If your relative has been undergone a Multi-Disciplinary Team assessment (MDT) and the Clinical Commissioning Group (CCG) have advised that there are insufficient healthcare needs to justify NHS Continuing Healthcare Funding, then read on to find out how to appeal the decision if you believe it is wrong…
Once the MDT’s Decision to reject funding has been made it will be communicated to you by the CCG in writing. Some CCGs will usually ask you for a response within 28 days if you intend to challenge the decision, otherwise no further action will be taken.
This is an arbitrary, self-imposed deadline that is it actually unenforceable. There is nothing in the NHS National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care (revised 2018) that imposes this deadline. However, the CCG will try and hold you to it nevertheless as it suits their position.
Just so you know, the actual time frame to lodge your appeal is 6 months from the date you receive the outcome letter from the CCG rejecting funding. So diarise forward so as not to miss this back-stop deadline.
Make sure that you at least lodge your intention to appeal swiftly and in writing, and do it well within the 28 day period stipulated – otherwise the CCG might close their file on this case. Once closed, it can be an uphill task to persuade the CCG to re-open it, as it is not in generally in their interests allow you more time.
We therefore recommend you write a simple letter (and also an email) to the CCG immediately you get the rejection letter telling the CCG that you are going to appeal their decision. At least that way, you can buy yourself some time and the CCG are on notice of your intention to challenge their decision. Do not leave this important task to the last minute or you run the risk of missing their deadline.
Get proof that your letter appealing the decision has been sent to the CCG (eg send it by Recorded Delivery) in case there is an argument that you didn’t reply in time; equally check that it has been received by them to give you peace of mind.
For the avoidance of doubt, it also a good idea to email your letter to the CCG as well, confirming your intention to appeal. Add a ‘delivery’ and ‘read receipt’ if you can, again in case of any argument that you didn’t reply in time.
If the CCG haven’t provided you with a copy of the Decision Support Tool (DST), with their outcome letter rejecting funding, you must ask for it. You cannot really consider the merits of an appeal without knowing the arguments you face and why CHC funding was rejected in the first place.
We have set out a sample letter below to help you:
Re: [name of relative / individual being assessed]
Your reference: [insert]
Thank you for your letter dated [insert date], which I received on [insert date].
I note with disappointment the outcome of your Decision rejecting the claim for CHC funding (or partial funding). I do not agree with the Decision and wish to pursue an appeal.
Please take this letter as notice of my intention to appeal the Decision.
Please forward any necessary forms to me for completion together with a copy of the Decision Support Tool when replying.
I look forward to hearing from you in due course as the guidance provides that I have 6 months from receiving your letter to lodge my appeal.
What Happens Next…
A review will be conducted by the CCG through their local resolution procedure. There is a 2 stage process set out at paragraphs 192 to 195 in the revised NHS National Framework for NHS Continuing Healthcare (revised 2018).
Stage 1– A review:
There is an optional preliminary stage which you may want to consider. This initial stage is quite informal and is to go through your case file (ie the DST and decision) and to address any concerns you have.
The revised National Framework for NHS Continuing Healthcare (2018) provides that the CCGs coordinator will set up a ‘two-way’ meeting to review and discuss the DST, the scores and comments made against each of the Care Domains.
Although this is intended to be a ‘two-way’ process, in reality tends to be nothing more than an opportunity for the CCG to explain the reasons behind their decision – to demonstrate transparency and fairness.
Whilst this exercise might tick some boxes at the CCG and they may note your disappointment and any comments, this informal review stage can often prove to be a waste of your time and the CCGs valuable resources. Yes, you can vent your frustration at this ‘talking shop’ phase and put your points of view across – but the reality is, this is often a ‘one-way’ process as the CCGs representative does not always have the power to overturn the decision already made to reject CHC Funding. However, very occasionally, decisions have been overturned at this stage if they are so obviously wrong.
If you remain unhappy with the outcome of this informal meeting and still want to appeal – or alternatively just want to skip this preliminary review stage entirely and go direct to the appeal phase – then the next stage is to present your appeal formally to the Local Resolution Panel.
Stage 2 – The Appeal
Again, the coordinator should be in contact with you to set up the Local Resolution Panel (LRP) meeting, and ask who else will be present.
Make sure you are given plenty of notice and tell them quite clearly that you want to attend.
If the date of the LRP meeting is not convenient or the notice given is too short, tell them so.
You need time to prepare for the meeting and consider the outcome letter and the reasons for rejecting funding.
For convenience purposes, sometimes these meetings can be conducted over the telephone – which some people find less daunting, but others prefer to contest matters in person.
It is generally a good idea to get hold of a copy of the current care home records and GP records in advance of the LRP, as this may help you formulate your arguments and identify any incorrect assumptions, errors or mistakes that the CCG have made in their assessment. The records can support arguments over Care Domains where you feel they have simply underscored. These records combined with your personal knowledge of your relative are your best ammunition.
But even so, you will be facing a representative from the CCG who will be well versed in the NHS National Framework and will be presenting the CCGs ‘party line’ at the LRP, to support the reasons for rejecting CHC Funding. You can get an advocate to represent you. Consider getting professional help with this part of the process. If you do, we strongly recommend that you engage help early in the process, as there is generally much preparation needed in advance of the LRP meeting if you want to maximise your chances of success. A professional advisor will take the strain and stress of this process from you, obtain the records, review them and prepare detailed written submissions to the CCG in advance of the LRP to narrow down the areas in contention. They will argue on a level playing field with the CCG and Local Resolution Panel.
If your appeal at the LRP is not successful and you believe that the decision not to grant CHC Funding is wrong, you can appeal again to the next tier.
Read our next blog entitled “Rejected for CHC funding? Part 2: How to appeal the LRP Decision” for more information.