There are a number of tiers, or stages, to go through when you are making/appealing a decision for Continuing Health Care Funding (CHC). Each one can cause tears!
The tiers to success are in sequential order. In Tears within Tiers Part 1, we looked at the first three stages and the potential frustrations that you might experience, namely:
2. Decision Support Tool
If you missed Part 1, click on the link to catch up quickly: https://caretobedifferent.co.uk/tears-within-tiers-the-stages-of-making-an-application-for-chc-funding/
In Tears within Tiers Part 2, we now look at the remaining three tiers:
4. Local Review
5. Independent Review Panel
6. Parliamentary and Health Service Ombudsman
4) Local Review
If you remain dissatisfied with the Integrated Care Board’s (ICB) outcome decision, rejecting your application for CHC Funding, you need to appeal.
You will have received written notification of the decision not to award funding, and will have just 6 months to lodge an appeal for a Local Review. The Local Review process is normally dealt with by the same ICB team that dealt with your Decision Support Tool (DST). The quality of reviews varies from ICB to ICB, and case to case. The Local Review consists of a panel from the ICB, often nurses and/or managers. They listen to your reasons for appeal and can alter the levels of need awarded on the DST, and can alter the decision to ‘eligible’.
Your chances of achieving a successful outcome are greater if you have professional support from us. Failure to secure vital CHC Funding at this appeal stage can leave you paying ongoing expensive care fees and in a long queue for whilst processing your next appeal.
- The Local Review can be poorly conducted. You can be left feeling unheard, frustrated and deflated. The Local Review might skim over your concerns and not address the core issues that you wish to raise. The outcome may remain ‘not eligible’ and you may feel aggrieved that this decision is still incorrect. If this has happened to you, contact us using the details given below.
5) Independent Review Panel
If you are not successful in obtaining full funding at the Local Review, you have the right to appeal further. This next appeal stage is to an Independent Review Panel (IRP). The IRP consists of at least three members. The IRP is conducted through NHS England, rather that the local ICB.
The three members of the IRP will be from different backgrounds: one from a Local Authority (not the one that dealt with the Checklist/DST); one from an ICB (not the one that dealt with the DST/LR); and one Independent member who ‘Chairs’ the IRP.
The IRP will consider all of the evidence and can make decisions about the ICB’s process and about eligibility. This appeal stage is effectively your last real chance of being awarded CHC Funding. It is more likely that you will be successful in changing the ‘no’ decision to a ‘yes’ at IRP, if you have help. We can assist you at any stage in the process, including at IRP. Contact us for help using the details given below.
- Information relating to your case is ‘Missing’. Sometimes care records cannot be found or are not provided. If this happens, there should be a note in the IRP file that confirms what steps were taken to find the missing evidence. The IRP can ask for more steps to be taken if the ICB has not tried hard enough to find the evidence.
- If GP records as missing: Check that the ICB have contacted the correct GP.
- If the care home records are missing: You can ask the care home yourself for the records, although care home records are often misplaced when the care home is no longer operating or has new management.
- When you get a copy of the IRP file, which should be at least 2 weeks before the IRP meeting, check the sections of the file that records ‘missing information’. Normally, if the ICB has requested information from an outside agency and they have not had a response, it would be expected that the ICB make at least 3 requests for the information. These requests should be in writing and should be provided in the file.
- The IRP upholds the decision of the ICB: This means that you are told that your appeal has been unsuccessful. It could be that all or only part of your claim is turned down. The decision will be sent you in writing, usually within 8 weeks of the IRP. You can appeal to the Parliamentary and Health Ombudsman (PHSO).
6) Parliamentary and Health Service Ombudsman
You must have gone through an IRP in order to complain to the PSHO about being turned down for CHC Funding. Generally, you only have 12 months to lodge your Complaint with PHSO from the date you receive the negative IRP outcome. If you complain to them before the IRP has finalised their decision, your complaint will be turned away. Their contact details will be on your letter which accompanies the IRP decision. https://www.ombudsman.org.uk/
You can complain to the PHSO using their online service: https://ombudsman.achieveservice.com/module/home?
Or you can complain to the PHSO by downloading a complaint form: https://www.ombudsman.org.uk/making-complaint/complain-us-getting-started/complaint-forms
- The PHSO will generally only uphold a procedural complaint: This means that the ICB or IRP have done something wrong in the process that materially impacts on your case. For example, they have not considered material records. You will need to read the National Framework for NHS CHC Continuing Healthcare (July 2022) in order to identify procedural errors: The National Framework requires some understanding, and it is easy to get your facts wrong or to misinterpret the Framework. We can help. Contact us using the details given below.
- The PHSO will not usually overturn the eligibility decision: The best you can hope for is that they uphold a procedural complaint, that the matter is returned to the ICB for the procedural matter to be dealt with correctly, and this may result in the IRP being reconvened, or a new IRP being held. The PHSO will not alter the IRP’s eligibility decision, however unpopular or blatantly wrong you perceive it to be.
- Our experience is that the PHSO takes a long time to investigate complaints and mostly the outcome is wholly unsatisfactory! So to avoid wasting time, money and sheer frustration, we suggest you try and make sure that you get the right decision at the DST, the LRM or the IRP. We can help you at any stage.
For more background reading look at these blogs: