NHS Cheshire and Merseyside

3. In November 2018, Mrs L says she asked the ICB to reinvestigate whether her mother was eligible for CHC funding for the period 9 June 2014 to her death in February 2015. This is care provided over an extended period of time, to meet physical or mental health needs that have arisen as a result of disability, accident or illness. The ICB completed a desktop review and sent the outcome to Mrs L on 20 April 2021. Mrs L is unhappy the ICB decided her mother was not eligible, and complains: · the ICB based its decision on minimal care home records · the outcome of the desktop review conflicts with scoring given in a 2014 checklist · the desktop review scorings for the Behaviour, Skin and Mobility care domains.

4. She also complains about the ICB’s process saying: · it found a procedural error relating to the 9 June 2014 checklist but this should have been found earlier · it did not do a CHC review six months after the 2014 checklist · it took too long to review the period · its communication was poor and it did not keep her updated as it said it would.

5. She says her mother deteriorated rapidly from the start of the review period. She feels the ICB ‘guessed’ where there is little information, and gave an inappropriate score. She explains having to revisit the last months of her mother’s life has caused much pain and stress.

6. She feels the time the ICB has taken is unacceptable and the process continuing many years after her mother died, has been upsetting and caused distress.

7. She would like the eligibility decision to be reviewed. She would like compensation for the distress caused by the delay and lack of contact. She would like the ICB to improve its service so others do not experience the same problems.

8. The ICB wrote to Mrs L on 10 June 2019 saying there was a delay due to a high number of complaints about historic decisions. It said a CHC checklist (the first stage of process) and Funded Nursing Care (FNC) assessment was completed on 24 February 2014. FNC is the contribution from the NHS that covers nursing care received while a person is in a nursing home. It did not find Mrs U to be eligible for CHC funding.

9. It said a further checklist and FNC assessment were completed on 9 June 2014. It did not find Mrs U eligible and scheduled a review of her needs for 4 March 2015. It explained although it did review this period, it did not write to Mrs L with the outcome or explain the appeals process. It refers to these as procedural errors. The ICB agreed to do a desktop review to remedy this.

10. Mrs L replied on 12 June 2019 asking for a response to the lack of communication, to review the period, and to explain why Mrs U did not have the six-monthly assessment in December 2014, before she died.

11. The ICB’s response, dated 20 April 2021, apologised for the delays and the distress this caused. It confirmed it did a desktop review and found Mrs U not to be eligible for CHC as she did not have a primary health care need. It enclosed its findings.

Resolution

14. We saw that the ICB completed a desktop review, meaning it did more work than was required when redoing a CHC checklist. It considered the 12 care domains and the four key indicators (nature, intensity, complexity and unpredictability). We are not critical of the ICB doing this, but needed to understand whether it had effectively gone on to complete a Decision Support Tool (DST). When a checklist decision indicates eligibility, this tool is used to look at the needs in more detail and help to inform a decision. This is because with CHC eligibility decisions there is a set process to follow and part of this allows a person to challenge the ICB’s decision if they disagree with it.

15. The National Framework paragraph 118 says: ‘Once an individual has been referred for a full assessment of eligibility for NHS Continuing Healthcare…then, a multidisciplinary team must assess whether the individual has a primary health need using the Decision Support Tool’.

16. The National Framework paragraph 123 explains the multidisciplinary team (MDT) stage: ‘The MDT works together to collate and review the relevant information on the individual’s health and social care needs. The MDT uses this information to help clarify individual needs through the completion of the DST, and then works collectively to make a professional judgment about eligibility for NHS Continuing Healthcare, which will be reflected in its recommendation. This process is known as a multidisciplinary assessment of eligibility for NHS Continuing Healthcare’.

17. The ICB confirmed it wanted to review the period fully and it had effectively completed a DST by doing a desktop review. It recognised that it had held an MDT, or given Mrs L the opportunity to appeal its desktop review decision. It outlined how it had recently started an improvement process focused on the retrospective review pathway. It says robust arrangements are now in place to make sure the right process is followed. It has developed new guidance to implement this.

18. The ICB was keen to give Mrs L the opportunity to appeal and offered to complete further work to allow for this. In line with the process, set out in the National Framework, we have agreed a resolution with the ICB. We have asked it to: · Continue with the local resolution process, in line with the National Framework and arrange for an MDT · Contact Mrs L to give her a dedicated contact point, advise of the timescales for completing the MDT stage, and to keep her updated

19. This resolution will mean the ICB will complete the process for making an eligibility decision. It will allow Mrs L to appeal the decision and raise concerns about its process. If these cannot be resolved locally, Mrs L is able to take her issues to NHS England for it to independently review. If Mrs L remains unhappy after this, she can bring her complaint to us. This is the process set out in the National Framework.

1. We have carefully considered Mrs L’s complaint about the NHS Cheshire and Merseyside Integrated Care Board (ICB). We can see the ICB reviewed her mother’s, Mrs U’s, eligibility for NHS Continuing Healthcare (CHC). We understand Mrs L disagreed with the eligibility decision and has concerns with the ICB’s process. We have agreed a resolution with the ICB to allow Mrs L to progress these concerns through the local resolution process, and on to NHS England, if necessary. We have explained this in full below.

2. We thank Mrs L for bringing this complaint to us. We appreciate she has been pursuing this for a long time and it means a lot to her.