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! Below are the various stages and the potential frustrations that you might experience.
The tiers to success are in sequential order with you having to pass through each tier, starting with the Checklist:
- Decision Support Tool
- Local Review
- Independent Review Panel
- Parliamentary and Health Service Ombudsman
1) Stage 1 – the Checklist
The preliminary starting point is the Checklist – a basic screening tool used to see if you have sufficient healthcare needs to move on to a full assessment – which we’ll come to later. Many people mistakenly think that a positive Checklist guarantees CHC Funding. It does not. It simply means that you can move on to the next stage – a full assessment.
To get a Checklist completed you need to make a request to your local adult social services team. To do this, contact the Local Authority (LA) that deals with the address of the person that is the subject of the request.
- Trying to find out which team applies. To find out, use the LA to whom council tax is paid. If you are applying from a new address and don’t know which council tax is involved, check with your new GP surgery; or if in a care home, check with the manager.
- Being refused a Checklist – put your request in writing to the correct LA, address it to the Adult Social Services Team, ask for written reasons for refusal.
- The Checklist is completed, but you have not qualified to go any further. You have the right to see the completed Checklist and to appeal it. Contact the LA to do these things.
If you still do not qualify, contact our Nurse Advice Line for more help: https://caretobedifferent.co.uk/product/advice-line-service/
2) Stage 2 – Decision Support Tool (DST)
If your Checklist is ‘positive’ you will qualify for the next stage of the assessment process.
The LA will then contact the relevant NHS Continuing Health Care team to trigger a Multi-Disciplinary Team (MDT) meeting. The MDT is constituted with a member of the LA Social Services team and a nurse assessor from the NHS, who get together with you and/or your family members, and any other relevant persons involved in your care, such as your carer, or specialists, to assess your needs using a DST.
Use the link below to see a copy of the DST and guidance on how to complete it: https://www.gov.uk/government/publications/nhs-continuing-healthcare-decision-support-tool
- What to do if the DST is completed but you are told you are not eligible: You have a right to have a copy of the completed DST sent to you and to appeal it. You must lodge your appeal within 6 months of being notified of the negative outcome decision. Reply in writing to the contact given on the outcome letter. You are more likely to be successful appealing if you have assistance. Contact us for help. Rather than rushing to respond in haste and in the heat of the moment, take some time to think how you are going to formulate your appeal response and gather supporting evidence. It can often be helpful to delay appealing until after you have first taken professional advice, as long as you remain within the strict 6 month deadline. You need to give your appeal the best shot, otherwise you could end up paying thousands of pounds a month in care if you fail.
- The DST is completed but there is confusion as to who is the correct Integrated Care Board (ICB) within the NHS responsible for processing it: This may cause a significant delay. The confusion is only likely to arise if you have recently moved area. As a general rule the correct ICB is the one that deals with your new GP practice.
After the MDT meeting has taken place, the completed DST will be returned to the ICB with the assessors’ recommendation for funding for internal approval (ratification).
A panel of nurses and/or managers within the ICB will check the DST to see if they are happy with the way it has been completed. If you have been turned down for CHC Funding, the application is likely to just be rubber stamped. Conversely, if you have been awarded eligibility there could be tears.
- What if the Ratification Panel disagree with the findings on the DST? They could either say that they do not support one or more of the levels of need selected within the form, or they disagree with the overall decision. If this happens, the DST will be referred back to the nurse assessor within the ICB. It could be that the Ratification Panel have requested more information on a specific issue. The nurse assessor and social services representative will need to discuss the DST further. They should report back to the Ratification Panel. You may not be told that this is happening.
- The Ratification Panel has prescribed powers, but we frequently see many instances where they reject an MDT’s recommendation that the patient is eligible for CHC Funding – but, on occasion, have also exceeded their remit. The Ratification Panel should not be used as a ‘gatekeeping’ function to save the ICB the cost of funding care. If the decision on your DST has been altered from ‘eligible’ to ‘not eligible’, it is likely that this is a result of the Ratification Panel changing the MDT’s decision. If this has happened to you, contact us using the details given below.
Look out for Tears within Tiers Part 2 next week, when we delve into appeal stages at Local Resolution level, NHS England, and the Parliamentary and Health Service Ombudsman!