14. It is our role to decide whether NHS England’s IRP acted in line with the National Framework) when it considered whether Mrs U was eligible for CHC. The National Framework sets out the principles and processes CCGs (now ICBs) and NHS England should follow when considering if someone is eligible for CHC.
15. We cannot consider the discretionary decisions the IRP made when it decided on eligibility. This includes the decisions it makes based on clinical judgement and clinician’s opinions. We can only consider if the IRP has followed the National Framework. This means we can only uphold a complaint about a CHC eligibility decision if we find the IRP did not follow the National Framework when it made its decision.
16. The IRP reviews if the CCG should have found a person to have a primary health need and therefore be eligible for CHC. It also reviews the CCG’s procedures when it was coming to its eligibility decision to make sure it was acting in line with the National Framework. If the IRP does find the CCG made a mistake, it can recommend the CCG: · reconsiders if the patient had a primary health need, and · addresses any procedural faults the IRP identified.
Did the IRP apply the eligibility tests properly and reach an evidence-based conclusion about them?
17. The IRP applies an eligibility test to help it make a decision about an individual’s CHC eligibility. This is what we refer to as the ‘primary health need’ test. The National Framework separates this test into four key characteristics: nature, intensity, complexity, and unpredictability. This test is used to establish if the quantity or type or an individual’s care needs are more than what the local authority can provide. This indicates they have a primary health need, which in turn indicates they are eligible for CHC.
18. The National Framework sets out questions for the IRP to consider to help establish a person’s level of need. They are outlined in the National Framework section, ‘Practice Guidance 3, When identifying a primary health need, how should the four key characteristics be approached?’. The National Framework is clear the questions it provides are not meant to be strictly applied and are there to guide the IRP’s considerations. We use these questions when we are looking at whether the IRP properly considered the four key characteristics of Mrs U’s needs.
19. Mr U has not specifically told us about why he does not think the IRP properly considered the four key characteristics. But we can see he and his family did contribute to the discussions during the IRP and sent written submissions. Those views are recorded in the IRP’s report.
Nature
20. The National Framework says this characteristic should ‘describe the particular characteristics of an individual’s needs (which can include physical, mental health or psychological needs) and the overall effect of those needs on the individual, including the type (‘quality’) of interventions required to manage them.’
21. Mr U told the IRP his mother was doubly incontinent and needed carers to help her with this. She needed them to help maintain her hygiene as a result of her incontinence and poor cognition(understanding). Mr U said his mother had an itchy rash on different parts of her body which was caused by her skin condition. Mr U also gave his concerns about her complications from tonsillitis, and she needed full assistance with eating and drinking.
22. We can see the IRP considered the nature of Mrs U’s needs at a level we would expect to see and with the guidance in mind. The IRP focussed on Mrs U’s individual needs rather than her diagnosed medical conditions. It commented on her needs relating to continence, nutrition, and cognition which Mr U had mentioned. It specifically discussed the impact of her skin condition. Mr U said it made it painful for Mrs U to eat. The IRP explored this and found no evidence in Mrs U’s records, including hospital records, to support Mr U’s view.
23. It considered Mr U’s view she needed full assistance with eating. It noted Mrs U was taken to the dining room where she needed some assistance with eating, and she needed prompting to drink. However, it found no evidence Mrs U needed full assistance. It acknowledged Mrs U’s poor short-term memory meant she could not remember if she had eaten so the carers needed to give her meals. This was done on the care home’s regular meal schedule.
24. The IRP established Mrs U needed the support of her carers for all aspects of her daily life. It looked at the types of care she needed to keep her safe and well and the report set this out in great detail. Mrs U needed support to go to the toilet, taking to the dining room and caring for her fragile skin. Mrs U also needed her carers to give her medication as she would not remember to take it herself.
25. We can see the IRP considered the type of care Mrs U needed on a day-to-day basis. The guidance suggests the IRP should look at whether the level of care needed any particular specialist knowledge or training to manage the level of need. The IRP acknowledged this and considered if Mrs U needed specialist treatment. It considered her MUST score, which is a screening tool used to assess if someone is at risk of malnutrition. The MUST score showed Mrs U did not need specialist treatment from a dietician. It looked at Mrs U’s medication plan and saw it was consistent and did not need regular involvement from a GP. It also saw Mrs U’s skin did not need specialist dressing from a district nurse and could be treated by carers with medicated creams.
26. We think the IRP acted in line with the guidance set out in the National Framework when it considered the nature of Mrs U’s needs. We appreciate Mrs U needed support with all aspects of her day-to-day life. The IRP has acknowledged this and discussed Mrs U’s needs rather than her health conditions, it has discussed the impact these needs had on Mrs U’s welfare and whether the carers needed specialist knowledge. It has also made clear reference to Mrs U’s medical records to support its view.
Intensity
27. The National Framework says this characteristic relates to ‘both the extent (‘quantity’) and severity (‘degree’) of the needs and to the support required to meet them, including the need for sustained/ongoing care (‘continuity’).
28. The IRP report does not say Mr U made any specific points about the intensity of his mother’s needs. He has not raised any specific points in his written submissions either. But we know he disagrees with the IRP’s consideration of the whole primary health needs test and intensity, is part of that test.
29. The report shows a detailed discussion about the intensity of Mrs U’s needs. It focussed on her mobility, skin, and nutrition. It acknowledged Mrs U was at risk of falling due to her medication and frailty. For most of the review period, she needed two carers to help her stay mobile. This included helping her out of bed, to go to the toilet or to help her out of a chair. It recognised Mrs U would try to get out of bed on her own, and the carers needed to be aware of this. They used an alarmed pressure mat to help them monitor Mrs U’s mobility.
30. The report considered how Mrs U’s skin condition affected the intensity of her needs. Her carers applied creams daily and needed to be careful when helping Mrs U move not to tear her skin. It noted this made helping her move and dress take longer, and it recognised no skin tears were recorded.
31. The IRP saw Mrs U needed some assistance with eating and needed prompting to drink. Unfortunately, Mrs U had very poor eyesight and could only see the food on the side of the plate in front of her, so she needed a carer to turn it for her.
32. We can see the IRP considered the intensity of Mrs U’s needs alongside the guidance. Mrs U did need a lot of support as described above, and with her medication due to her poor cognition. It recognised much of Mrs U’s care could be provided by one carer but there were occasions when two carers were needed such as when she needed support moving around the care home. It acknowledged Mrs U’s needs related to different care domains but found it was not to the degree of a primary health need.
33. We think the IRP acted in line with the National Framework when it considered the intensity of Mrs U’s needs.
Complexity
34. The IRP carefully considered the complexity of Mrs U’s needs. The National Framework says, ‘this is concerned with how the needs present and interact to increase the skill required to monitor the symptoms, treat the condition(s) and/or manage the care.’
35. Mr U and his family gave written and verbal evidence for the IRP to consider. The IRP looked at the evidence Mr U provided. It said Mrs U was often constipated, needed her medication given secretly, could not express when her skin caused her pain, and had complications caused by tonsillitis. The IRP did not find any evidence in Mrs U’s records these conditions were too complex for the carers to manage. She was not prescribed any laxatives to manage her constipation, and Mrs U did not need specialist treatment to treat her skin rash. It also noted she did not have a specialised medication plan.
36. The IRP recognised the care Mrs U needed was not complex and could be provided by the local authority. Mrs U’s needs could be addressed by trained carers alongside visiting NHS services such as her GP. The carers provided Mrs U with support for her day-to-day activities such as eating her meals, going to the toilet, and maintaining her personal hygiene. They also routinely cared for her skin and gave her medication.
37. The report shows how the IRP considered the interaction of various combinations of Mrs U’s needs. It specifically discussed the interaction between her breathing and mobility. It acknowledged she had instances of breathlessness, but this was rare, and was not complex to manage because she could only move very short distances.
38. The IRP also considered how Mrs U’s cognition impacted her nutrition. When the IRP considered the nature of Mrs U’s needs, it noted she could not remember if she had eaten. This was not complex for her carers to manage as they provided meals on a set schedule.
39. We can see why the IRP did not consider Mrs U’s needs to be too complex for the local authority to manage. It is clear Mrs U did need care in her day-to-day life and we do not wish to take away from this. The IRP weighed up all the evidence and set out why it thought the level of skill needed to manage the interaction of her needs was not complex, or that any of the interactions posed a significant barrier to the carers looking after her.
40. We think the IRP acted in line with the National Framework when it considered the complexity of Mrs U’s needs.
Unpredictability
41. The final key characteristic of a person’s level of need is unpredictability. The National Framework defines it as: ‘the degree to which needs fluctuate and thereby create challenges in managing them. It also relates to the level of risk to the person’s health if adequate and timely care is not provided. An individual with an unpredictable healthcare need is likely to have either a fluctuating, unstable or rapidly deteriorating condition.’
42. The IRP report shows a detailed review of the unpredictability of Mrs U’s needs. We can see the panel had the guidance in mind to inform its discussion. The report says Mrs U had a consistent level of need and carers knew what to expect. It specifically referred to Mrs U’s poor mobility and her risk of falls. It acknowledged her carers could not anticipate when Mrs U was going to try to stand up on her own and recognised they used a pressure mat to alert them if she got out of bed. This is a key piece of evidence showing the IRP that while Mrs U was at risk of falling, it was a predictable risk and suggested she had a stable level of need.
43. The report also discussed the unpredictability of Mrs U’s angina attacks. The carers did not know when Mrs U was going to have an attack and they needed to monitor her pain and treat it when necessary. The carers could respond and treat Mrs U’s angina attacks very quickly using a glyceryl trinitrate (GTN) spray. The carers did not need specialist knowledge to use the GTN spray and Mrs U’s care needs did not change.
44. We think the IRP acted in line with the National Framework when it considered the unpredictability of Mrs U’s needs.
Did the IRP consider the procedural issues?
45. Mr U complains the CCG did not gather all the relevant evidence to help it make an informed decision about Mrs U’s care needs. He said the CCG ‘cherry picked’ the evidence to find Mrs U ineligible for CHC. He asked the IRP to include this in its considerations.
46. We have looked at how the IRP considered Mr U’s specific concern about this. We can see from the report it considered this. The CCG could not gather Mrs U’s mental health and social services records. We appreciate this would have been frustrating for Mr U and his family and we understand why he asked the IRP to look at this.
47. The IRP acknowledged there was evidence to show the CCG requested the information from the relevant organisations. Unfortunately, the information was not available. We have also reviewed the IRP’s case file and we can see the CCG did make reasonable attempts to gather this information. We are sorry the CCG did not have access to this information, and we understand Mr U feels the eligibility decision would have been different if these records were available. Unfortunately, the CCG and IRP cannot assume what information would be in the missing records, and then find Mrs U eligible for CHC on that basis. There must be clear evidence a person is eligible.
48. The IRP also considered if the CCG ‘cherry picked’ its evidence The IRP found the CCG came to its decision using a variety of different pieces of evidence. It acknowledged there were records missing as discussed above and could not see any gaps in the CCG’s consideration of the available evidence.
49. We are satisfied there are no failings in how the IRP considered the four key characteristics of Mrs U’s needs, or in how it considered the procedural issues Mr U raised. We think it acted in line with the National Framework. This does not take away from the account Mr U has given us, or the challenges he and his family faced towards the end of Mrs U’s life.
50. We appreciate Mrs U was fully relied on care, and we do not wish to undermine the challenges her care staff faced in meeting her needs. The IRP’s conclusion that her care did not indicate a primary health need and fell within the remit of the local authority, appears to be in line with the National Framework.