Following a positive Checklist Assessment, your relative will move on to a formal assessment of their healthcare needs. This formal assessment is conducted by a Multi-Disciplinary Team (MDT) using the NHS’s approved Decision Support Tool (DST). The DST contains the 12 Care Domains and scores the different levels of need in each. The NHS’ appointed assessors will complete the matrix summary of scores at the end of the DST and add their comments regarding the 4 Key Characteristics (Nature, Complexity, Intensity & Unpredictability). To finalise the DST they will conclude with their recommendation as to whether your relative meets the criteria for NHS Continuing Healthcare Funding (CHC) and has a ‘Primary Healthcare Need’. The completed DST with the MDT’s recommendations will be passed to the local NHS Integrated Care Board (ICB) who will consider the matter.
If your relative is found eligible for CHC, the ICB will put in place a package of fully-funded care to meet those assessed healthcare needs. Great outcome!
However, what happens if there is a negative outcome at the MDT stage? Read on to find out what you need to do next…
If you agree with the negative decision not to grant CHC Funding, then that’s fine. Remember that if your relative’s needs become more challenging in due course, you can always ask for another Checklist to be done. However, despite the disappointing outcome, at least you will have the benefit of an existing DST to refer back to and that should be of great assistance as a comparator to help identify where needs have changed and become more complex, intense or challenging etc and why it justifies completing another Checklist.
If you disagree with the negative outcome, then you only have 6 months to lodge an appeal to the ICB’s NHS CHC Department from the date upon which that decision was communicated to you in writing.
If you are going to spend time mounting an appeal, you need to have reasonable grounds to argue your position. Here are some examples – although the list is not intended to be exhaustive:
1.Has there been a procedural breach or abuse? For example, was the guidance in the NHS National Framework followed? For example, were there:
(A) at least 2 professional assessors at the MDT? There should be one from a healthcare profession and one from a social care profession as a minimum, who were (B) familiar with your relative’s health and social care needs, and (C) where possible, have recently been involved in your relative’s assessment, treatment or care and (D) are, of course, familiar with the NHS National Framework? (See paragraphs 139 to 141)
2.Did the MDT assessors actually see your relative at the assessment? As incredulous as it may seem, yes, we have heard of circumstances where the MDT assessors did not wish to see the individual they were assessing – despite the NHS National Framework repeatedly stating, on some 25 occasions, that the assessment process is intended to be ‘person centred’ i.e, putting the individual at the heart of the assessment and care-planning process! Clearly, pre-judging needs and deciding that the individual wasn’t eligible is a breach of process and may be good grounds for appeal.
3.Was the DST assessment carried out without prior notification to, or consultation with, the individual and their family representatives or advocates? The National Framework states that the individual and their appointed representatives are entitled, pursuant to the repeated ‘person-centred’ mantra, to be informed of, and encouraged to, take part in the assessment process. You cannot be excluded and should try and make every effort to attend.
However, if the MDT is at short notice or you cannot be there on the selected date, see if you can get it adjourned and do so promptly! After all, you are entitled to reasonable notice and we would certainly recommend that you are present to support your relative’s application and ensure the assessment is completed fairly, thoroughly and robustly.
4.Were you prevented from speaking or having your say? You are entitled to speak, be heard, and indeed are encouraged by the National Framework to contribute to the MDT’s assessment. You will be better placed to fill in any gaps in the assessors’ knowledge about your own relative’s healthcare needs; correct any misunderstandings, wrong or misleading information gleaned from the records or else provided by speaking to care staff – who may unhelpfully understate your relative’s needs (perhaps due to a lack of real understanding of them, poor use of language, or in an effort to try and make the care being provided sound better than it is).
Don’t let the MDT assessors try to intimidate or bully you, or suppress what you want to say. But, think carefully before you speak. Only contribute if it is going to be of benefit to your relative’s application for CHC. Too often, family members feel they need to say something and have ‘their day in court’, but unfortunately, witter on about irrelevancies, which not only delays the assessment but annoys the assessors; and in doing so can actually undermine a good case.
So, be warned! Think and plan ahead, about the key points you want to cover and stay focused. Don’t get side-tracked and waste time on issues which won’t increase the level of need.
5.Is the outcome decision robust? I.e do certain healthcare needs clearly indicate a higher level of need than recorded in the DST? Have the 4 Key Characteristics been applied properly and accurately? Have the assessors underplayed and down-scored certain care needs – perhaps due to inexperience, or by overlooking certain sections of relevant records, or not picking up on certain health conditions, implications of medication, or grasp how the care needs are met? All this (and more) can impact across the Care Domains and contribute to a wrong negative outcome. Read our blog below, as an example of how a pressure ulcer can impact on so many other Care Domains.
Skin Integrity: Beware the Danger of Pressure ulcers!
6.Is the decision blatantly wrong? Are you left scratching your head and asking yourself in sheer frustration, how any right-minded assessor, who supposedly understands and has been trained in using the National Framework, and who has had the benefit of seeing your relative, can possibly come to this blatantly incorrect outcome?
As you will see from the plethora of comments on our Facebook page, posted by families who have first-hand experience of the CHC assessment process, the overwhelming consensus appears to be that it seems to conspire against the individual in favour of the ICB – despite the intended ‘person-centred’ approach.
No more so, was this evident in the BBC drama, “Care”; Victoria Derbyshire’s BBC exposé (11/06/019) – Exposed: NHS Continuing Healthcare makes headline BBC News; and Rear Admiral Mathias’s own personal struggle to get CHC Funding for his mother – ‘Fighting for NHS Funding for my mother was a complex as my work on the nuclear deterrent’; and Channel 4 News Spotlights The Complexities And Frustrations Of Claiming NHS CHC Funding
Unfortunately, the CHC process is still the same and nothing really has changed to create a level playing field and shifting the balance of power away from the NHS in favour of the individual. Getting an award of CHC Funding is generally a tough uphill ask, that’s why so many families seek professional advice and advocacy support.
The nature of the MDT assessment process is entirely subjective as it requires an assessment of an individual’s healthcare needs against set criteria and descriptors set out in the DST. Sometimes there is a conflict of opinion between the assessors as to which level of need should be scored in a particular Care Domain and then how that impacts on the other Domains. But where there is disagreement, the National Framework provides at PG32.3, that the higher level should be chosen. We wonder how often the individual is actually given the benefit of doubt and instead, a lower level of need is scored?
7.Has the MDT reviewed all available records when completing their DST? It is common for the assessors to look at available care home and other clinical records (eg, GP, and physio records etc) to get a wider picture of their history and daily care needs.
It used to be accepted best practice that they would consider records going back 3 months. However, more recently since Covid, some ICBs are only going back 1 month in an effort to speed up assessments. However, reviewing such a short period can potentially have a detrimental effect and significantly skew results to the ICB’s advantage, leading to a negative outcome. To get a more balanced picture, we recommend that the MDT should really be looking at 3 months’ worth of records.
How much clinical evidence should an MDT assessment consider?
8.Was the MDT’s positive recommendation for CHC Funding overturned by the ICB? If so, look carefully at who overturned the decision and why. Was it an individual acting arbitrarily using their discretion, or do it go before a panel? It shouldn’t be left to a sole person to review the MDT’s DST and recommendations and act as ‘judge, jury and executioner’. The National Framework provides that the MDT’s decision should be accepted by the ICB unless there are exceptional circumstances. Financial budgeting is not one of them! So look at the reasons given for changing a positive MDT recommendation into a negative outcome. Are there any grounds for appeal due abuse of process or the rationale being incorrect?
Appeal! Appeal! Appeal!
If you disagree with the negative outcome, you must appeal. But you only have 6 months to do so! Whilst there is a lot of work to be done to prepare for your appeal and timescales are quite short to do a proper job, don’t rush in to lodging your appeal in anger or frustration. Appealing requires really careful consideration and planning to have the best chance of success. Those who naively rush head-on into an appeal, could trigger the ICB into action and catch you off guard by setting an early appeal date and tight timescales to lodge your appeal submissions before you are actually ready to do so!
Look out for our next blog for help on your appeal.
Preparation for the MDT is absolutely paramount in giving your relative the best chance of securing early CHC Funding. Don’t ‘wing’ it and hope it will be fine on the day. But, if all fails and you are dissatisfied with the outcome, consider appealing the decision but don’t forget there are strict timescales that apply.
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Get help via our Nurse Advice Helpline or contact Farley Dwek Solicitors for professional help with your MDT or appeal.