4. Mrs U complains about the CCG’s decision not to reimburse the advocate fees she paid while she was claiming retrospective CHC costs for her mother.
5. Mrs U says that she suffers ongoing stress and emotional upset. She also tells us that she has suffered severe financial loss.
6. Mrs U would like to be reimbursed for her advocacy costs.
7. Mrs U tells us that she spent several years fighting to be reimbursed for care home costs through the NHS CHC retrospective process. She received a retrospective award after her mother was found eligible, however this did not include costs that she says were for an advocate to assist in her claim. She also tells us that she would have found this process impossible without the advocate’s assistance.
Reimbursement of Advocacy Costs
10. Mrs U tells us she had the right to enlist the help of an advocate in order to maximise the chances of successfully securing funding. She refers to the National Framework and explains this says, ‘An individual may wish to be supported by an advocate to help ensure their views and wishes are taken into account’.
11. The CCG has said that it would not be appropriate for it to refund any legal or professional fees.
12. The CCG has referred Mrs U to the NHS Continuing Healthcare Refreshed Redress guidance which states that, ‘The Parliamentary and Health Service Ombudsman has indicated that it is rarely appropriate to receive a refund of legal and professional costs in bringing forward an NHS continuing healthcare dispute’.
13. This guidance also says that: ‘Individuals do not need to seek legal advice in order to request an assessment of eligibility for NHS Continuing Healthcare and there is also a mechanism to request a review of a decision on eligibility. CCGs and third sector services will help and advise individuals or their representatives on the process that will be followed in line with the 'National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care’
14. Mrs U says that these points do not apply to her situation, as she did not seek legal advice, and she does not believe that an advocate comes under the definition of ‘legal and professional costs’.
15. In order to determine if the decision not to reimburse these costs was in line with the guidance, we have referred to the National Framework.
16. In the section entitled ‘Individual Requests for a Review of an Eligibility Decision’ the National Framework states that: ‘Independent review panels have a scrutiny and reviewing role. It is therefore not necessary for any party to be legally represented at independent review panel hearings, although individuals may choose to be represented by family, advocates, advice services or others in a similar role if they wish’.
17. We have also considered the NHS Continuing Healthcare Refreshed Redress guidance.
18. Under the section on ‘Legal costs and complaints’, it states that ‘The Parliamentary and Health Service Ombudsman has indicated that it is rarely appropriate to receive a refund of legal and professional costs in bringing forward an NHS continuing healthcare dispute.’ This is the guidance the CCG has already referred to.
19. We agree that the National Framework does state that Mrs U could have the support of an advocate if she wished. However, this was optional, and the National Framework does not state that this is a mandatory requirement, nor does it say that any costs associated with seeking representation would be paid by the NHS. We also note there are free advocacy services available to support individuals through this process.
20. The guidance does not provide a definition of what a ‘professional’ might be and although Mrs U says she did not seek legal assistance, we consider an advocate that receives a fee for their work would be considered a ‘professional’ in this context. Therefore, any costs incurred would be included in the ‘legal and professional’ costs as stated above. There is nothing in the guidance above that indicates the costs paid by Mrs U should have been reimbursed.
21. We have therefore not seen an indication of a failing in the CCG’s decision not to reimburse these costs.
1. We have carefully considered Mrs U’s complaint about Barking and Dagenham, Havering and Redbridge Clinical Commissioning Group (the CCG). We have seen no indication of a failing in the CCG’s actions.
2. Mrs U complains about the CCG’s decision not to reimburse costs she incurred for an advocate, while claiming retrospective continuing health care (CHC) costs for her mother.
3. We appreciate that pursuing her case over such a long period of time has been very distressing for Mrs U and we understand she has paid costs that have left her in financial difficulty.