Compass CHC win NHS England appeal and secure c£100,000 continuing healthcare funding for patient incorrectly denied money by BaNES Clinical Commissioning Group
Overview:
The patient, who lived at home, was diagnosed with Parkinson’s Disease and Dementia and had several severe health issues associated with these conditions. They required constant supervision during waking hours with 24-hour care provided by live-in carers and paid for privately at great cost to family.
Compass CHC was brought in by the family to oversee the appeal process after BaNES Clinical Commissioning Group (and Sirona Care & Health) deemed that the patient didn’t have primary health needs and denied the family access to NHS continuing healthcare funding which would have paid for their care in its entirety.
NHS continuing healthcare is free healthcare provided by the NHS to individuals who have significant and ongoing healthcare needs. It is not means tested. This package of care can be received in any setting outside of hospital including care homes, hospices or even within a patient’s own home.
To be eligible for NHS CHC, it must be established that your need for care is primarily health related. Additionally, this need must be assessed as complex, unpredictable and intense.
BaNES (Bath & North East Somerset) Clinical Commissioning Group outsource their services to external company Sirona Care & Health to undertake clinical assessments for continuing healthcare funding.
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Compass CHC, a private company who specialise in securing NHS continuing healthcare funding for clients who have severe, complex and unpredictable primary health needs, was approached by the family of a Bath resident who had been turned down for funding by BaNES Clinical Commissioning Group despite having severe health issues including Parkinson’s Disease and dementia.
The patient’s family thought the health needs were sufficiently severe in nature to be considered a ‘primary health need’ which would entitle their relative to NHS continuing healthcare funding and requested that an assessment of care needs be undertaken. In BaNES, these services are commissioned to an external company, Sirona Care & Health.
A Decision Support Tool (DST) assessment took place 3 months after the initial checklist assessment which immediately raised an issue as the National Framework for NHS continuing healthcare funding stipulates that the whole process should be completed within 28 days of the date of the initial checklist.
Secondly, and separately, there was not a representative from the local authority in the form of a social worker in the DST assessment (the National Framework states that there must be a multi-disciplinary team panel of individuals involved in the assessment to look at matters from both a clinical and social care perspective). Unfortunately, the absence of the social care representative meant this was not possible in this case.
Despite the recommendations of the nurse assessor present at the Decision Support Tool assessment, Sirona Care & Health down scored and downgraded the levels of need the nurse assessor had awarded at the initial assessment and the patient was deemed ineligible for funding.
It was at this point that the family contacted Compass CHC who instigated an appeal of this assessment.
As part of the appeal process an independent panel must be convened to review the initial DST recommendation and afford the family an opportunity to explain why they disagree with the outcome and how the evidence contradicts the negative decision. This took place a year after the initial checklist assessment and Tim Davies of Compass CHC represented the family’s interests as the advocate.
Despite presenting the panel with evidence that incorrect scores had been attributed throughout the initial assessment and demonstrating how the patient had a clear primary health need, the appeal panel upheld the initial decision.
Therefore, the family advanced through Compass CHC to an appeal at NHS England level where Mr Davies again represented the families’ interests and presented matters to the NHS England panel.
Examples were provided of issues which occurred when BaNES Clinical Commissioning Group down scored the patient’s needs from ‘high’ to merely ‘moderate’ across several domains (or categories).
The NHS England appeal panel agreed and continuing healthcare funding was awarded and backdated to the date of the original Decision Support Tool assessment almost 2 years previously. In total Compass CHC managed to secure an entitlement to reimbursement of care costs paid in the region of c£100,000 for the patient.
This one case demonstrates the growing number of cases Compass CHC is involved with because CCGs are ignoring the guidelines set out in the National Framework and incorrect decisions are being made at every stage of the continuing healthcare funding process. However, it also illustrates that even when the initial appeal process has been exhausted there is justification to pursue matters further to ensure that an individual receives the funding they should be entitled to.
As a company Compass CHC has a high success rate of assisting individuals in securing continuing healthcare funding, both on a retrospective basis (securing refunds of fees that should not have been paid), and also securing funding on an on-going basis from day one.
The Compass CHC team of continuing healthcare experts, comprising lawyers (non-practising) and clinicians (including nurses, tissue viability specialists and pharmacists), review and consider the evidence from a clinical perspective before drafting reasoned arguments which identify an individual’s entitlement to the funding by cross-referring the medical evidence to the National Framework for continuing healthcare criteria. Further, the advocates are all (non-practising) lawyers specialising exclusively in continuing healthcare funding matters.
This story has recently been reported in Bath by The Bath Magazine
Author: Tim Davies LLB
