BBC: “Medical opinions have been ignored in the assessment of NHS payments to patients receiving care, it is claimed.”
We comment on the recent BBC report which highlights the wide difference between clinical commissioning groups in England who award NHS continuing healthcare funding and those who don’t. (To read the full BBC report click here)
The report shown on BBC Inside Out East found a “wide difference among clinical commissioning groups (CCGs) in England in the percentage of patients rejected following assessment for continuing health care (CHC).”
According to the BBC researchers, in the 12 months between July 2016 and July 2017, “Birmingham South and Central CCG rejected 75% of its new CHC assessments, Manchester CCG turned down only 17% of assessments, while Tameside and Glossop CCG only rejected 5% of those assessed.”
The process surrounding continuing healthcare funding assessments is set out by the government in a document called The National Framework for NHS continuing healthcare and NHS-funded nursing care therefore, given the existence of a National Framework, all assessors should use the same criteria meaning these regional disparities should not exist.
The BBC spoke to North Norfolk MP Mr Lamb, where 73% of NHS continuing healthcare cases within his North Norfolk CCG consituency were denied. Mr Lamb told the BBC that “the regional disparity amounts to an injustice between individuals with the same conditions which can’t begin to be justified“.
Unfortunately, at Compass CHC we were not surprised to read this BBC report – our experience with many Clinical Commissioning Groups has been similar to the finding of this research and we find many CCGs are incorrectly denying funding despite the clear medical evidence to the contrary. In cases such as these we would always advise instructing a specialist continuing healthcare company such as Compass CHC to undertake the appeal process.
Time and time again, clients tell our specialist advisors that they feel the National Framework is open to interpretation by the Clinical Commissioning Groups who seem to choose which parts to adhere to and which sections to ignore.
Tim Davies, Managing Director and (non-practicing) solicitor at Compass CHC clarifies, “the National framework is absolutely not open to interpretation or cherry picking by different Clinical Commissioning Groups. However, I know first-hand that left unchallenged this can occur which is why I always encourage clients to use a reputable continuing healthcare expert when navigating the often-complex funding process.”
If you do not agree with the decision that has been reached by the CCG, then the decision can be appealed. This is where Compass CHC can help. The appeal has to be backed by evidence, e.g. the decision reached was flawed. We can assist in this process. With our expert knowledge and experience of this complex area, we can determine whether you have a basis for an appeal by reviewing the evidence, and assisting you with the full appeals process. We have a strong success rate of securing funding after attending the panel hearings and arguing our client’s case.
To be eligible for NHS Continuing healthcare funding, the individual’s need for care must be a healthcare rather than a social care need. It must be established that the need for care is primarily health related. Additionally, these needs must be assessed as being complex, intense and unpredictable in their nature or a combination of the same. It should be noted that a person’s health needs – not their diagnosis – determines whether they are eligible for funding so having a certain diagnosis, for example having been diagnosed with Dementia, Alzheimer’s Disease or Parkinson’s disease, is not in itself an automatic entitlement to free care.
There are several stages individuals must go through before being awarded, or denied, continuing healthcare and funding can be denied at each stage of the process.
A continuing healthcare checklist is the first stage in determining whether an individual is entitled to free care. To trigger a checklist, you can ask your social worker, GP or other health and social care professional – such as a care home manager – to organise one.
An assessment should be carried out before a patient is discharged from hospital to a nursing home. This is a crucial point. If the patient is already in a nursing home or remains in their own home, then the responsibility for conducting an assessment is with the NHS Clinical Commissioning Group for the area.
If the checklist identifies the need to carry out a full assessment, your Clinical Commissioning Group (CCG) will be contacted. The full assessment is carried out by a multi-disciplinary team comprising two or more health or social care professionals familiar with the patient’s needs. In some cases, the multi- disciplinary team will contact the specialists involved with the care to build a better picture of the health needs the individual has.
The information taken from your full assessment will be used by the multi- disciplinary team to complete a ‘Decision Support Tool’ (DST). The DST document was developed to ensure assessments are carried out as consistently as possible across the national NHS network.
The multi-disciplinary team will allocate a level of need to each care domain to determine if the individual has a ‘primary health need’ and then make a recommendation to the CCG as to whether the individual should be entitled to NHS continuing healthcare.
Once your continuing healthcare assessment has taken place, the NHS health and social care professionals involved with your care will recommend whether you are eligible for funded care. This recommendation is forwarded to the Clinical Commissioning Group (CCG) responsible for funding in your area. The CCG will decide whether to accept or decline your assessment results and, if upheld, the level of care and support package available to you.
Should you, or a relative, have any concerns regarding NHS Continuing Healthcare funding, our expert advisors can assist by explaining the ins and outs of what can be a perplexing and complicated process. There is no time limit placed on this free, no obligation consultation. Should you wish to discuss matters further, do not hesitate to contact us directly on 0121 227 8940.
Author: Tim Davies LLB