11. Our role is to decide whether NHS England’s IRP acted in line with the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care (2018) when it considered if Mr R was eligible for CHC and whether the CCG followed the correct processes. The National Framework sets out the principles and processes CCGs and NHS England should follow when considering if someone is eligible for CHC.
12. The National Framework (Annex D, paragraph 2) says the IRP should review the CCG’s CHC eligibility decision or the process the CCG followed when in coming to its decision.
13. We can see from the IRP’s final report that the panel concluded Mr R had a primary health need and should have been found eligible for CHC. The CCG accepted the IRP’s recommendation and retrospectively awarded Mr R CHC. Mrs O says the IRP should have made recommendations for the CCG to improve its processes too.
14. The National Framework gives NHS England guidance on what it should do when it considers making a recommendation for a CCG. Annex D, paragraph 21 says:
‘In reaching a view on whether the CCG followed the correct process and whether it correctly applied the eligibility criteria, the range of recommendations made by the IRP for considering by the CCG should include:
a) that the case should be reconsidered by NHS England or the CCG, addressing identified deficiencies in the process used or in the application of the eligibility criteria; or b) that, on the evidence submitted, when compared to the eligibility criteria, the individual should or should not be considered to have a primary health need.’
15. NHS England recommended Mr R did have a primary health need. When it made this recommendation, it acted in line with the National Framework.
16. NHS England did acknowledge procedural errors and gave details of this in its report. It did not make any specific recommendations for the CHC to improve its processes. We understand Mrs O’s reasons for bringing this complaint to us as her, and that her family were feeling distressed by the CCG’s long processes. Further recommendations about process were at NHS England’s discretion. We have considered whether it should have used its discretion to do that.
17. Mrs O has told us she is concerned that other people with motor neurone disease will have the same experience of having to go through the CHC appeals process, because the CCG has not made service improvements.
18. First, we should clarify that a decision about CHC eligibility is not based on the person’s condition. It is based on their needs. But clearly the needs can arise from a particular condition.
19. We have looked at what procedural concerns Mrs O raised with the IRP. These related to the CCG’s poor communication about the purpose of the DST meeting so the family were unprepared, and that it did not allocate enough time to properly discuss Mr R’s needs.
20. When we look at the IRP’s view on Mr R’s eligibility, there were only a small number of aspects of the CCG’s decision it disagreed with. It changed just two domain weightings: continence and drug therapies and medication (both moderate changed to high). It also only disagreed with the CCG’s view on one of the four eligibility criteria: intensity. The IRP’s view on the intensity of Mr R’s needs was ultimately the reason it decided he did have a primary health need and was eligible for CHC.
21. Decisions about CHC are often finely balanced. There is an appeal process so there is a clear way to check any disputed decisions and rectify any mistakes. That is what happened in Mr R’s case. If the IRP could see the CCG had made significant errors throughout its decision making, or if the IRP thought the CCG did not understand the needs arising from Mr R’s condition, this may have been grounds for NHS England to have made recommendations about the procedural errors. But there was nothing to suggest to the IRP that the mistakes the CCG made in the DST meeting arrangements were the reason it got those few aspects of the decision making wrong, or that the CCG misunderstood motor neurone disease.
22. We can understand Mrs O does not want any other person with this condition to have the same experience. When we weigh everything up, we do not think there is evidence to suggest the IRP should have exercised discretion to make further recommendations, further to telling the CCG Mr R was eligible for CHC.
23. Overall, it is clear Mrs O was concerned about how her family would fund Mr R’s care and we appreciate the distress this caused for her and her family at such a difficult time. We are pleased NHS England’s IRP resolved this part of Mrs O’s complaint by finding Mr R eligible for NHS funded CHC. We do not think NHS England did anything wrong when it made its recommendation to the CCG.