Can a CCG overturn a multi-disciplinary team recommendation for NHS continuing healthcare funding at a decision support tool assessment?
Increasingly we are encountering instances whereby individuals have engaged fully in the NHS funding for care homes assessment process and secured a recommendation at the Multi-Disciplinary Team (MDT) meeting that their relative is entitled to continuing healthcare funding.
This will of course be based on having gone through the various domains and scoring’s and would have been considered by the nurse assessor and the representative from the local health authority at the decision support tool assessment. Then on having reviewed all the evidence available to them, they will have concluded the assessment and made a recommendation for the entitlement to continuing healthcare to meet the care home funding expenses.
Why Has My Care Home Costs Funding Been Denied?
Unfortunately, there appears to be an increasing scenario whereby the CCG responsible for implementing the funding following this recommendation are seeking to overturn these decisions without there being any basis for doing so.
The National Framework for continuing healthcare funding makes it abundantly clear that the CCG may not overturn the recommendation of the Multi-Disciplinary Team following a Decision Support Tool assessment unless there are ‘exceptional circumstances’. Further, these exceptional circumstances must be clearly articulated and should not ever be made by one person acting unilaterally.
Further, exceptional circumstances would only be applicable where, for example;
• Where the DST is not completed fully ‘for example where there is no recommendation’.
• Where there are significant gaps in evidence to support the recommendation.
• Where there is an obvious mismatch between the evidence provided and the recommendation made.
• Where the recommendation would result in either authority acting unlawfully.
As such there are a very clear set of limited areas whereby the CCG may overturn the decision of the MDT or the recommendation of the MDT. The clear point would be where there is insufficient evidence to support the recommendations made and this is something that the CCGs often seek to rely on. However, where the case has been fully prepared, for example the care records clearly evidence the need that has been documented in the scoring for the domain, clearly this is not applicable.
Can A Refused Healthcare Funding Claim Be Overturned?
As such in the instances where we have encountered the recommendations being overturned by the CCG, we have successfully challenged this point and ensured that the process is correctly adhered to and the recommendation for funding is implemented.
Who Can Help With My NHS Continuing Healthcare Funding issues?
The key here is to ensure that you have an expert assisting you with the process. Compass Continuing Healthcare specialise exclusively in matters of CHC (continuing healthcare) funding and we are experts in this area with an exceptionally high success rate.
Should you or a family member have any issues relating to care home funding, you should not hesitate to contact our office for a free, no obligation discussion. We can be contacted on 0121 227 8940 or complete our Continuing Healthcare Assessment survey.
Author: Tim Davies LLB