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

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

Appeal rejected

This is the second part of an article relating to appealing a decision following an initial Multi-Disciplinary Assessment.

First a quick recap of the previous article, “Rejected for CHC Funding? Part 1: How To Appeal The MDT Decision” which provides helpful information and guidance on appealing the decision of a Multi-Disciplinary Assessment to the Local Resolution stage.

If your appeal to the Local Resolution Panel (LRP) is then rejected, don’t give up!

Read on to find out how to appeal to the next level.

Step 1:

The CCG will provide you with a letter setting out the Local Resolution Panel’s decision to reject funding. The letter should have detailed reasons and tell you how to appeal if you still remain dissatisfied with the outcome.

If not, you must ask for the LRPs rationale so that you can understand their reasoning why they found your relative was ineligible for CHC Funding.

Timescale: You only have 6 months from being notified of the outcome to lodge an appeal.

Advice: Do not delay! The sooner you get the ball rolling – the less care home fees you may have to continue paying.

We strongly recommend that you diarise forward as you cannot afford to miss this deadline. Without very good reason, an appeal lodged after 6 months will be out of time. Once time-barred you will not be able to pursue your appeal further.

IMPORTANT: Look at the advice in our previous blog which is summarised below:

  1. Write a simple letter to the CCG immediately you get the rejection letter telling the CCG that you are going to appeal their decision.
  2. 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;
  3. Check that it has been received in time by them to give you peace of mind.
  4. For the avoidance of doubt, it also a good idea to email your letter to the CCG as well, confirming your intention to appeal.

Chase the CCG for their formal acknowledgement and appeals process. They should set out their appeals process and tell you that your appeal has to be made to NHS England for an independent review. A correspondence address will be provided with contact details of your regional NHS England team.

Step 2:

Next, write a formal letter to NHS England advising that you did not agree with the LRPs decision and that you want to pursue an appeal. You can adapt the template set out in the previous blog.

Again, chase an acknowledgement. NHS England will usually send you a form (or questionnaire) to complete setting out your reasons for appeal.  Your appeal will go to an Independent Review Panel (IRP).

You will need to correspond with NHS England from now on, and not the CCG. Remember to quote their reference on your correspondence to avoid unnecessary delays.

NHS England will contact the CCG directly to obtain all the relevant files, records and information that was previously available when the earlier decisions were made. No new evidence is generally obtained at this stage. There is no set timescale for this, and so this can often take some weeks to process.

Step 3:

Once the CCGs papers have been obtained, the matter will be allocated to an independent Chair to conduct a preliminary review of the evidence and to check whether there are any other outstanding issues or other missing information required.  Only if the case is suitable for the appeal to proceed, will NHS England then set up an Independent Review Panel meeting.  A hearing date to consider the evidence at the IRP appeal will then be notified to you. However, due to lack of resources, this could be some months away.

Make sure the date is convenient and that you can attend.

The Independent Review Panel will consist of the following people:

  • an independent chair
  • a representative nominated by a Clinical Commissioning Group (not involved in the case);
  • a representative from a Local Authority (not involved in the case); and
  • at times there is also a clinical advisor in attendance.

It is vital to present the IRP with your detailed written reasons (or submissions) for your appeal in writing, together with any new helpful evidence you have obtained. A deadline for doing so will usually be notified to you in advance.

Step 4:

Preparing your written appeal submissions can be quite a daunting process. To really do the job properly, ideally you too need to get hold of all care home, GP and hospital records, consider them carefully line by line, to find areas of challenge to support your appeal, and cross-reference them against the Decision Support Tool and previous LRP outcome.  Be under no illusion, preparing detailed written submissions is a skill, and can be extraordinarily time consuming if done properly. It involves spending a lot of time reviewing the evidence in each of the Care Domains, looking for discrepancies, factual errors or omissions, and drawing on evidence from all the various assessments and records to try and present your appeal.

Step 5:

It is preferable to attend in person at the IRP to argue your case for appeal. The meeting is formal and you will be given your chance to speak and address the Panel. This is not an opportunity to rant, but to calmly present your case in a professional manner before the Panel.  The CCG will be represented too, and will endeavour to put their case forward in support of their previous decision to reject CHC Funding.

If you do not feel confident that you can give it a ‘good’ go, then get support, but do not leave it until the 11th hour. A skilled professional advocate will need time to collate the necessary records (which can often many weeks whilst waiting for care homes, GP surgeries and hospitals to copy records!), consult with you, draft the written appeal submissions for your prior approval before lodging them with NHS England; nearer to the IRP hearing date they will need time to prepare as your advocate. Having an advocate means that you don’t have to speak at the IRP unless you want to.

Your appeal to the IRP can be thought of as ‘your last chance saloon’ and is one area where we really do recommend you get professional advice both to prepare your written submission and to help with advocacy.’

If all fails, what next…

Appealing the Independent Review Panel outcome…

If your appeal fails at the IRP stage, your only other and final route of redress is to apply to the Parliamentary and Health Service Ombudsman (PHSO).

However, they will not consider an appeal if you merely disagree with the IRPs decision – even if you find it perversely wrong.

The PHSO will only intervene if there is an evident abuse of process, and even then, the chances of success are unfortunately quite slim. They won’t simply overturn a decision just because you don’t agree with the IRPs findings.

13 Comments

  1. Marc Cherry 1 week ago

    Hi I’ve just received notification of outcome from IRP review 1 severe 3 high 5 moderate 1 low 2n/a. Whilst they reinstated cognition back from high to severe & one other from low to moderate after LRP had downgraded 4 agreed domains behind closed doors so denying us a chance to put our case fwd. However they are justifying CHC funding refusal re 4 key indicators have not been met even tho evidence to contrary was provided. However it looks like I’ll have to go to ombudsmen with this appeal any pointers would be most helpful towards hopefully a successful outcome. Also from feedback how likely is successful outcome with ombudsman. My mother had severe dementia was doubly incontinent with high risk of falls.

  2. Stephen Reeve 7 months ago

    I refused to continue with my mother’s LRP because they were not following NHS guidelines and the DST were not present so I could not question them. We reconvened on Nov 15th 2018 – again they were not following NFD to the letter and admitted that they had still not produced their own guideline to the appeals process. I decided to continue, challenged the DST decision on points of law / process / needs then left them to make their decision. Three months later I have still not heard. They are still paying – least the care home have not asked for extra payment so I assume that is the case.In mid-December mum left unattended had a bad fall and suffered a gruesome procedure in A&E without anesthetic so I did relay this to CCG who have yet to respond. I am not going to chase them ! Adult Care have found the care home ‘guilty’ of abuse and neglect with regard to the fall so solicitors are now involved.

  3. H 8 months ago

    The best thing to do is raise a formal complaint to the CCG. They then have to answer your complaint (which they will do indirectly, probably from stating their policy which they haven’t followed!). Quote the National Framework if it states a timeframe. Then if they don’t answer your complaint to your satisfaction you can respond and ask again (this is the complaint process). Once they have had two chances at answering your complaint you can escalate the complaint to the PHSO.

    Officially the Parliamentary & Health Ombudsman (PHSO) can’t get involved until you have gone through appeal or complaint process, but i have found that they will open a case reference and guide you through.

  4. Mel Hallworth 8 months ago

    It is now almost 12 months since since the Local Resolution meeting and I have had no decision. I have written and emailed but have had no response whatsoever. It seems I am just being ignored and treated with disdain. What do I do next? Any help would be greatly appreciated.

    • Judy 8 months ago

      Is this current or retrospective review.Is it CCG or CSU. You are being ignored and “they” hope you will just give up. Don’t. Depending on who you are waiting from for the decision but consider a visit to the CCG Local Governing Body.Meetings are held every month and public are allowed to attend.You don’t have to advise in advance of your attendance or what you question to the panel will be..Ask the panel at the meeting who is responsible for CHC decisions/ratifications if CSU and why in your case so long since local appeal without a decision . You won’t be able to go into any detail but should prompt the Chair into looking into it and will form part of the minutes of the meeting. Ensure it does. Also consider copying into any chase communications the CEO, Executives etc and tell them you won’t hesitate to take the matter further, Court if appropriate. Or you may want to seek legal advice.

  5. H 8 months ago

    Thanks Judy x

  6. H 8 months ago

    Hi, We, like everyone else have had an horrendous experience to date. Non adherence to the NF, omissions of relent information, verbal & passive aggression and intimidation. We have an appeal meeting on Tuesday and have asked to audio record the meeting. The CCG have said that we can’t but they will if all attendees agree (we are expecting them to refuse last minute) they have said they will provide us with a written transcript. The reason we want to record is to ensure they follow process, and behave in an appropriate manner towards us, a written transcript will not give us tone of voice or context (if they do record, we expect they will lose the recording, tactics they have used previously).

    Does anyone know if we have a legal right to audio record the meeting?

    Thanks very much
    H x

    • Judy 8 months ago

      There are some comments on the legal aspect on Facebook recently .We were allowed to record 2 meetings and found the minutes did not accurately transcribe what had been said..Essential elements in our favour were left out of the minutes.We haven’t even got the assessment report let alone any minutes of the 2nd assessment hence currently the tape recording is the only evidence we have there was even a 2nd assessment . Record anyway,.Only passing to a third party is illegal.Wonder what the legal definition of “third party” is ??

    • DD 4 months ago

      Apologies as this is a few months after the post, but maybe this will be helpful to others as I have had a similar situation. I attended a pre-appeal meeting with the CCG recently at which they asked to record the meeting, although I was denied the same privilege (because of data regulations). I agreed and was offered the opportunity to listen to the recording at a date in the future. A couple of days after the meeting, when asking to arrange this, we were advised that we would have to go through a formal Subject Access Request. In the meantime, I contacted the Information Commissioner’s Office and my understanding from that call is that we should have been able to record the meeting for personal use, and could quote GDPR Article 2, Section 2, Recital 16 c. Covert recording would also be permissible as it satisfies the criteria for personal use.

  7. Maggie 11 months ago

    Following an unsatisfactory LRP last October I applied for an IRP. My CCG has still not forwarded the relevant notes to them. What can I do?

    • Care to be Different 11 months ago

      Hi Maggie – I’m afraid that it can take an age at the moment to get an IRP date. Keep chasing and lodge a letter of complaint to NHS England. Regards

    • Jennie 11 months ago

      Be wary of stage 2. Our CSU ( who manages CHC for CCG ) failed to adequately provide the evidence to NHS England, so much so that no care home records were supplied at all. Just dermatology records that made it look like the District Nurse managed her skin needs when in fact the Nursing Home employed their own TV Nurse ( tissue viability ) appointment letters, why I don’t see relevance and G.P. factors, nothing in fact to show there was any nursing at the home. It took them 6 months and endless chase emails to cherry pick it . Also failed to properly adhere to a SAR request .IRP is on hold whilst we complain but we would not have got further than a screen out by the Chair otherwise. Shameful!! Soon 3 years since the initial DST. Relative died some 5 years ago.The period under review is just over a year , why waste so much admin time & money on such a small case ?? We are still fighting on principle and to expose the appalling practices of the CSU. This comment is not for social media.

      • Care to be Different 11 months ago

        Hi Jennie – this whole process can be so frustrating and time-wasting is endemic I’m afraid! Don’t struggle alone if you feel that you might benefit from some help with it all. Regards

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