The news of NHS England’s deadline of March 2017 for Clinical Commissioning Groups (CCGs) to deal with all outstanding retrospective NHS Continuing Healthcare (NHS CHC) applications has sent many CCGs into a hive of activity. People who have waited years for a decision on their relative’s NHS CHC eligibility for a previously unassessed period 2004-2012 have been inundated with requests for information from the NHS, often with short deadlines for reply.
How can individuals ensure success in their long-neglected retrospective NHS CHC cases and prepare themselves for the sudden interest from CCGs?
Most CCGs have their own retrospective NHS CHC departments to process applications but many, overwhelmed by the number and complexity of cases, have outsourced them. Commissioning Support Units (CSU) and private companies such as Capita and Bray Leino Broadcare have been appointed by CCGs to administer retrospective NHS CHC cases. You may well receive correspondence from organisations appearing to have nothing to do with your relative’s NHS CHC eligibility. CCGs are supposed to notify the family that another organisation is handling their case but many do not. If your case has been taken over by another organisation make sure you know who and where to send additional information, especially if deadlines are short.
With their own time limit imposed by NHS England, CCGs rushing to process retrospective NHS CHC cases are only too keen to throw out applications where deadlines are missed. Having waited two or three years for the CCG to gather medical and care notes from hospitals and care homes and assign the case to a nurse assessor, you may be sent a Needs Portrayal document and a demand for comments within two weeks. These deadlines are imposed by the CCG for their own benefit so, if you aren’t going to be able to send your information by the date set, let the requesting organisation know and ask for an extension.
Many retrospective NHS CHC cases that should have a reasonable prospect of success are found ineligible through lack of evidence. Care Homes shut down, GP surgeries move or merge and care and health records go missing. If you have notes from your relative’s care home or hospital stay keep them safe. Read through the care records so you know what you are looking for when comments on a Needs Portrayal are requested. NHS Continuing Healthcare eligibility is especially difficult to establish where the older person was cared for at home. Don’t let the lack of detailed notes on their care needs be the reason your relative’s eligibility is declined by the CCG. If the care agency who visited them at home still exists, ask for a statement describing your relative’s needs and the care given. Prepare and submit your own statement.
The language of NHS CHC is complex and confusing but learning it may help you establish your relative’s eligibility for the period under consideration. Become familiar with the Decision Support Tool (DST) document and the domains and definitions so that you can describe your relative’s care needs in appropriate language. Make sure that you read the NHS CHC Framework Guidance which explains what Nature, Intensity, Complexity and Unpredictability are. These central concepts are just as – or arguably more – important than the “scores on the doors” from the healthcare domains.
Your relative may well have self-funded their care home or home care package for a lengthy period between 2004 and 2012, but you need to establish whether they had a primary healthcare need for all of that time. CCGs like nothing better than to ‘screen out’ all but a short period under review. We have clients who are disappointed with only a few hundred pounds refunded, having expected all of the care fees to be reimbursed. Concentrating on a shorter period of time when your relative had a demonstrable primary care need for which you have good evidence is much better than a long, poorly evidenced application which the CCG will find it easy to decline.
The September 2012 cut off deadline was a badly managed process and many families have spent time and money pursuing applications that never had a chance of success. It didn’t help that large organisations and law firms used publicity such as “last chance to claim back care fees” or “did your relative pay for their own care?” NHS CHC retrospective funding will not be awarded for someone who had social care needs – no matter how long they needed care for, and no matter how much they spent on their care.
Still don’t know your NICU from your Needs Portrayal? Martin Searle Solicitors can help you navigate the NHS CHC minefield. We can provide you with a tailor-made and detailed care needs analysis and a realistic assessment of your prospects of success in the retrospective NHS CHC case. We can draft comments on Needs Portrayals and grounds of appeal for you and can attend panel meetings if required.