It will not come as a surprise to learn that most NHS Clinical Commissioning Groups (CCGs) are generally understaffed and under-resourced, and so have to look externally to recruitment agencies and pay for additional resources. One such area for nurse recruitment is the need for CCGs to carry out regular reviews of existing NHS Continuing Healthcare packages, to determine whether they are still appropriate to meet the recipient’s ongoing healthcare needs or whether funding should be removed.
NHS Continuing Healthcare (‘CHC’) is a package of fully-funded care provided by the NHS free of charge to individuals who have intense, complex and unpredictable healthcare needs. CHC is not means-tested, and is free at the point of need. So, if an individual meets the eligibility criteria, they are entitled to this free care for all their healthcare needs, and this includes the cost of accommodation in a care home or other care facility.
Don’t get CHC confused with social care which is provided by the Local Authority and is means-tested. For more information, read our blogs:
Once CHC has been awarded, many families wrongly assume that funding will be in place for the rest of their relative’s life, to cover the cost of care, whether living in their own home or in a care home. That is a fundamental misconception.
The revised National Framework (October 2018) specifically deals with reviews and sets out the guidance. CCGs are obliged to review individuals 3 months after they have received CHC Funding, and again at least every 12 months thereafter, to check that the package of care is still sufficient to meet their ongoing healthcare needs. The underlying intention of the National Framework is that these reviews are not to be used as an opportunity to conduct a fresh reassessment of the individual’s healthcare needs, but are means of genuinely checking that the existing package of care is still adequate to support their needs.
The underlying risk to individuals is that, in some cases these 3 and 12 monthly reviews have given CCGs a veiled excuse to remove existing CHC. Annual reviews can lead to CHC Funding being withdrawn arbitrarily based on flawed assessments, incorrect information or insufficient knowledge of the patient’s day-to-day needs.
Our caretobedifferent website contains many personal experiences shared by contributors, detailing how their relative’s CHC Funding was wrongly withdrawn after a review, only for it to be reinstated following a lengthy and tortuous appeal.
Why was CHC Funding wrongly withdrawn? Because it’s all to do with saving money!
We know that the NHS has to save £855m by 2021, and so, these reviews can potentially present an opportunity for CCGs to screen individuals out of the system, and in doing so, put them through the frustrating process of appealing if they believe the decision is wrong.
So, if your relative’s CHC package of care is withdrawn incorrectly, the burden now shifts to you to appeal. That is no simple task and you can expect an uphill battle fighting the NHS to get their funding reinstated.
Inevitably, some families will simply give up or be left floundering, not knowing how to go about appealing successfully, and what is really expected of them in the appeal process. Others who try and go it alone, are likely to get steam-rolled out of the ballpark by the CCG’s representatives, who can use the rules (ie the National Framework for NHS Continuing Healthcare), to their advantage. Unfortunately, some individuals may not survive long enough to get their CHC Funding reinstated, and so, their current claim for CHC will become a retrospective claim instead, and get kicked into the long grass by the CCG or put on the back burner – until you stir it up. Those who cannot do this themselves or lack the confidence to tackle the CCG, should seek professional advice. Visit our one-to-one page if you need help.
The cost paid to recruitment agencies to supply additional support for these reviews, may seem a waste of valuable NHS resources. But, it is obviously a price that some CCGs are willing to pay – both to help clear their backlog of outstanding reviews – and potentially to save funds at the same time by ‘financial gatekeeping’ contrary to the National Framework.
We agree that CHC Funding should be withdrawn where it is clearly no longer appropriate or where the individual’s healthcare needs no longer exist – as that, too, is a waste of valuable NHS funds.
Equally, we have no objection to CCGs recruiting external resources from outside the NHS, to assist in these reviews, if they are satisfied that is a truly more cost effective option. But, the appointed assessors must be familiar with the patient, know and understand their daily healthcare needs, and be trained in the National Framework. What is not acceptable, in our opinion, is assessors being recruited to undertake reviews, who are apparently clueless as to the individual’s needs (perhaps meeting them for the first time), who don’t understand the National Framework, and who are empowered to make arbitrary decisions which bear absolutely no reality to the patient’s challenging daily needs.
These are potentially life-changing outcomes which could make the difference to having ongoing NHS ‘free care at the point of need ‘, or having to self-fund and pay for it from private means – and in many cases having to sell your home.
The public needs to have confidence in their CCG and be certain that any review of their relative’s CHC award will be conducted properly, fairly and robustly in all cases. Sadly, as many readers will testify, that has not always been the case. So beware! Don’t let your relative’s review of their care package turn into a fresh reassessment of needs, contrary to the National Framework.
Take, for example, the case of John Morrison, featured on BBC’s Victoria Derbyshire show. This is an example of one such disgraceful failing by the NHS. John suffers from cerebral palsy and has no use of his limbs. John is totally dependent on his family and carers to do everything for him. John had CHC in place before it was wrongly withdrawn in 2009 following a reassessment, leaving his family to fight a 10 year battle to seek reinstatement of funding. In the meantime, John’s family are reported to have paid out £300,00 which they are now seeking to recover retrospectively, plus interest. John’s mother, Suzanne, told the BBC, “This is the dark side of the NHS. This is the hidden side. This is the disabled side, the dementia side, the Alzheimer’s side…..”
If CHC Funding is removed, then the likely result is that your relative will have to pay for their own care. If you believe the decision is wrong and want to challenge it, then you only have 6 months to lodge an appeal – but again, may be forced to pay for the cost of care (ie self-fund) until the appeal is heard and the outcome is notified to you. Pre-COVID-19, that appeal decision could easily come a year later, costing your relative upwards of £45,000 to £100,000 a year, depending on the particular care home’s annual fees. We deal with appeals extensively in many articles on the subject which you can find on our caretobedifferent website.
But, with the advent of COVID-19 and the recent Coronavirus Act 2020, these 3 monthly and annual reviews are currently on hold. That will benefit those individuals who are already in receipt of a CHC package, as they will now be saved the anxiety and stress of a review, and of course, the risk that their CHC Funding could be withdrawn. However, those whose current package is now inadequate to meet their increasing needs, may well be underfunded. For more information, read our blog:
For further background reading on the subject, also take a look at:
If your relative has had their CHC Funding improperly or incorrectly withdrawn at a 3 month or annual assessment, and you have mounted a successful appeal, let us know and share your story with others below.