The process of securing NHS continuing healthcare funding can be a protracted one, so when we complete a case it is always a pleasure to share the successful outcome
SUMMARY: after a protected battle, we took the case to the NHS England Independent Review Panel who unanimously agreed with our original position that our client was eligible for continuing healthcare funding.
Mrs J C’s family instructed us to act for them in May 2015. We gathered and reviewed the care records in the case and drafted detail representations which we submitted to the Clinical Commissioning Group (CCG) to instigate the Continuing Healthcare (CHC) process. We concluded that Mrs J C had complex and intense healthcare needs and ought to be entitled to CHC funding.
Our Managing Director and Senior Advocate, Tim Davies, attended Mrs J C’s Decision Support Tool (DST) in November 2015 and secured Continuing Healthcare funding.
In brief, Mrs J C was unable to weight bear and was nursed in bed. Mrs J C had rheumatoid arthritis and suffered from severe pain and manic depression. Mrs J C presented with passive non-aggressive behaviour; she was resistant to positional changes and turning, placing herself at significant risk of pressure sore damage. At the time of the full assessment in November 2015, Mrs J C had a grade 4 pressure sore (full thickness tissue loss with exposed bone, or directly palpable, tendon). Although Mrs J C had been assessed as having capacity, it was apparent that she did not fully appreciate the significance of the risk, hence her decision to refuse repositioning which placed her at significant risk regarding pressure sores and the risk of infection. This was further complicated by Mrs J C’s severe level of pain and her non-compliance with her medication regime. In addition, Mrs J C’s nutritional status was at risk.
NHS Continuing Healthcare funding is subject to review (initially at 3-months and then annually). The CCG in Mrs J C’s case were pushing for the 3-month to be carried out within 6 weeks of the positive outcome. We objected to this and a 3-month review was carried out in February 2016.
Mr Davies attended the 3-month review to represent Mrs J C in February 2016. Mrs J C’s needs were reviewed at this meeting. It was felt by the tissue viability nurse (TVN) that Mrs J C’s pressure sore had improved from a grade 4 to a grade 2 pressure sore. It was also felt by the assessor that Mrs J C’s behaviour did not pose a predictable risk to herself and that she was not in severe pain. We disagreed with several levels of need and instructed our own private tissue viability nurse. Our TVN confirmed that the pressure sore was still a grade 4.
The Assessor sought further information after the assessment which was not disclosed to Compass CHC or the Family. Mr Davies did not feel that the CHC Assessor correctly assessed Mrs J C’s needs and also failed to properly interpret her primary health care need.
A Multi-Disciplinary Panel was convened in March 2016 and Mrs J C’s CHC funding was incorrectly removed. We disputed this decision and lodged our grounds for appeal.
The first stage of the appeal process, the Local Resolution Meeting, took place over the telephone in July 2016. Mr Davies disputed the levels of need, rationale and outcome over the telephone. This meeting was hostile and a waste of time. The CCG refused to overturn the decision and the case proceeded to a Local Independent Appeal Panel in August 2016. Mr Davies represented Mrs J C at the appeal panel and the panel re-iterated that Mrs J C was not eligible for CHC funding.
Our Advocate/Paralegal, Natasha Cattel, also assisted with this case and obtained a detailed statement from the Care Home Manager to support our case that Mrs J C was entitled to CHC funding.
We requested an NHS England Independent Review Panel (IRP) and after chasing NHS England for several months the IRP took place in May 2017. Mr Davies presented detailed submissions to the Independent Review Panel regarding the disputed levels of need, the 4 key indicators and our firm view that Mrs J C ought to be in receipt of full CHC funding. Whilst the two-previous local appeal stage meetings had been hostile and dismissive, the IRP were receptive to Mr Davies submissions.
Although Mrs J C was refused CHC funding on 3 separate occasions (at the 3-month review, Local Resolution Meeting and Local Independent Appeal panel), the NHS England Independent Review Panel unanimously agreed with our original position that Mrs J C was eligible for CHC funding.
The CCG in question are now under a duty to reimburse Mrs J C’s Care Home fees from the date CHC funding was removed.
Once we accept instructions to act on a patient’s behalf, our team of continuing healthcare experts, comprising lawyers (non-practising) and clinicians (including nurses, tissue viability specialists and pharmacists) work tirelessly to review and consider all the medical evidence from a clinical perspective before drafting reasoned arguments to the patient’s Clinical Commissioning Group identifying how the individual is entitled to NHS continuing healthcare funding. They do this by cross-referring the medical evidence to the National Framework for continuing healthcare criteria.
Should you, or a relative, have any concerns regarding NHS Continuing Healthcare funding, or you are thinking about starting the funding process, 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