is the future for Appeals?

There is no sign of any face-to-face appeals at Local Resolution Meetings, at present.

In the meantime, despite COVID restrictions, some CCGs have been resourceful and have successfully conducted local appeals by telephone hearing, albeit in reduced numbers. From what we hear, this seems to be working well for those families who have tried it. Perhaps it will become the norm in due course, and be offered more widely by all CCGs, as it is efficient and avoids the time and travelling costs of a face-to-face meeting.

Independent Review Panels conducted by NHS England have virtually ground to a complete halt, save for a handful of IRPs who have been proceeding by telephone appointment, again in small numbers. Whilst not ideal, it does have some advantages and appears to be working well.

4 Key areas for concern

However, when CCGs are able to resume business again on a full basis, there are some key areas for concern which families need to be alert to and need to start thinking about now, so that they are prepared:

1. The initial Checklist

The Checklist screening assessment is the usual starting point to see whether the individual is able to move forward to a full assessment – to determine their eligibility for NHS Continuing Healthcare Funding. However, if the Checklist assessment is delayed, then that will have a direct impact on the rest of the assessment process, and inevitably delay the chance of getting CHC Funding for your relative. When CCGs resume business in due course, we don’t anticipate that they will have a problem undertaking Checklists, as they can be carried out relatively quickly by a wide variety of different skill sets – so resources here shouldn’t be a problem. The bar to passing the Checklist assessment is set deliberately low to ensure all those who merit a full assessment (the next stage) are not deprived of that opportunity. However, this is where the backlog is likely to begin.

Firstly, care homes will also need the administrative skill and resources available to facilitate access to patients for these full assessments, and also to make their records available. Some care homes will undoubtedly fare far better than others, with more available staff and administration to deal with the flood of pending assessments and requests for records.

Secondly, passing the Checklist is only the preliminary stage – to screen out those who aren’t eligible for a full assessment. The full assessment is conducted by a Multi-Disciplinary Team appointed by the CCG. We have raised our concerns above as to how the CCGs will be able to get back on track after months of inactivity. Given the existing backlogs of assessments already in the pipeline, whether pending or postponed, families can expect a lengthy wait. In the meantime, they will have to find alternative means of funding their relative’s care.

2. Interim funding

To encourage prompt discharge from hospital during the COVID-19 crisis period, under the COVID legislation the Government has provided emergency funds to support individuals who may be waiting for an initial Checklist assessment for CHC or other Funding, plus an enhancement to those with existing packages of care, post 19th March 2020. But beware! These interim measures may only be temporary, and you need to be giving thought as to what will happen when Covid Funding is removed, and how your relative will continue to fund their ongoing healthcare needs.

3. Three and twelve monthly reviews post-CHC award

If your relative has an existing package of care in place, you may well be feeling relieved that their CHC Funding is continuing, at least for now. But beware, as many may have their funding reviewed and removed once CHC assessments resume post-COVID. Don’t forget, an individual’s care needs will fluctuate and change over time. Some healthcare needs may become more challenging and complex, whilst others may become better managed and controlled and dissipate. Just because CHC funding is in place now, does not guarantee that it will remain in perpetuity and in certain situations it can justifiably be removed. Please speak to us if you are unsure.

Once CHC Funding is awarded, a CCG is supposed to carry out an initial review at 3 months, and thereafter every 12 months, to check that the current package of care in place remains adequate to meet the individual’s ongoing needs. However, since COVID these assessments have been placed on hold. Great news – if your relative has an existing care package which meets their needs and is continuing. Not so good, however, if that package is out of date and is actually inadequate to meet their increasing healthcare needs, and they are now underfunded.

But how will CCGs manage the review process? What additional resources will be needed to catch-up? Will the work be outsourced, and if so, how reliable are the outsourced providers?

From the CCG’s perspective, we anticipate they will try and make huge strides to play catch up and get as many reviews done as quickly as possible. There are two driving motives:

1) To help patients by ensuring that their care package is still sufficient to meet their needs; and

2) To save money and remove CHC where it is no longer appropriate! There will be many individuals who are in receipt of CHC Funding who are no longer eligible and have been left on CHC unchecked for too long at great expense to the NHS. Others who are legitimately in receipt of CHC Funding may face the worrying risk of having it arbitrarily withdrawn upon review.

Remember, the NHS are mandated to save £855m by 2021. So, it should be a matter of concern for those who already have CHC funding awarded and are expecting a review. If CHC Funding is removed, they will have other means to fund their care.

4. Fast Track Pathway Tool

Fast Track Funding is awarded to an individual who has a “rapidly deteriorating condition that may be entering a terminal phase in their life”. This Funding is typically awarded in an end-of-life scenario. However, to assist with speedy discharge from hospital and to release beds for more COVID patients, many individuals have been given Fast Track Funding. But beware! In many cases, Fast Track Funding has been provided a ‘sweetener’ just to get patients out of hospital quickly and prevent bed-blocking. If the patient survives, a review should ordinarily take place after 3 months. However, post-COVID these reviews have been postponed. Although, some may be fortunate enough to retain the benefit of their CHC package until a review takes place and indeed beyond, others may face the stark reality of having it withdrawn when it is found that their relative didn’t meet the eligibility criteria for CHC in the first place. Their relative may have placed in a more expensive care home based on that Fast Track award, only to find that they have to fund this cost themselves if CHC is subsequently removed. That can create a lot of anxiety both for the patient and their family, especially if they have to relocate their relative to a more affordable care home.

In conclusion:

There is much uncertainty at present as to how CCGs will be able to manage their inevitable backlogs or how they will possibly cope with existing and new assessments and appeals. What resources will they have at their disposal and how will they be funded? What the state of play will be remains to be seen. However, we fear for families already in receipt of CHC and COVID Funding through different routes, who may be subjected to a curt review of their relative’s care package and potentially be at risk of having it removed and withdrawn.

Preparation is paramount. If you need advice, seek it early on and don’t leave it to the last minute as there could be many people in the same boat, all scrambling for the best advice and help they can get. If you need help, don’t forget to visit our one-to-one page or contact our Advice Line. If you have a query, email to: enquiries@caretobedifferent.co.uk

For additional reading, here’s a selection of helpful blogs. You can visit our website and search for many more related articles:

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

Are you worried that Continuing Healthcare Funding may be withdrawn?

Fast Track Pathway Tool

How To Fast Track The Continuing Healthcare Funding Process

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

June 18, 2020/31 Comments/by Care To Be Different

Care system in the UK

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.

February 24, 2020/3 Comments/by Care To Be Different

Care system in the UK

How the care system puts patients at serious risk of harm

Alistair shared his father’s story with us about the lack of care and coordinated thinking in his father’s case. It’s a seeming lack of concern for a frail and vulnerable man – and it shows how people in care homes can be invisible to the wider NHS.

His story highlights how, in this context, the care system puts patients at serious risk of harm.

Alistair also makes an interesting comparison between his father’s ‘care’ and that of his dog.

(Names have been changed to protect the father’s identity.)

Alistair explains…

Five months ago, my father who is 92 and lives in a care home in the south east of England, was taken ill. He said he had diarrhoea and stomach pains.

As it happens, at the same time one of my elderly dogs had a similar problem and we took her to our vet.

The care home monitored my father, as the staff said that this happens often with the elderly and they often recover after a few days. However, they didn’t think there was much wrong with him. A week later my father said he was feeling worse.

In the meantime, the vet had now thoroughly examined my dog and said he was not sure of the precise problem. Further tests were needed, which included a stool sample. He gave her an analgesic to help her with the discomfort.

After three weeks my father was now losing weight and said he was having to empty his bowels after almost every meal, but the care home said they still had no evidence of diarrhoea.

The results of my dog’s stool test came through from the Path Lab the following day, by email. She had a bacterial infection of the small intestine. The vet gave her antibiotics and within five days she had made a full recovery.

After a whole month, the care home decided to send my father to the doctor, who concluded that he could not find anything wrong with him. He thought my father may be making it up, but as a precaution reviewed and modified my father’s medication for diabetes and gave him anti depressants. He also arranged for a stool test to be undertaken. The test came back 10 days later as ‘negative’. It now also turns out it was the wrong test.

My dog is now ‘full of beans’ and has now resumed hunting and spends her days chasing rabbits.

After another month, my father is finding it difficult to walk, has lost 12 kg and says that he has constant diarrhoea and feels very ill and spends most of his time in bed. I phone the doctor who reluctantly talks to me. He says there is not much more he can do, but maybe my father should have a colonoscopy. He said he would arrange this, but the waiting list is more than two weeks long. He said he saw no point in visiting my father as he was being well cared for.

My dog catches her latest rabbit.

My father’s condition further deteriorates. He loses more weight and can hardly move or speak. He is getting no treatment. It is now three months since he became ill and we still do not know what is wrong with him! If we don’t know what is wrong with him how can he be treated?

I decided to seek private help and made an appointment at the local private hospital for my father to see a specialist. The next day I took my father to the hospital and paid £150. After 20 minutes the specialist concluded my father most probably has complications as a result of the winter vomiting virus he had in August. He gave my father a prescription to coat the lining of the small intestine and wrote to my father’s GP suggesting a further stool sample be taken.

He ruled out a colonoscopy due to my father’s fragility. He also recommended a number of medications that could be given to make my father more comfortable, should the first medication not work.

My dog catches her second rabbit.

The stool sample was sent to a London hospital. My father’s condition further deteriorated. He is now spending most of his time in bed asleep, exhausted and now totally incontinent. He was moved to the nursing floor of the care home – for an extra charge.

After a further phone call I eventually persuaded the GP to visit my father. He concluded there is nothing more he can do, as he says my father is well cared for and we have to wait for the results of the stool test (which he then said he had never heard of – and that he would not be able to interpret the results).

Today my dog catches a squirrel.

My father was now at death’s door and when we visited him he was always asleep. His weight continued to drop – to 61kg from 77kg in three months. After three weeks there were no signs of the stool test results and the GP refused to chase them, saying we have to be patient and “the results will come when they are ready”. One of the care staff at the home phoned the Path Lab to chase the results but they said they would only speak to the GP, who was now on holiday for two weeks.

The receptionist from the vet phoned me as part of their follow up to ask how my dog was.

We were expecting my father to pass away over Christmas. In a last ditch effort to save him, I phone the GP’s locum, who phoned the Path Lab and chased the results. The results arrived on Christmas Eve by fax saying my father had raised calprotectin levels, and suggestions for treatment were made. My father received his first medication later on Christmas Eve and we hoped it would work. As it happened it made matters even worse.

Dare I say the moral of this story is that if you are old and ill in this country, you can expect better treatment if you are a dog. My father has unnecessarily suffered pain, distress and humiliation for months due to the failure of our National Health Service.

Further update from Alistair:

My father has a new GP, and this is the note I recently sent to the new one:

“I visited my father yesterday, and he seems to have taken a downturn. A small piece of cake caused severe diarrhoea within five minutes of eating. It is possible that this may be a reaction to dairy cream which was given to him yesterday, despite care staff knowing he should be on a non-dairy diet.

As we have no notes, due to the change of GP and for the unbelievable fact that the new GP cannot have his notes for up six weeks (why?) and the almost certain long wait for a NHS specialist to examine my father, could you please advise me of a reliable private consultant that you work with, so that I may make an appointment to have my father examined.

I am deeply concerned that four months after the first symptoms appeared we still do not have a precise diagnosis. I am not prepared to stand by and let the system kill my father.”

Alistair continues…

I have been informed that if you change GP’s the new GP has to request your notes, by letter, to the NHS local HQ. They then write to the old GP and ask for the notes. Then, once a week, a courier collects the notes from the old GP. They then go to a central NHS ‘Post Office’ where they are sorted and then sent on to the new GP. This can take six weeks!

I phoned the ‘NHS post office’ today and asked why they are using such an antiquated method and was told, “That is the system.” I asked why the old GP couldn’t just send the notes to the new GP – and why the notes can’t be online. Both questions were met with hysterical derision. No wonder the NHS is in such a mess.

I have made an official complaint, and NHS England is undertaking an urgent investigation.

After weeks of chasing, the GP finally informed me of an appointment for my father with a gastro consultant at a local hospital. The problem is that my father is now so ill that he is bed ridden and doubly incontinent. They want me to get him to the hospital, in the freezing cold, so that the consultant can talk to him where the consultant works, for the convenience of the consultant. There is no way that anyone will visit him in the care home. This is like living in Dickensian times.

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Alistair’s story no doubt resonates with many families up and down the country who may also feel that the care system puts patients at serious risk of harm. At the same time Alistair is also having to battle for NHS Continuing Healthcare funding for his father.

If you’ve come up against a similar situation or have a comment about this, please share your thoughts. What can we do to make things better?

February 1, 2015/16 Comments/by Care To Be Different

Care system in the UK

Dementia care – why the little things matter

Dementia care is not only about the disease; it’s about a person’s whole life. And in dementia care it’s often the little things that matter more than anything.

Why dementia care is not only about dementia

Every time I go to a funeral and listen to the eulogy, I find it sad that many people at the service won’t have known the person’s life story until that moment. Knowing it while the person is still alive makes such a difference to the way we relate to that person – and it can make a huge difference to the way we care.

I know there is already some great work going on in improving dementia care in many care homes – reminiscence rooms, life stories, and so on – and it’s always good to see care that does take account of who the person is ‘behind’ their dementia.

It’s so much better for the people delivering that care too – a richer experience, and a deeper understanding of the behaviours that a person with dementia might display.

Personal insights into dementia care…

My father was in a care home with my mother. They both had dementia. My father’s behaviour could be aggressive, and he was thought to pose a threat to my mother, requiring him to be repeatedly removed from her room. But no one had taken the time to understand his behaviour.

My father displayed this aggressive behaviour for one simple reason: He had two daughters and a wife. He’d had two daughters and a wife since the age of 30, and a man of his generation considered himself the protector and provider for his family, as indeed he was for many years. In later years he had also been carer for his wife.

His own dementia meant he no longer understood why all control had been taken away from him; he had lost his sense of identity and was bewildered and angry. He didn’t want to harm his wife; he wanted to continue to be her carer and continue to express his love for her in this way. It was heartbreaking.

His dementia care needed to be about his whole life, and the effects of the disease were not just about what was physically going on in his brain.

Recognising what actually makes a difference in dementia care – and why the little things matter

I can understand that it’s often very difficult to care for someone with dementia, especially if they display challenging behaviour, too. I’ve seen some lovely examples of really thoughtful care that warms the heart. Equally I’ve seen examples of completely thoughtless care – where someone is going through the tasks of caring, but without regard to the person they’re caring for.

The examples that spring to mind perhaps highlight some of the things that may go unnoticed in formal training…

The A&E doctor who was perplexed when a (different) relative of mine with dementia couldn’t answer his questions. I still don’t really know what he was expecting.

Two nurses in the hospital ‘Observation’ ward firing instructions at a lady with dementia when trying to change her pad, and expecting her to comply. When she didn’t, their instructions just got louder.

My father became withdrawn in the care home. It turned out he was in pain from bleeding gums and toothache, because no one had been cleaning his teeth, and he no longer knew how.

Leaving someone with dementia in front of a TV can be hugely distressing, especially when they never usually watch TV, when they’re distressed by the sound and the images and they’re unable to turn it off.

My mother was so weak that her head always dropped forward. She was also very confused about where she was, often thinking she was at home. Given that she couldn’t raise her head, it was understandably difficult to feed her. However, this still needed to be a thoughtful process. A carer pushing my mother’s head back quickly in order to get food in her mouth, just didn’t appreciate how terrifying that would then be for my mother to suddenly see a roomful of people she didn’t know.

Cleaning and trimming someone’s finger nails can make someone feel so much better. And enabling someone who has to be taken to the toilet to actually wash their hands afterwards (or have them washed), leaves that person feeling infinitely better.

These are all little things in the main – but they can make a huge difference to a person with dementia. Ignoring the little things makes the impact of dementia so much worse.

What are your observations of the little things that make dementia care better?

August 19, 2014/2 Comments/by Care To Be Different

Care system in the UK

What are the assessments needed for long term care?

The different care and care funding assessments can be confusing

So what are the assessments needed for long term care? There are a number of different ones that may need to be carried out – and not all of them will be funding assessments.

It can be confusing when someone from health or social care tells you they’re about to ‘do an assessment’. So, if this happens, be sure to ask them two things:

What is the assessment called?
What is it for?

This may sound obvious, but in a time of crisis, and especially if the health and social care authorities are not keeping you properly in the loop, you can lose track of what’s going on.

Here’s our mini guide to some of the assessments needed for long term care that you might come across. (It’s not a comprehensive list – just some of the most likely ones. We’ve assumed here that your relative has health needs and that you are acting on their behalf.)

Assessments needed for long term care…

Home hazard assessment / safety assessment / rehab-to-home assessment

This isn’t always directly linked to long term care, but it can be part and parcel of the decision making process about where care should best be provided.

Who does it? Often it’s an Occupational Therapist.

When should it be done? It’s often done after someone has had a fall and/or a spell in hospital, and it determines whether a person’s home is safe for their return – and what adaptations may be needed.

Why is it important? It allows the person to be safely discharged back home. However, if you believe the assessor and/or the local authority has a vested interest (for whatever reason) in your relative going back home instead of into a care home – and that your relative’s safety could be compromised as a result, or if you feel that the hospital just wants to discharge your relative as quickly as possible, you can object to your relative going back home.

The assessor may ask you for a key to your relative’s house. If you’re not comfortable with this, say no.

Mental Capacity Assessment

Who does it? Someone who is well-versed in the Mental Capacity Act and is competent to follow the correct procedure for such an assessment. Read more about Mental Capacity Assessments here.

When should it be done? When a decision needs to be made about your relative’s care (or other matters). It looks at your relative’s capacity to make that specific decision; it’s not about their overall mental/cognitive state.

For example, if your relative is in hospital they may be asked whether they want to go back home; they may say yes, and yet they may not actually understand the implications of their answer – or the reasons they’re being asked.

Why is it important? Because if someone lacks mental capacity to make a specific decision, someone else will need to make that decision for them – and in their best interests. On the other hand, if someone does have mental capacity to make a specific decision at a certain point in time, that right should not be taken away from them.

However, if you believe the assessor does not properly understand your relative’s mental capacity (or lack of), or you suspect the assessor is not competent to carry out a Mental Capacity Assessment, and/or that the result of the assessment is wrong, be sure to object. Otherwise your relative’s safety and/or their rights could be seriously compromised. Ask the assessor what qualifies them to carry out a Mental Capacity Assessment.

NHS Continuing Healthcare assessment

Who does it?

Stage 1, The Checklist, can be done by any health or social care professional who understands the assessment process and the eligibility criteria, and is familiar with your relative’s health needs.

Stage 2, the Decision Support Tool, should be completed by a multidisciplinary team (MDT) involving both health and social care professionals – plus you. This MDT is led by a Continuing Healthcare nurse assessor.

If your relative is in a period of rapid decline (whether or not they are at the end of their life), a Fast Track assessment for NHS Continuing Healthcare may be done so that a quick funding decision can be made.

When should it be done? A Continuing Care assessment should be done before your relative starts receiving full time care – and certainly before your relative starts paying. No one should ask about your relative’s money or house before this has been done. It can also be done if your relative is already receiving full time care and nobody told you about it before or your relative’s health has deteriorated.

Why is it important? An NHS Continuing Healthcare assessment determines who is responsible for paying for your relative’s care; it may not be your relative who needs to pay – regardless of how much they have in savings or other assets. It’s vital that you are involved in these assessments and that your input is recorded in the assessment notes.

Financial assessment

Who does it? The local authority/local council.

When should it be done? Only after it has been clearly shown, through a Continuing Healthcare assessment, that your relative does not qualify for full NHS funding.

Why is it important? It looks at your relative’s savings and assets. If the value of these is over the current upper means test threshold, they will have to pay for their care. If they fall below the means test threshold, the local authority will need to pick up the bill. Your relative may still need to contribute something.

You will be asked to submit financial information. You do not have to do this – you can choose to just start paying the care fees, and the local authority will consider your relative to be ‘self-funding’.

Social care report

Who does it? Someone from the local authority or local council or social services.

When should it be done? When anyone’s care needs are being looked at.

Why is it important? To ensure that all needs are properly recorded and that suitable care is put in place. A record of social care needs is also important in NHS Continuing Healthcare assessments, because Continuing Healthcare funding covers nursing care plus social care needs.

Risk assessments

Who does them? Various people – health and social care people, the care provider, hospital teams, mental health teams, etc – depending on the type of assessment.

When do they happen? The relevant ones should be carried out at the start of long term care and updated regularly. Different or additional risk assessments may be needed as your relative’s health needs change.

Why are they important? The may include things like a falls risk assessment, a Waterlow chart (risk of skin breakdown), behaviour chart, tests for cognition, MUST scores (malnutrition risk), SALT assessments (speech/swallowing), etc. They are used to build a picture of care needs and risks (as well as indicating what care is required), and they play an important role in the evidence required for a Continuing Healthcare funding assessment.

Care assessment

Who does it? It is often carried out by a care manager (or similar person) from a care home or care provider.

When should it be done? Before you start receiving care from that organisation.

Why is it important? It looks at whether that care organisation can actually look after your relative – whether they have the skills and the facilities for your relative’s safety, health and wellbeing. It is not an NHS funding assessment, nor is it a local authority financial assessment of your relative’s means.

It can be useful to attend so that you can raise all the various health needs and risks that the care provider should be aware of.

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With the possible exception of a Mental Capacity Assessment, it’s a good idea to attend each of the above assessments yourself, so you can input valuable information and be sure that things seem in order. Ask for a copy of the assessment notes afterwards, too, these will show what has and hasn’t been taken into account.

With some risk assessments, there isn’t an actual meeting to attend; instead notes should be kept by the care provider and updated regularly. It’s a good idea to check these from time to time.

March 21, 2014/12 Comments/by Care To Be Different

Care system in the UK

How to start the care conversation with a parent

For a son or daughter, talking to a parent about the need for care can be very hard

Knowing how to start the care conversation can be very difficult. Not only are the usual family roles reversed, with the son or daughter effectively becoming the ‘parent’, but there are also delicate issues of maintaining trust throughout.

In the case of a parent with dementia, for example, the parent will often not realise that they need care, and that makes things more challenging for the family.

This problem can of course also arise with a relative with other health challenges who is reluctant to accept they need help or who is perhaps afraid of losing control or moving out of their home.

Ideally the conversation would start before your relative needs any care – by making sure they have made a power of attorney. Waiting until they actually need care before you do this can make things more difficult.

Someone with dementia may not be aware of the hazards and dangers they’re exposed to without care, but how far do you go in forcing them to have care?

Perhaps the person is no longer able to wash and dress properly, but seems unaware of this.

Maybe their short term memory is such that they don’t remember what they have or haven’t done at any given time.

Perhaps they insist they can still ‘pop to the shops’ for anything they need, when the reality is that they don’t – and can’t.

They may be adamant they’re eating properly, and yet it’s clear from their weight loss that they’re not.

And of course, if you do manage to start the care conversation, but your relative doesn’t remember afterwards, it can feel as though you’re continually back to square one.

If you’re in this kind of situation with a relative, or if you have been in the past, how have you handled the care conversation? Have you involved other support services straight away, or have you handed things on your own? Have you been able to put care in place carefully, without too much objection from your relative, or has your relative refused to let carers in?

Add a comment below to share your your own experience and ideas. It will be really valuable for others in the same difficult situation.

September 28, 2013/0 Comments/by Care To Be Different