What you need to know to overturn adverse decisions on NHS Continuing Healthcare funding
This factsheet applies to England and is designed to help you understand and challenge NHS Continuing Healthcare (NHS CHC) eligibility decisions where you or a relative have been found ineligible. It explains how to challenge decisions on NHS CHC.
The dispute resolution or review process is complex. A solicitor or other specialist will analyse all the evidence in order to:
The national framework for NHS continuing healthcare, introduced in October 2007 and revised most recently in October 2018, is not prescriptive about the process of dispute resolution, so local NHS Clinical Commission Groups have adopted different procedures. Ask for a copy of the relevant NHS review/appeal rules immediately to ensure you do not miss any deadlines. There should be two stages:
The dispute resolution process can only address whether the National Framework guidance and the Decision Support Tool have been applied correctly in your case. Concerns about the type of care, or the location of the care package, are addressed by a separate complaints process.
Apply for a review of the ineligible decision in writing. The Framework directs that you have 6 months from the date of the decision to challenge it. You should check for any shorter deadlines imposed by the CCG. If you are requesting a new assessment because your relative’s needs have changed and increased since the decision, do not be put off by deadlines. The CCG is supposed to deal promptly with review requests, although the process can take months. The local resolution may involve one or more of the following:
When you are asked to give your opinion on your relative’s continuing healthcare needs, issues to raise include:
If the CCG maintains it’s original ineligible decision, you can apply to to NHS England’s Independent Review Panel (IRP). You must make this application within 6 months of the date of the CCG local resolution outcome letter. The IRP process is also characterised by long delays and you should be prepared for a long wait.
The IRP has an advisory role and can only offer guidance on:
The IRP should let you have a bundle of the documents that will be used in considering your relative’s case and should ask you for information about their health needs. However this information is often only provided a week or so before the hearing. It is advisable to meet your solicitor or adviser well in advance to prepare your written submissions. You can then update the written arguments when you receive the panel bundle.
The IRP hearing consists of three people and will normally include a clinical adviser in a non-decision making capacity. It is a relatively informal fact gathering and decision making process, unlike a court hearing.
You will generally be notified of a decision in writing within 6 weeks. If the IRP decides the person is entitled to NHS CHC funding, the award should be backdated to cover the dispute period.
The ombudsman can investigate a limited range of issues, such as:
While the ombudsman’s office cannot make a substitute decision, it can remit the case back to the strategic health authority or NHS for a proper and fair determination.
If you would like to speak to an expert in NHS funded care about problems accessing continuing NHS care funding (including the use of the continuing care decision support tool) contact us today on 01273 609911, or email firstname.lastname@example.org.
The national framework applies to continuing healthcare funding in England. Different guidance operates in Wales and Northern Ireland. Anyone seeking funding should consider seeking specialist advice. A different approach applies in Scotland where nursing and personal care costs (but not accommodation costs) are funded at set levels.
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