Top-up fees are back in the public domain again as the Competition and Markets Authority (CMA) is reported to have reached an agreement with Care UK to repay its residents more than £1m for unfairly charged top-up fees, in contravention of the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care.

The CMA contend Care UK had breached consumer protection law by improperly charging their residents an unfair top-up fee towards the cost of their essential long-term complex healthcare needs. It is said that most of the residents were charged more than £300 per week. As a result, Care UK has now agreed to repay more than £1m to 160 residents across at least 20 of its premium care homes by the end of November this year.

You can read the full article here: More that £1m in refunds secured for care home residents

If this applies to your relative and you haven’t been contacted for a refund by the end of November, you can email: CHC.Fundingoffice@careuk.com

In our previous blog: TOP-UP FEES – Unfair Care Home Practices Now Face Government Sanctions (07/12/18) we first mentioned that the newly formed government-backed competition watchdog (CMA) had been set up. The CMA’s guidance, Care homes: consumer law advice for providers gives added consumer protection to residents in care homes. Breaches and infringements can lead to legal action under consumer law and also criminal fines imposed for care homes that do not comply. In particular, under CMA guidance, care homes must give clear, accurate and unambiguous information about the top-up fee arrangements. Transparency is critical. Some examples of breaches include: asking a resident to pay a large upfront non-refundable fee prior to becoming a resident; or insisting on the resident paying a shortfall as a condition of entering the home. We recommend that you read this blog if you think your relative has been charged an unlawful top-up fee , or visit their website: https://www.gov.uk/government/organisations/competition-and-markets-authority

This latest outcome indicates that the CMA are now flexing their muscles and are expected to investigate other care homes who may have also breached the rules set out in the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care rules. This could result in millions of fees that were unlawfully charged being refunded to residents.

This latest success for the CMA will undoubtedly send deep shockwaves throughout care homes in England and Wales, as many have been getting away with charging residents unlawful large upfront or top-up fees for years. We suspect many residents didn’t know what the additional charges were for, nor that they were actually unlawful.

This is great news for thousands of current and past residents in care or nursing homes who have been improperly charged and either coerced or deceived into paying additional top-up fees for their essential healthcare needs in contravention of the National Framework rules.

What are the National Framework rules about charging top-up fees?

The National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care makes it quite clear that when an individual is awarded NHS Continuing Healthcare Funding (CHC) all the cost of their assessed healthcare needs (including social care needs) and accommodation, should be paid for in full by their local Clinical Commissioning Group (CCG). Paragraph 180 of the National Framework sets out the core tenet that CHC is ‘free at the point of delivery’ (ie when it is needed):

“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. Therefore it is not permissible for individuals to be asked to make any payments towards meeting their assessed needs.”

So, if CHC is supposed to fund the whole care package, free of charge, why are elderly and vulnerable residents in care homes being charged any additional fees?

These additional charges are often referred to as ‘top-up’ fees and are usually paid in relation to the cost of essential care, or more typically, for accommodation. Where a resident has CHC Funding in place it is unlawful for care homes to charge top-ups. Some, however, are quite open about it and make no bones that they are charging a top-up fee to meet the cost of living at their home. Transparent? Yes – but it still could be unlawful! More commonly, most care homes try and disguise this payment and call it something else such as a ‘personal contribution’ – perhaps deliberately trying to conceal the unlawful nature of its true identity. Whatever description is applied, if they relate to the individual’s assessed healthcare needs it is unlawful – as funding should be met in full by the CCG, not by the individual. This is why the CMA outcome against Care UK will have care homes nationwide running to re-examine their contracts and charging structures, and getting busy redrafting.

It is, however, permissible for care homes to charge ‘top-up’ fees for additional non-related healthcare needs such as social care needs; for example, manicures, pedicures, hairdressing, physiotherapy (sometimes referred to as hotel or spa-type services), or for personal preferences eg choosing to have a non-standard/larger room or one with a better view and amenities or luxuries. Top-up fees that relate to a personal ‘want’ rather than actual healthcare needs, are lawful, and your relative will have to pay for that preferential choice.

Why do care homes charge top-up fees?

The answer is quite simple. It’s all to do with cost.

The care home will have a contract with the CCG which is likely to pay them a fixed rate for the individual’s assessed healthcare needs at that home. If the costs of keeping the resident at the care home are more than they are being paid by the CCG, someone has to foot the bill for any shortfall. Care homes are businesses, too, with staff, grounds and usually high overheads. That all has to be paid for if the care home is going to maintain standards and not cut corners, avoid a CQC investigation, and moreover, stay open for business.

When challenged about top-up fees, care homes typically raise excuses such as:

• it was your choice to place your relative in our care home;
• this is what it costs for your relative to live here;
• this is a high-end care home in an expensive residential area which costs more. You could always move to a cheaper home down the road;
• you knew what you were paying for at the outset, so why are you now surprised by these additional charges?

If the current package of care funded by the CCG is insufficient to meet the individual’s increasing healthcare needs, then the care home should approach the CCG on behalf of the family for a reassessment and seek an increased package of care that more accurately reflects the true cost of that person’s care. For example, if more staff are required throughout the day and night to manage their challenging behaviours or complex healthcare needs, then that cost should be passed on to the CCG, not the individual. However, what happens in practice can be very different. Rather than contact the CCG to increase the care package, it is far simpler to take a direct approach and ask the family to pay (ie top-up) from private means instead. They are a captive audience and, of course, want their relative to be looked after in a secure, caring environment. So, for obvious reasons and to avoid confrontation, many will pay the asking price, thinking that is the norm. They are in a vulnerable position and just want peace of mind. In most cases, the top-ups can be very substantial – amounting to many hundreds of pounds (eg Care UK charge £300 per week). We have known top-up fees to be much higher. But, when multiplied over a number of months and years, can make a huge hole in your relative’s finances. Some care homes may also insist on taking security to guarantee payment eg a charge over your relative’s home.

What to look out for

Families often complain that their relative is being charged additional fees, but they have no idea what for, and tell us the care home is not providing anything extra or different from any other resident.

If this sounds familiar to you:

• Check what the contract with the care home says about charging.
• Check the invoices and annual payments. Has the cost gone up without explanation?
• Does the invoice or contract blatantly refer to charging a ‘top-up’ fee or use some other description to try and conceal that it is really a top-up fee by another name (eg ‘personal contribution’)?
• Was the contract fully explained to you and did you understand what you were signing?
• What were you told or what justification was given about being charged additional fess over and above what the CCG are paying the care home for CHC?
• Did you feel forced or coerced into paying these additional charges?
• Was payment a condition of keeping your relative in the care home or were you ‘threatened’ (expressly or by implication) that if these charges weren’t paid, your relative couldn’t stay and would be put out onto the street?
• Was your relative offered a choice of different levels of room (eg ‘superior’, ‘deluxe’ or ‘standard’) and did they choose a better standard of room or were all the rooms exactly the same? If they chose a better than standard room eg bigger with better facilities/view, then unless it is specifically required for their assessed healthcare needs (common examples include wheelchair access and use of a hoist)  the care home can charge this extra cost.

What can you do?

If you think your relative is charged unlawful top-up fees, then if you feel confident to do so, you should consider raising the issue with the care home manager. Request an explanation as to what these charges relate to, and if it appears they truly are unlawful top-up fees, ask why they have been charged in contravention of the National Framework, and seek a refund.

If it’s clearly an unlawful top-up fee, don’t accept the usual excuses that “this is what it costs to keep your relative here…”

You can always threaten to report the matter to the CCG if you feel their actions are contrary to the National Framework, and point out that the CCG may remove them from the list of approved care home providers.

Try contacting the CMA and request that they carry out an investigation as to any unlawful top-up fees. However, the CMA can only secure refunds dating back to 1^st October 2015.

The care home is unlikely to take kindly to being challenged on the matter. This is a very specialised area and we recommend you seek legal advice. Visit our one-to-one page for details.

How far can I go back to claim?

Unfortunately, the position is not very clear.

Now that the CMA are now aggressively operating in this area, it may be a question of making a complaint to them and letting them investigate the matter for you.

Under the National Framework there is no time limit. The Framework merely provides guidance that such charges are unlawful, but it doesn’t necessarily give rise to legal action in itself.

Whilst we don’t give legal advice. Generally speaking, if you want to bring a legal action yourself to recover the care home fees in court, under the Limitation Act 1980 there is a 6 year period within which your claim should be settled, or court proceedings should be issued to extend the life of the claim beyond this date. This 6 year period usually starts from the date of the contract or from when the last payment was made  or when you discovered the mistake. It really depends on the individual facts and circumstances of each particular case. However, we recommend that you seek legal advice to make sure you are in time to claim.

If your contract was more than 6 years ago, and your last payment was also more than 6 years ago, and you only discovered the extra charging after 6 years, then it is unlikely much can be done.

If your contract was more than 6 years ago, but your last payment was made within the last 6 years, you may still be in time. However, if you have delayed pursuing a claim, then you might be out of time and statute-barred, too.

The matter is complicated and is an area where we strongly recommend you seek legal advice if you wish to pursue a legal action as the matter is not clear cut.

For additional reading: Are You Paying Top-Up Fees Unnecessarily?

If your relative has been charged an unlawful top-up fee, tell others what you did and how you handled the situation and whether you were successful in getting reimbursed…

From 1^st September 2020, the Government has instructed Clinical Commissioning Groups (CCGs) to restart their retrospective appeals.

Retrospective appeals look at whether an individual was historically entitled to NHS Continuing Healthcare Funding (CHC). If found eligible on appeal, they should have all their care fees that were paid during the period of eligibility refunded by the NHS in full, including the cost of accommodation.

Often families have been forced to sell their relative’s home or use savings or other assets to pay for their care. To retrospectively recover these funds for care fees that were wrongly charged can make a huge financial difference to most families and give them a true sense that their relative’s rights have been vindicated.

However, the current backlog of retrospective reviews is thought to be substantial and includes both appeals that were previously waiting to be decided pre-COVID (19^th March 2020) as well as those deferred or postponed since this date due to COVID-19. One would expect that these outstanding appeals should take priority over any new appeals now being lodged with CCGs since 1^st September 2020. It is anticipated that there are many thousands of cases currently waiting in the appeal queue.

But don’t be surprised if CCGs have a ‘knee-jerk’ reaction to the Government’s mandate and proceed with all haste, throwing huge resources at the problem to try and catch up and make some quick inroads into their backlogs. Wishful thinking? Perhaps.

The result: you might not get too much notice that your relative’s appeal is ready to be heard. Contrary to years of lethargy and delays chasing appeal dates, your relative’s appeal might now be dealt with at panel far sooner than expected. Whereas pre-COVID it could take many, many months waiting for an appeal to come to panel, it is possible that these timescales may be substantially truncated as CCGs try and bash out as many appeals as possible in a short timeframe and meet targets. Only time will tell whether this is a realistic or even achievable prospect. However, reduced waiting times will generally be welcomed by families if this becomes a positive reality. Quicker decisions should convert to quicker refunds!

If your relative’s retrospective claim for CHC Funding has been turned down by their local Clinical Commissioning Group and you think the decision is wrong or flawed or did not follow the correct process, then you must appeal.

You only have 6 months to lodge your appeal from the date you receive notification of the CCG’s outcome letter rejecting your relative’s claim for CHC. Whilst that might seem like a long time, from experience, there is much work to be done if you are going to present your appeal successfully. Take time to do the job properly.

Your relative’s appeal deserves proper consideration. A successful outcome could see many thousands of pounds (plus backdated interest!) being refunded for care fees that were incorrectly charged and should never have been paid had a fair and robust assessment of their healthcare needs been properly undertaken by the CCG in the first place.

Excluding the Parliamentary and Health Service Ombudsman, there are 2 principal levels of appeal:

1. The first is from the Multi-Disciplinary Team Meeting (MDT) to a Local Resolution Meeting. The LRM is conducted by the CCG themselves and is your first real chance to get your relative’s CHC Funding reinstated. This is a very important appeal stage and often families do not prepare for it adequately, and so consequentially find themselves totally out of their depth or outflanked by the CCG’s appeal team. Decisions should never be influenced by financial budgeting constraints.

Failure at LRM can lead to months of delays (12 -18 months are quite common) whilst waiting for your next appeal and outcome decision. So, take advantage of this opportunity to give your appeal its best chance of success.

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

2. Don’t worry if your appeal to the LRM is unsuccessful as you can still appeal to the next stage. This is an appeal to an Independent Review Panel conducted by NHS England. The IRP is chaired by a lay independent chairman and is also comprised of at least 2 other members (a representative from the social services team and one from the NHS). The IRP follows a similar process to the LRM panel appeal but is entirely independent of the CCG.

By now most of the arguments have been raised by both sides and it is a question of refining your case based on the LRM’s findings set out in their outcome decision and challenging their rationale (reasoning for their decision). Consequently, your appeal submissions will be far less lengthy, but must be punchy and targeted for direct pinpoint attacks to achieve a successful outcome. Concentrate your efforts on finding errors in the LRM’s rationale and looking at the 4 Key Indicators.

Read this exclusive blog by an IPR Chair which offers some very helpful practical tips: An exclusive Q & A interview with an IRP Chair – a rare insight into conducting your appeal and knowing what to expect on the day.

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

Here are 10 tips to help you prepare for your appeal to the LRM or IRP:

1.  Don’t procrastinate! 6 months soon fly.

2.  Early preparation is essential to maintaining momentum. Make no mistake, preparing your appeal is onerous and will take many hours, if not weeks, to do the job properly. It is not something that can be rushed or else vital information may be missed from your appeal submissions.

3.  Get hold of all relevant medical notes and records, including GP, hospital and care home records as soon as you can. It is not enough that you know your relative’s healthcare needs and can articulate them before an appeal panel. You also need to be able to point to records in support. Your testimony and evidence is vital, but so, too, is what is printed in the notes in black and white. Look for the evidence to support your written appeal submissions. Here are two previous blogs to help you:

Need help getting copies of your relative’s care home records?

June’s feature on flawed CHC assessments and the importance of good record keeping

There should be no cost getting the care notes and medical records and the record providers should comply within one calendar month of receiving your Subject Access Request. However, due to COVID and induced staff shortages, it is often taking some organisations far longer than the allotted time. So be prepared for delays and keep chasing the records. They are essential to support your appeal submissions.

For more information as to collating your relative’s records look at the sub-paragraph, ‘How to access your notes and records’ contained in this blog: Essential Preparation and Planning As CCGs Restart Assessments and Appeals From 01/09/2020

4.  Read the National Framework for NHS Continuing Healthcare Funding and NHS-funded Nursing Care. Understand the appeal process and what is required. Whilst helpful guidance is provided within the National Framework, it doesn’t tell you how to actually draft your appeal submissions and what is needed to make a fist of your appeal and give it your best shot. That is where years of professional expertise in CHC Funding can really assist. If you don’t have the time or are totally bewildered by the appeal process and don’t know where to start, visit our one-to-one page for more information and professional expert help.

5.  Get to grips with the 4 Key Indicators and understand how the appeal panels adopt a holistic approach when assessing overall care needs and reaching their rationale decision on eligibility for CHC Funding. Read our blogs for more information:

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

PART 1 – Looking At The 4 Key Indicators: Unlocking the Basics
PART 2 – Looking At The 4 Key Indicators: Gathering pieces of evidence
PART 3 – Looking At The Four Key Indicators: Completing the Jigsaw
PART 4 – Looking At The Four Key Indicators: Drafting Your Conclusions

6.  Once you have lodged your appeal the CCG will provide you with their Needs Portrayal Document (NPD) – click on this link to see a sample template.

The NPD incorporates a similar format as the Decision Support Tool used at the MDT and includes a patient summary, summary of evidence reviewed and the 12 Care Domains. At the back there are guidance notes which state the author of the NPD must have appropriate skills and training to complete it.

Under each of the 12 Care Domains (Breathing, Nutrition, Continence, Skin integrity, Mobility, Communication, Psychological and emotional needs, Cognition, Behaviour, Drugs/Medication, Altered states of consciousness & Other), the CCG will list a chronology of relevant entries taken from all the available medical notes and records that reflect your relative’s changing needs. The CCG will use the NPD to make their recommendation as to retrospective eligibility for CHC Funding (or more cynically, to support their previous decision rejecting eligibility for CHC).

Your job is to analyse these records in detail and point out all missing entries in their chronology that support your relative’s intense, complex and challenging healthcare needs within each Care Domain. Whilst you may feel that some entries in the records are trivial or repetitive, they can all be very useful evidence in building up a picture of your relative’s needs and the nature and frequency of skilled care required to manage them.

Watch out, as some of the CCG’s entries stated in the NPD may be abbreviated, misquoted or incomplete, throwing a different slant on the actual entry in the records and impacting on the overall outcome.

Each entry in the CCG’s NPD has to be meticulously checked and cross-referenced against the original to ensure that it is fully and accurately quoted. There is an art to drafting your own written appeal submissions in response to the CCG’s NPD, and from experience, it is extremely time-consuming! You need to have the patience to diligently consider every single relevant entry throughout mountains of records and then, where appropriate, allocate it to one or more of the relevant Care Domains. Knowing what evidence is relevant and where to insert it is an acquired skill. Whilst doing this, you also need to check whether the CCG have already included it in the NPD, and if so, whether it has been quoted correctly as written exactly in the records. Point out their errors to your advantage. Paraphrasing an entry or putting spin on it as to what they think it says is not good enough. The entry must be accurately stated to be meaningful. As you can appreciate, this is a laborious and emotionally challenging task, which is why many families seek professional help.

7.  Families often tell us that attending the appeal itself can be an intimidating and daunting process. Those who have been through the process alone tell us that confronting the CCG’s assessors face-to-face (or now over Zoom) at an LRM or IRP is no easy task. They know the National Framework inside out and have had years of experience attending appeals. Most CCG representatives are battle-hardened and used to defending their decisions to refuse CHC Funding. Not only is it an emotional time for families having to recap and recount their dear relative’s healthcare needs in detail, but there is also the real fear that they may not succeed and do their relative’s case justice. A poor appeal showing could result in the loss of huge care fees paid from the sale of family assets or home, not being recouped. The pressure to succeed and achieve a successful outcome can be stressful and too much for many as there can be a lot riding on the outcome of the appeal.

To prevent ‘red mist’ and becoming frustrated, losing your temper and risk the appeal descending into a controversial adversarial shouting process, you should consider getting professional advocacy support. A trained CHC advocate who ‘knows their stuff’ should be able to take the strain and weight off your shoulders and argue with their CHC counterparts on at least a level basis.

Employing an advocate as a hired gun doesn’t automatically guarantee success. However, it should give you a much better opportunity than presenting the appeal yourself against the NHS. Even a seasoned CHC campaigner like retired nuclear submarine commander, Admiral Mathias, featured on our website, struggled with his mother’s retrospective claim. How much more so will the average person on the street be overwhelmed by the appeal process and know how make the most of this opportunity. Some lone ‘soldiers’ will inevitably be successful and will be emboldened by Admiral Mathias’ heroic struggle and the free resources and information on this website. But sadly, there will be many casualties along the way for those who fight alone without expert reinforcements to support their battle. For more information read: ‘Fighting for NHS funding for my mother was as complex as my work on the nuclear deterrent…’

Remember though, CHC is not black and white. And whilst you can argue for eligibility, you must be realistic and pragmatic and not let your emotions overtake you. However strongly you feel, you cannot simply make your relative eligible for CHC if they clearly aren’t. It just doesn’t work that way. You have to look at their healthcare needs holistically.

8.  Read our self-help book: How To Get The NHS To Pay For Care available as an e-book/PDF or paperback.

9.  If you want to speak to a registered nurse to discuss your CHC queries get in touch via our CHC Nurse Advice Line Service.

10. When thinking about your relative’s appeal, don’t forget that you if you succeed, you will need to produce evidence to satisfy the CCG as to the amount of care fees that are due to be reimbursed. Too often, families discard vital evidence and correspondence too quickly, not realising its critical value if the retrospective claim is successful. The burden is on you to prove your loss. You must keep all relevant letters and documents. No proof may mean no reimbursement!

You must keep (or get hold of) invoices and a detailed Statement of Account from the care home on official stationery showing what sums were charged and when they were paid. This still might not satisfy most CCGs, so in addition, we strongly recommend that you obtain bank statements from the account(s) the care fees were paid to the care home. Keep these documents safe!

For further reading: What Evidence Do I Need To Prove My Claim For Past Care Fees Paid?

We recommend that you also read these helpful blogs:

Part 1 – Revealing Insights From A Continuing Healthcare Nurse Advocate…

Part 2 – Revealing Insights From A Continuing Healthcare Nurse Advocate…

Retrospective Reviews for past periods of care – avoiding fatal mistakes

Tell us about your experiences of preparing your appeal and share your tips for success (or mistakes made) to help others who are waiting for their appeal…

We’re often asked this question, and it’s an area many people find confusing. We always advise people not to start paying care fees automatically, but to consider challenging what they’re told by the Continuing Healthcare assessors. However, whether you are obliged to pay largely depends on what stage of the assessment, review or appeal stage you have reached. We explore 5 different situations below and offer our guidance to help you.

There are many good health and social care workers. At the same time, there are many who seem to have only scant understanding of the official guidelines (and the law) when it comes to NHS Continuing Healthcare Funding (CHC). Unfortunately, this can lead to many families being given incorrect information and their relative being inappropriately railroaded into paying care fees before the proper funding decision-making process is complete.

The National Framework for NHS Continuing Healthcare and NHS-Funded Nursing Care (revised October 2018) provides the official guidelines that dictate how eligibility for NHS CHC Funding should be carried and who has to pay. All Clinical Commissioning Groups (CCGs) are bound by these NHS guidelines and are obliged to follow them when carrying out their CHC assessments, reviews and appeals.

Only if it is clearly and reliably shown that a person is not entitled to NHS care (no matter what their age or circumstances) should CHC Funding be refused. However, if you genuinely believe that your relative has had their funding incorrectly withdrawn or wrongly declined, then consider whether there were any flaws in the CHC process or if the eligibility criteria were incorrectly applied. Take immediate action to address any concerns you have as delay could be detrimental to your relative’s entitlement to funding.

Disputes about CHC eligibility are always ultimately about money and who pays – whether it’s your relative who may be self-funding, the NHS and/or the local authority.

Let’s look at 5 common scenarios where your relative could be asked to pay for their care and what you can do:

1. Waiting for an initial Checklist assessment after discharge from hospital

Under the 2018 revised version of the National Framework, it is now preferable that assessments for CHC Funding should take place outside the acute hospital setting so as not to delay a patient’s discharge and to get a more accurate assessment of their long-term healthcare needs (see paragraphs 109 – 111).

Under new Government guidance, with effect from 1^st September 2020, when an individual is ready to be discharged safely from hospital, the NHS should put funding in place to support their recovery and rehabilitation needs for the first 6 weeks whilst an assessment for CHC Funding is completed.

If this process takes longer than 6 weeks, the NHS and/or Local Authority will continue to pay for care until that assessment takes place and the decision is notified to you. In the meantime, your relative should not be required to pay for their care.

The position is similar to paragraph 112 of the National Framework, which states that when a person who needs a care package is discharged from hospital: “There must be no gap in the provision of appropriate support to meet the individual’s needs.” And so, they are entitled to an interim package of care until their healthcare needs can be properly assessed.

So, just because an assessment has been deferred or delayed by the NHS, this should not let the NHS off the hook in funding your relative’s care in the interim period.

What’s more, if there is a dispute between the NHS and Local Authority as to which organisation has to pay for care, that should not affect your relative’s funding which should continue regardless without any gaps. The National Framework helpfully sets out detailed guidance as to how these organisations should attempt to resolve disputes over funding between themselves:

208 & 210: “Individuals must never be left without appropriate support while disputes between statutory bodies about funding responsibilities are resolved.”

213: “In situations where there is a dispute between CCGs regarding responsibility for an individual, then the underlying principle is that there should be no gaps in responsibility as a result. No treatment should be refused or delayed due to uncertainty or ambiguity as to which CCG is responsible for funding an individual’s healthcare provision. CCGs should agree interim responsibilities for who funds the package until the dispute is resolved. Where the CCGs are unable to resolve their dispute using current guidance, as a last resort the matter should be referred to NHS England.”

The clear overriding principle is that there should be no gap in your relative’s care and that the nature of the funding should not be changed (or illegally forced upon someone) just because a final funding decision has not yet been reached.

This applies whether or not your relative is already in care or not. If the NHS can’t get its act together regarding funding decisions, it’s not the fault of the individual being asked to pay fees.

But should you pay care fees?

In short, the answer is ‘no’. If your relative has been discharged from hospital and is awaiting a Checklist assessment, they should not be asked to pay for their care until it has taken place and the decision has been notified to you.

However, if your relative does not pass the initial Checklist assessment, then it is likely that their care needs are not of a sufficiently high level at that stage, and so, they will have to pay for their care unless local authority funding is available instead.

2. You’ve passed the Checklist assessment and are awaiting the outcome decision of the Full Assessment

The Full Assessment is carried out by a Multi-Disciplinary Team (MDT). If CHC Funding is awarded, then the NHS will pay for all your relative’s assessed healthcare needs including their accommodation and they shouldn’t be asked to pay a penny. Success!

But should you pay care fees?

However, whilst waiting for the MDT outcome, your relative may be required to pay for their own care. Read our suggestions below, if your relative falls into this category.

3. Refused funding after the Full MDT Assessment?

If, however, the MDT do not recommend CHC Funding and your relative’s application is rejected by the CCG, ordinarily, they will be expected to pay for their own care fees – whether through local authority funding or else from their own private means.

If you believe that MDT assessment was flawed or the decision to refuse funding is wrong, then make sure you appeal. You only have 6 months to lodge your appeal, so do not delay!

In the meantime, your relative will usually be required to pay for their care whilst their appeal is pending. Beware, that some appeals can take many months – sometimes as long as 12 to 18 months, so the sooner you can lodge your appeal, the better. There are plenty of helpful blogs and resources on our website giving guidance and help with your appeal, but don’t forget you can always seek professional expert advice and advocacy support with your appeal.

4. Been turned down for CHC funding after a 3 or 12 monthly review?

If CHC Funding is awarded, CCGs are obliged to carry out an initial review at 3 months, and then again, every 12 months thereafter. In the current COVID-19 environment, nearly all these reviews were put on hold since March 2020. But, since the 1^st September 2020, CCGs have been told by the Government to get back to business and restart reviews.

Often, people receiving CHC Funding for care find that their funding is taken away after a review. From viewing our readers’ comments, there was a time where it seemed that CCGs were targeting people who have previously been awarded full CHC Funding – and systematically taking it away. This was happening to people whose care needs had actually increased and whose health was deteriorating, and to people who needed round-the-clock nursing care.

The case of John Morrison highlighted in Victoria Derbyshire’s BBC documentary on 11^th June 2019 is one such vivid example. John suffers with cerebral palsy and has no use of his limbs. John was initially granted CHC Funding, but it was then withdrawn upon review in 2009 – despite clearly having healthcare needs which had not improved. Following a  lengthy 10 year battle with the CCG, John’s CHC Funding was finally reinstated – leaving his family to retrospectively reclaim an estimated £300,000 for wrongly charged fees. You can read more about John’s case and the issue concerning reviews in our blog: Exposed: NHS Continuing Healthcare makes headline BBC News.

However, with the latest 2018 edition of the National Framework, the emphasis has noticeably changed. According to paragraph 183 of the National Framework, “These reviews should primarily focus on whether the plan or arrangements remain appropriate to meet the individual’s needs. It is expected in the majority of cases there will be no need to reassess for eligibility.”  Therefore, reviews should no longer be regarded as an excuse for CCGs to withdraw existing funding unless there is evidence of a clear change in the individual’s needs, in which case the matter can be referred back to an MDT for reassessment. This is probably why so many families still fear these reviews and have sleepless nights worrying that their relative’s genuine need for funding could still be taken away, leaving them to self-fund, despite the obvious need for CHC Funding (just like John Morrison’s case).

But should you pay care fees?

Whilst the review is underway or reassessment by an MDT is in process, your relative should not be required to pay for their care until the outcome decision is made.

If, however, CHC funding is subsequently withdrawn, your relative will probably be told to start paying for their care – often using private means and savings, or they may even be forced to sell their home (unless they are eligible for local authority funding instead).

For more information, read our blog:

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

5. Been turned down for CHC Funding on appeal?

If you’ve reached the end of the line and your appeal to either the CCG’s Local Resolution Panel or to an NHS England Independent Review Panel are unsuccessful, then your relative will have to pay or make arrangements to cover the cost of their care either with the help of local authority funding or from their own private assets or savings.

What can you do about care fees?

If your relative has been awarded CHC Funding, the CCG will pay the cost of their care directly to the care home on your behalf. There will be an agreement in place between the CCG and the care home, so if the CCG stop paying, then arguably, it is for the care provider to chase payment and ensure that they are paid.

Generally speaking, if you are waiting the outcome of an assessment or appeal, you can try speaking to the care home manager to see if they are willing to defer payment until a decision has been reached. Suggest that they send their invoices to the CCG for payment pending resolution of these matters or else hold them in abeyance, as ultimately, you believe the CCG will be responsible once the matter is resolved (or any flawed decision is overturned).

Naturally, most care homes may not be too sympathetic to the idea of deferring payment or putting themselves into direct conflict with their local CCG (or local authority) whilst you wait for a decision on funding. Don’t forget, they too have a business to run, and in many circumstances it will be easier to seek payment from the family under the terms of their contract for care services, than it will be to approach the NHS. Understandably, many families will tread carefully, for fear of affecting the relationship with the care home, especially whilst they are looking after your relative. Some families will therefore choose to continue paying care fees as the safer option and just for peace of mind, while others may try to negotiate and hold out until the funding decision has gone through. It often comes down to doing what you feel most comfortable with and whether you think you might get a sympathetic response from the care home.

Remember, you are entitled to have specialist advocacy support at any stage of your relative’s assessment, review or appeal. Visit our one-to-one page if you need specialist assistance.

Share your experiences below of situations where you felt coerced into paying care fees and how you successfully dealt with the situation…

Following the COVID-19 restrictions imposed for NHS Continuing Healthcare Funding (CHC) since 19 March 2020, the Government has just announced some positive news.

From 1^st September 2020, Clinical Commissioning Groups (CCGs) have been mandated to resume their NHS Continuing Healthcare assessments and appeals. New NHS Guidance has been published for the reintroduction of CHC assessments. But is it back to business, as usual?

At the outset of the COVID-19 pandemic, acute hospitals were instructed to discharge all patients who no longer needed to be in a hospital setting as soon as it was clinically safe to do so. To assist these patients, between 19^th March 2020 to 31^st August 2020, the Government introduced a COVID discharge support fund. This was an emergency interim financial measure to help speed up the discharge of patients from NHS hospitals whilst recognising that it would not be possible to undertake assessments for NHS Continuing Healthcare during the pandemic and lockdown period. Patients were therefore provided with automatic emergency funding for their care. This interim funding was designed to help support the cost of their recovery, rehabilitation and reablement care, with the intention that they would undergo an assessment for CHC in due course, when the situation returned to some kind of normality.

Many individuals will have been discharged from hospital and admitted to care or nursing homes during this period and will have been in receipt of emergency COVID funding. It is important to remember that this is not NHS Continuing Healthcare Funding, and subsequent assessment will inevitably find that some individuals do not meet the criteria for CHC Funding. This does not mean that they were previously eligible and funding has now been withdrawn – the previous funding was solely emergency COVID funding and does not in any way reflect an individual’s eligibility or otherwise.

Thankfully, it now seems that the time has come for CCGs to restart their assessments and appeals. As from 1^st September 2020, the Government wants to resume ‘normality’ as best it can and address the issues of both CHC and Local Authority funded care.

Understanding the difference between these two funding routes is vital. CHC is free at the point of need and is not means-tested. Social care is provided by the Local Authority and is means-tested, and may result in you contributing to the cost of your care or paying for it in full.

For more information, read our blogs:

Part 1 – Explaining The Vital Difference Between Social Needs vs Healthcare Needs

Part 2 – Explaining The Vital Difference Between Social Needs and Healthcare Needs

The NHS expects these following outcomes on discharge from hospital:

• 65% of people will require no further care
• 35% of people will require an ongoing package of care

Of those 35% of people who receive ongoing care, it is expected that 10% will require a package of lower intensity than at the start of recovery and will have either a CHC or Local Authority assessment.

Our blogs below have previously raised several concerns, in particular, how the CCGs will cope with the backlog of outstanding assessments and appeals that were deferred, postponed or put on hold due to COVID-19, and at the same time, also deal with the new assessments pending in the pipeline. Our main concerns focused on:

1. Timing – when will normality resume, and what will it look like for those undergoing CHC assessments or appeals?
2. Resources and delay – how will CCGs cope with the huge volume of past, current and future assessments and appeals?
3. How good will the training and supervision be of any new resources and staff coming back from frontline redeployment?
4. Cost implications – will the NHS budget be large enough to recruit resources and fund care?

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

COVID-19 – The Impact on NHS Continuing Healthcare Funding (‘CHC’) and How The Current Changes Will Affect You!

The Department of Health and Social Care recently published new guidance on 21^st August 2020, which also addresses our concerns. The new guidance deals with the reintroduction of CHC assessments and appeals, specifically:

• How NHS Clinical Commissioning Groups will restart NHS Continuing Healthcare assessment processes from 1st September 2020
• Routine NHS Continuing Healthcare referrals, starting from 1st September 2020

Here is a brief overview of some of the key points you need to know that are taking effect from 1st September 2020:

1. CCGs will need to reintroduce reviews:

CHC assessments, 3 month reviews, 12 month annual reviews and appeals (both at CCG local resolution level and NHS England), will resume.

2. CCGs and Local Authorities will have to:

• Clear backlogs including: CHC outstanding deferred work, referrals, reviews and assessments put on hold between 19 March and 31 August 2020 due to COVID-19
• Manage the reintroduction of routine new CHC referrals
• Ensure that CHC assessments are carried out and eligibility decisions are confirmed within the 6 weeks following a discharge from hospital

3. Comply with the National Framework:

To help get back on track without undue delay, CCGs and Local Authorities will have to liaise closely to establish efficient, robust and legally compliant processes to manage the reintroduction of CHC work whilst still having regard to the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care.

4. Manage staff resources issues and ability to cope:

This may require recruiting additional professionals to cope with the volume of work.

Additional temporary health and/or social care staff will undoubtedly be required and recruited in order to manage their existing workload as well as catch up with outstanding CHC and social care funding deferred assessments and appeals that have been held in abeyance since March 2020.

This process needs to be strategically planned and managed carefully, to ensure that staff who were redeployed to other frontline roles to help fight COVID since March 2020, are now integrated smoothly back into their CHC roles and are able to restart work from no later than 1 September 2020.

The guidance expects CCGs to also consider using well-trained non-clinical staff, wherever possible, to allow clinical or professional staff time to focus on robust eligibility recommendations for CHC.

Good training and supervision are critical to success and for restoring public confidence in their expectation that assessments and appeals will be conducted robustly in this new climate. Hopefully, this will be an improvement, but we shall have to wait and see!

5. Quality control and training:

The guidance recognises that there will need to be formal arrangements to confirm who is undertaking the Checklist screening assessments on behalf of the CCG and a ‘checklisting’ training programme.

The Checklist is the beginning of the assessment process, and if positive, will enable individuals to progress to a Full Assessment where their eligibility for CHC Funding is considered. Training in the assessment process and the National Framework is essential – both to ensure that everyone who requests a Checklist assessment has that opportunity – and when it does takes place, it is done correctly. It is important to ensure that individuals aren’t screened out of the process prematurely or incorrectly, only causing delays and setbacks to their entitlement to CHC Funding. 

6. ‘Checklisting’:

From 19 March to 31 August 2020 additional Government funding through a COVID-19 budget has been available to enable the NHS to pay for new, or extensions of, existing packages of care and support for patients discharged from hospital, or who would otherwise have been admitted to hospital.

From 1^st September 2020, CCGs and Local Authorities will need to work in close partnership to ensure that an initial Checklist assessment is carried out promptly and in accordance with the National Framework, save, of course, where it is not necessary, such as:

• Where it is clear to practitioners that there is no need for CHC at this point in time;

• The individual has short-term health care needs or is recovering from a temporary condition, and has not yet reached their optimum potential;

• It has been agreed by the CCG that the individual should be referred directly for Full Assessment of eligibility for CHC Funding;

• The individual has a rapidly deteriorating condition and may be entering a terminal phase and the Fast-Track Pathway Tool should be used instead;

• An individual is receiving services under section 117 of the Mental Health Act that are meeting all their assessed needs; or

• It has previously been decided that the individual is not eligible for CHC Funding and it is clear that there has been no change in their needs.

7. Beware the 2^nd Checklist!

Despite depleted resources during the COVID period, there is a suggestion that in some rare circumstances CCGs may have used the Checklist to monitor those individuals who may need longer-term care. However, pursuant to paragraph 115 of the National Framework, it is possible for CCGs to instigate a second Checklist if the individual’s needs reduce in the time frame between a positive CHC Checklist and a Full Assessment. Healthcare needs can, of course, fluctuate over time. But this specific mention will be of real concern to many families whose valid application for CHC Funding may be derailed even before it gets to a Full Assessment.

The guidance expects that individuals should be fully informed of this intervention as it could directly impact on their finances if a second Checklist is imposed on them.

Read our blog: Has your relative been “optimised?” NHS invent more delays to avoid CHC Funding…

8. Audits and checking:

Comprehensive processes will need to be implemented to monitor the speed and quality of deferred assessments and appropriate decision-making regarding eligibility for CHC Funding. Data will be collected regularly to monitor the completion of CHC assessments that were deferred between 19 March and 31 August 2020, and this will continue until the backlog of postponed assessments is completed.

9. Six-weeks to assess post-discharge from hospital:

From 1 September 2020, CCGs and Local Authorities should liaise closely to ensure that those individuals being discharged from hospital have funding and support in place to help them recover and rehabilitate.

An assessment for ongoing health and care needs should take place within 6 weeks of discharge from hospital and a decision about how this care will be funded should also reached within this timescale.

After this 6-week period, CCGs will not be able to draw down from the Government’s discharge support fund and will have to pay out of their own budgets. So, at least there is some pressure on CCGs to perform and carry out an assessment and reach a quick decision.

If, however, a decision is not reached within this 6-week time frame, the CCG or Local Authority paying for the existing care package should continue to do so until the relevant ongoing care assessments have been completed.

In the absence of agreement, it is suggested that the following default position is adopted at the end of the initial 6 week’s funded care:

• Where the CHC or NHS Funded Nursing Care (FNC) assessments are delayed, the CCG remains responsible for paying until CHC/FNC assessment is done.
• Subsequently, where the individual is assessed as not eligible for CHC, responsibility for funding will pass to the Local Authority (and subject to means-testing) in line with existing procedures until their means-tested assessment is completed, after which normal funding routes will apply.

In any event, from week 7 onwards, CCGs and Local Authorities will have to agree on a funding strategy but using their own funds, and not Government discharge support funds, to pay for the individual’s ongoing care.

10. End of the line

Important: The guidance states that the COVID-19 discharge recovery fund budget will not be available from 1 September 2020 onwards to fund any new packages of support for individuals discharged from, or who would have been admitted to, hospital between 19 March and 31 August 2020.

11. Transitional funding

In the meantime, individuals who received a COVID-19 discharge recovery funded package of care between 19 March and 31 August 2020, will continue to be funded under those existing arrangements after this date.

So, at the end of the assessment process:

If an individual is found eligible for CHC Funding, the payment of their care costs will now transfer from the COVID-19 budget over to the CCG’s budget. Any care fees paid by their Local Authority or from private means (self-funders) whilst waiting an assessment, should be refunded to the individual or the Local Authority, in accordance with the National Framework.

Conversely, if an individual is not eligible for CHC Funding, the payment of their care costs will transfer from the COVID-19 budget to their Local Authority and be subject to means-testing with the possibility that they may have to pay for their own care.

Summary:

The NHS should be congratulated on the tremendous service they have undertaken in risking their lives to fight the coronavirus pandemic. They have been supported by Government funding during this crisis which has undoubtedly helped many thousands of people with care and support packages following discharge from hospital. The guidance on the Reintroduction of NHS Continuing Healthcare should assist all those waiting for an assessment or appeal. But, it will inevitably take time, patience and need enhanced resources, whilst CCGs get to grips with clearing their backlogs of assessments and appeals.

Early planning and thorough preparation are essential ingredients for a successful application for CHC Funding. However, families often tell us that they find CHC assessments and appeals overwhelming, daunting, stressful and emotionally draining. If you need professional help or advocacy support with your assessment or appeal, visit our one-to-one page.

For further information, here are some useful links:

https://www.gov.uk/government/publications/hospital-discharge-service-policy-and-operating-model

https://www.gov.uk/government/publications/hospital-discharge-service-action-cards

https://www.gov.uk/government/publications/reintroduction-of-nhs-continuing-healthcare

Jane recently posted a comment which we wanted to share with you. She writes:

“I applied for CHC for my dad who, through my hard work and determination returned him home after a short but disastrous 6 weeks 21/2 years ago in a very highly rated home! He has Alzheimer’s, can be very aggressive and now needs to be fed, is doubly incontinent, we have the best Carer (private) as the system failed us massively in providing care! My mum also suffered from dementia! I applied for CHC for them both in December 2019 and Jan 2020 respectively! My mum’s health was failing fast! She died on 6th April – she had to be fed, had an ungradable sore (acquired in hospital) and was on oxygen and was doubly incontinent requiring regular manual evac [evacuation]! I watched my mum decline rapidly and yet neither were accepted for CHC! I’m not sure how dead a person needs to be to qualify but now I’ve experienced rebuttals and closing rank after appealing! I know it’s wrong but I am also tired of fighting and worry for my dad’s future that has been threatened by his GP in a veiled way. I’m beginning to wish I had never applied [as] mum suffered immeasurably because of my application and appeal, I firmly believe that, there is no other reason for her disgraceful treatment from DNS and GP – I’m saddened and disgusted ? my last communication said that no appeals would be accepted due to Covid 19! What kind of messed up system is this? They have paid for every ounce of their care and are by no means well off! Social workers don’t seem to want to know, they all sing from the same hymn sheet in this area it seems.”

Thank you, Jane, for sharing your personal comments with us about your dear parents and the struggles you have faced.

Your comments raise a number of interesting issues which may be helpful to our readers who are at different stages of their journey, whilst seeking eligibility for NHS Continuing Healthcare Funding (CHC) for a spouse, parent or relative:

1.  Lack of Consistency:

Over the years, many readers have commented on our Care To Be Different website, that applying for CHC Funding is both complex and frustrating, and the outcome is unpredictable. There is often is a fine dividing line between those who get funding, and those who don’t. The assessment process is subjective and therefore prone to inconsistencies, flaws and errors. National surveys indicate that some parts of the country are more likely to award CHC Funding than others and has been referred to as ‘the postcode lottery.’ More needs to be done to make the whole process fairer, more transparent and consistent throughout the country.

Read our blogs:

When are the Government going to fix CHC?
Is the National Framework still working effectively?

2. New to CHC Funding?

Firstly, you need to understand the vital difference between healthcare vs social care needs.

• Healthcare needs are provided by the NHS – free of charge – and include social care needs and accommodation. Healthcare needs are NOT means-tested – so your wealth should never be a consideration.

• Social care needs are provided by the local authority (via Social Services) and ARE means-tested. So, if you have assets, savings or a home, you may have to pay for some or all of your care.

Unfortunately, many people who have not visited our website just don’t grasp this concept from the outset, and will embark on a lengthy CHC battle only to become frustrated when they eventually find out that their relative’s needs are clearly social care needs and simply don’t meet the eligibility criteria for CHC Funding; or else, unwittingly, get corralled down the route of social care assessments (and means-testing) and end up paying for care unnecessarily – when in fact they were CHC all along.

For more information about what constitutes healthcare needs and social care needs, read our blogs:

Part 1. Explaining The Vital Difference Between Social Needs vs Healthcare Needs
Part 2 – Explaining The Vital Difference Between Social Needs vs Healthcare Needs

3. Primary Health Needs

Eligibility for NHS Continuing Healthcare Funding is NOT about a particular condition or diagnosis, such as Alzheimer’s or dementia. It is about the complexity, intensity and unpredictable nature of those needs and the level and type of care that is needed to meet them. There are claims companies who may tell you that having a diagnosis, or a label for a particular condition is everything, but that isn’t the case. Eligibility for CHC is all about proving that your relative has a ‘Primary Health Need’. In simple terms, this means that they have complex, intense or unpredictable healthcare needs that are not incidental or ancillary to the accommodation your local authority is under a duty to provide and are not of a nature typically provided for by a Social Services. For more information about the Primary Health Needs approach, read our blog:

Apply for NHS Continuing Healthcare Funding if your relative has a ‘primary health need’…

4. The 12 Care Domains

Jane lists a number of medical issues that have affected her parents, including, Alzheimer’s, aggressive behaviour, incontinence (and manual evacuation), skin integrity (ungradable pressure sore), breathing problems (need for oxygen). These, and any other conditions, should all be assessed by the Clinical Commissioning Group’s (CCG) assessors at a Multi-Disciplinary Team (MDT) assessment and be recorded in the Decision Support Tool (DST). The DST comprises of 12 Care Domains, namely:

1. Breathing
2. Nutrition – Food and Drink
3. Continence
4. Skin integrity (including tissue viability)
5. Mobility
6. Communication
7. Psychological and emotional needs
8. Cognition
9. Behaviour
10. Drugs/Medication/Symptom control
11. Altered states of consciousness
12. Other.

Each Care Domain is ‘scored’ and the corresponding level of need is stated in the DST. The CCG’s assessors should look at your relative’s overall healthcare needs holistically and in conjunction with the 4 Key Indicators (Nature, Intensity, Complexity and Unpredictability) when reaching their decision as to whether your relative has a Primary Health Need and is eligible for CHC Funding.

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

Has your relative been ‘made’ incontinent and developed a pressure sore?
PART 1 – Looking At The 4 Key Indicators: Unlocking the Basics
PART 2 – Looking At The 4 Key Indicators: Gathering pieces of evidence
PART 3 – Looking At The Four Key Indicators: Completing the Jigsaw
PART 4 – Looking At The Four Key Indicators: Drafting Your Conclusions

5. Closing Ranks

Sadly, Jane’s feelings are not uncommon. Many readers have previously told us how they feel let down by the whole CHC assessment process and believe that it is unnecessarily complex, unduly subjective and slanted in favour of the NHS.

Unfortunately, most GPs and medical practitioners who are not closely involved with the CHC process have little knowledge or understanding about it either, or the issues that affect families on a daily basis.

Social workers usually form part of the MDT assessment panel as a requirement under the National Framework for NHS Continuing Healthcare Funding 2018 (see paragraph 120). However, as with the CCG’s assessors, much depends on their training in the assessment process, understanding of the National Framework and their personal knowledge of the patient they are assessing. For some, it may be their first MDT assessment, and understandably, they may be taking their lead from the more experienced CCG appointed assessor (who may have an eye on budgeting).

6. How ill do you have to be to get CHC Funding?

Jane’s comments “how dead do you have to be…” are a typical reaction, echoing the sheer frustration expressed by many readers who cannot understand why their relative doesn’t qualify for CHC Funding – when their needs are clearly of a complex, intense or unpredictable nature that would justify funding! Remember, eligibility for CHC is all about healthcare needs. So, if you think your relative is eligible, you must pursue their right to a fair and robust assessment for funding and take it to appeal, if necessary. Read some other myths that people have been told about CHC Funding:

17 untruths about NHS Continuing Healthcare funding – Part 1
9 more untruths about NHS Continuing Healthcare – Part 2
The 10 Most Outrageous Excuses For Not Having An NHS Continuing Healthcare Assessment

7. Tired of fighting the NHS? Is the process wearing you down?

The CHC assessment and appeal process can be lengthy and tortuous. There are often long gaps waiting for the MDT and then for the outcome decision to be sent out, and then another lengthy wait for your appeal to reach Panel, followed again by a long wait for that outcome decision to be communicated to you. The process from start to finish should, theoretically, take months, but instead it is taking years! Many families lose patience and give up. Those that dig in for a fight can expect to wait years until a final outcome. In the meantime, they can be forgiven for feeling that they have been failed by a system that is supposed to support them yet leaves them angry and frustrated. You can, of course, get professional advocacy support at any and every stage of the assessment or appeal process, to help take strain off your shoulders. If you want help or wish to discuss a matter with a professional adviser, visit our one-to-one page. We applaud Jane, and all like her, who keep battling for CHC Funding. However difficult and time-consuming it may be, don’t give up! For inspiration, and an example that determination and perseverance pays off, read Admiral Mathias’ story:

‘Fighting for NHS funding for my mother was as complex as my work on the nuclear deterrent…’

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

Part 1 – Revealing Insights From A Continuing Healthcare Nurse Advocate…
Part 2 – Revealing Insights From A Continuing Healthcare Nurse Advocate
Don’t Give Up When Faced With Ongoing Delays
Frustrated with CCG delays? Here’s how to complain

8. Dealing with Appeals

The appeal process can be daunting for families, even for seasoned veteran campaigners like Admiral Mathias. But to succeed, you have to persevere. We have written many helpful blogs on tackling the appeal process, depending on whether you are appealing an MDT decision to a CCG’s Local Resolution Panel or to an Independent Review Panel (IRP) conducted by NHS England. Of particular mention, is a very informative blog kindly prepared by a Chair of NHS England panel to help readers understand the appeal process and what goes on at the meeting:

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

Here’s some more reading on appeals which you will find useful:

Attending an Assessment or Independent Review Appeal?
Rejected for CHC Funding? Part 1: How To Appeal The MDT Decision
Rejected for CHC Funding? Part 2: How to appeal the Local Resolution Decision
Battling NHS delays – join the queue!

9. COVID-19

Unfortunately, COVID has caused immeasurable delays in both MDT assessments, CCG appeals to Local Resolution Panels and with appeals to NHS England. Most have been on hold for some time whilst the NHS understandably refocuses their attention to battling coronavirus and redeploys key staff to the front line to help with hospital patient discharge.

During lockdown, we hear that some CCGs have been conducting appeals by telephone, and similarly some IRPs have gone ahead, too – albeit in limited numbers.

We agree with Jane, that more needs to be done to process these outstanding appeal cases expeditiously. But, at present, it is difficult to foresee how long it will take to clear the huge backlog of existing assessments and appeals, never mind deal with the new ones currently waiting to fill up the pipeline.

Some positive news!

We have recently heard from one CCG “that under the Restoration and Recovery programme, the CHC team are hoping to recommence Local Resolution Panels towards the end of August 2020, assuming all critical personnel are back in their substantive posts, following re-deployment in response to the introduction of the Covid-19 procedures.  It is expected that when panels recommence, they will be undertaken virtually via MS Teams, in recognition of the social distancing measures and therefore the limitations of face to face meetings. We anticipate undertaking cases in date order dependent on when rationales had been received. Any previously booked Local Resolution Panels that had to be cancelled at the start of the emergency response to Covid-19 will take priority.”

10. Interim Funding – Discharge from hospital and resuming healthcare assessments

Here is some more good news that we can share with you, taken from part of a recent letter from Sir Simon Stevens, Chief Executive of the NHS to CCGs.

“The Government have recently announced that it will continue to provide funding to support timely and appropriate discharge from hospital inpatient care in line with forthcoming updated Hospital Discharge Service Requirements. From 1 September 2020, hospitals and community health and social care partners should fully embed the discharge to assess process. New or extended health and care support will be funded for a period of up to six weeks, following discharge from hospital and during this period a comprehensive care and health assessment for any ongoing care needs, including determining funding eligibility, must now take place. The fund can also be used to provide short term urgent care support for those who would otherwise have been admitted to hospital.

The Government has further decided that CCGs must resume NHS Continuing Healthcare assessments from 1st September 2020 and work with local authorities using the trusted assessor model. Any patients discharged from hospital between the 19th March 2020 and 31st August 2020, whose discharge support package has been paid for by the NHS, will need to be assessed and moved to core NHS, social care or for self-funding arrangements.”

Here are some previous blogs concerning the impact of the COVID crisis on CHC Funding.

COVID: How Will Backlogs Impact on NHS Continuing Healthcare Funding?
COVID-19 – The Impact on NHS Continuing Healthcare Funding (‘CHC’) and How The Current Changes Will Affect You!

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