11. CHC describes care provided over an extended amount of time to meet physical or mental health needs arising from disability, accident or illness. If someone meets the criteria to receive CHC funding, their care will be funded by the NHS.
12. It is our role to decide if the IRP made its decision in line with the National Framework. We cannot question discretionary decisions when they have been made without maladministration (fault) and we can only uphold a complaint about an eligibility decision if there is some specific fault in the way the IRP reached its decision. Such decisions are based on clinical judgements and opinions, and if someone else has a different opinion this does not mean there must have been a fault in the decision-making process.
13. The purpose of the IRP is to review the procedure followed by the clinical commissioning group (CCG, now known as an ICB) in making a decision about a person’s eligibility, or the primary health need decision by the CCG. In reaching a view about whether the CCG has followed the correct process and correctly applied the eligibility criteria, the IRP can:
• recommend the CCG reconsider the case and address any faults identified in the process, or • reach a view on whether the individual should or should not be considered to have a primary health need.
14. When we look at a complaint about an IRP, we consider whether it took account of all the relevant information provided to it in reaching its decision. To help us reach a decision, we consider four key areas below.
Did the IRP get all the relevant evidence?
15. Paragraph 199 of the National Framework says, ‘The key elements involved in considering requests for independent reviews of NHS Continuing Healthcare eligibility include: scrutiny of all available and appropriate evidence as described in the Local Resolution section.’
16. We have reviewed the information provided to us in NHSE’s case file and we can see the IRP had access to the following:
• correspondence between NHSE and the applicant (Ms L) • correspondence between the ICB and the applicant • consent documentation • minutes of the complaint handling meeting held on 20 August 2020 • DST dated 27 February 2020 and decision letter dated 28 February 2020 • nursing needs assessment dated 17 February 2020 • 72-hour dependence and behaviour chart dated 17 February to 20 February 2020 • checklist dated 15 January 2020 • GP records • care home records from October 2019 • care and support plans (fall risk assessment, medication administration records, body map for insulin, blood sugar recording form, resident fall follow up, positional change recording form, wound assessment chart, professionals’ visits and referrals log, relative communication record), and • funded nursing care dated 23 December 2019
17. We also have a copy of the IRP’s report. The report documents the submissions Ms L gave in person.
18. It is clear the IRP had access to all the information the ICB used to make its decision in September 2021. It gave Ms L an opportunity to speak at the meeting on 23 September 2021 and complaint handling meeting on 20 August 2020. The IRP also had access to her written submissions. The IRP also received Mrs M’s medical records and care home records from the ICB, which show her needs during the review period.
19. The case file includes a missing evidence audit, setting out which information was missing from the care home record and the review period. We are satisfied there signs of failings in how the IRP established all the appropriate and relevant clinical facts. The IRP had access to information clearly detailing Mrs M’s needs in the weeks before the DST assessment in February 2020.
20. The IRP has acted in line with paragraph 199 of the National Framework here.
Before it made its decision, did the IRP consider all the relevant evidence?
21. We have looked at the information in the IRP report and considered how the panel discussed all the available evidence when it was weighing up the disputed care areas. We can see the IRP discussed Ms L’s written and verbal evidence. This is clearly detailed in sections five and six of the IRP report, which outline Ms L’s views on each care area and key characteristic.
22. We can see the IRP also considered the information in Mrs M’s medical and care home records. When it explains its weighting (scoring) for each care area, it refers to specific items of information taken from the records. We can also see the IRP had the National Framework in mind when it discussed its weighting of each area and key characteristic. It outlines how it weighted each area and explains how its weighting was in line with the National Framework.
23. Paragraph 199 of the National Framework is also relevant to this part of the IRP’s considerations, and we think it has acted in line with the guidance here.
Did the IRP clearly explain how it reached its decision?
24. Ms L tells us she disagrees with how the IRP considered one of the areas in which a person’s care needs are determined by the NHS.
Drug therapies and medication: symptom control
25. Ms L feels her mother’s level of need in this area should have been assessed as ‘priority’. The ICB considered the level of need in this area as ‘high’ and the IRP agrees.
26. Ms L told us her mother’s diabetes was very unstable and required her blood sugar to be monitored three times a day and her diet altered accordingly at each meal. She was sometimes denied food because her blood sugar level was too high. Ms L feels the IRP has not considered section 139 of the National Framework in respect of future worsening of her mother’s condition.
27. The DST assessment defines a ‘high’ level of need in the drug therapies and medication area as:
‘requires administration and monitoring of medication regime by a registered nurse, carer or care worker specifically trained for the task because there are risks associated with the potential fluctuation of the medical condition or mental state, or risks regarding the effectiveness of the medication or the potential nature or severity of side-effects. However, with such monitoring the condition is usually non-problematic to manage
OR
‘moderate pain or other symptoms which is/are having a significant effect on other domains or on the provision of care’.
28. The IRP notes Mrs M had type 2 diabetes. She was prescribed insulin, which was given as a daily dose each morning. Staff recorded her blood sugar levels two or three times a day and a range of five to 25 was assessed as being acceptable for her. The IRP notes Mrs M was on nine medications (doxazosin and ramipril for high blood pressure, senna and Laxido for constipation, dihydrocodeine for pain, paracetamol for pain as required, metformin for high blood sugar levels and mirtazapine for anxiety and depression).
29. The IRP notes Mrs M’s insulin levels went up and down but, overall, her medication regime was straightforward and she had no PRN medication during the review period (medication given as and when needed). Mrs M was fully compliant with taking her medication and was able to tell staff if she was in pain and needed pain relief. Mrs M’s GP was regularly involved in monitoring her diabetes and she did not require advice from a diabetic nurse.
30. The DST assessment defines ‘priority’ level of need in the drug therapies and medication area as:
‘has a drug regime that requires daily monitoring by a registered nurse to ensure effective symptom and pain management associated with a rapidly changing and/or deteriorating condition.’
OR
‘unremitting and overwhelming pain despite all efforts to control pain effectively.’
31. We have seen no evidence in the records to support a ‘priority' score level in the area of drug therapies and medication. The plan of care evaluation dated November 2019 notes Mrs M had type 2 diabetes and needed staff to give her medication, and a blood sugar level range of five to 25 was assessed as being acceptable for her. We note care staff recorded Mrs M’s blood sugar levels on the blood sugar recording form three or four times a day. The records show there were three occasions (24 January, 9 February and 15 February) when Mrs M’s blood sugar levels were below five but readings were taken several times that day and returned to the acceptable level.
32. There are several entries in the GP records (4 January, 25 February, 17 March, 28 May, 2 June, 3 June and 4 August 2020) showing concerns were raised about Mrs M’s blood sugar levels being high and the overall management of her diabetes. Mrs M’s GP provided recommendations to the care home staff to appropriately manage Mrs M’s diabetes.
33. We have reviewed the medication administration chart. Mrs M was on several medications and, during the review period, was given her medication as prescribed. When necessary, she was given paracetamol. The daily care home records note Mrs M was compliant with all aspects of her care.
34. The evidence does not support a ‘priority’ score level in this area. Mrs M’s diabetes was appropriately managed by the care home staff, registered nurse and GP. We do not see evidence of a diabetic specialist being involved in Mrs M’s care. We note Ms L says this care area should have been assessed as ‘priority’ as her mother’s condition was worsening. From the evidence, Mrs M’s diabetes was being appropriately managed. The IRP recognise Mrs M’s dementia would get worse. We can look at the care given during the review period only. Funding is not be given before a condition has worsened. Once Mrs M’s condition had worsened, another review would have been carried out.
35. We accept Ms L’s account of her mother’s needs in this area. Our view is the IRP considered her verbal submission and recognises her account alongside the medical evidence. The IRP explains the reasons for its views on the levels of need in this area. We can see no signs of failings in how the IRP considered this.
Did the IRP apply the eligibility tests properly and reach a conclusion about them based on the evidence?
36. Paragraph 150 of the National Framework says:
‘Where an MDT [multidisciplinary team] recommends an individual is not eligible for NHS Continuing Healthcare, a clear rationale that considers the four key characteristics must still be provided. This must be based on the primary health need test, as set out in paragraph 58.’
37. The National Framework sets out questions for the IRP to consider to help assess a person’s level of need. They are outlined in ‘Practice Guidance 3, When identifying a primary health need, how should the four key characteristics be approached?’ (PG3). 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 M’s needs.
38. Although Ms L is not complaining to us about the four key characteristics, we consider them below. We can see she gave her views on each key characteristic directly to the IRP and they are recorded in the IRP’s report.
Nature
39. The National Framework says nature ‘describe[s] 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’.
40. Ms L states her mother’s needs were such that she needed help in almost all areas, especially drug management.
41. The IRP’s report shows a detailed discussion about the nature of Mrs M’s needs. Her care needs were routine in nature, such as requiring assistance with hygiene and continence, and she was hoisted by two carers for all transfers in and out bed. Mrs M had type 2 diabetes and carers and her GP monitored her nutrition, diet and fluid intake. Her level of needs did not require constant skilled attention and there was no district nurses or outside agencies were involved in her care during the review period.
42. The IRP considered all evidence presented for this case when making their comments about the nature of Mrs M‘s care needs. Her care was delivered by carers following a care plan that was assessed, planned and monitored by registered nurses and carers in the care home, and her GP was consulted when required.
43. The IRP recognise Mrs M had a level of need in most of the DST assessment’s areas of care. It weighed up all the evidence before concluding the levels of care and monitoring required in these areas were not severe enough to determine a primary health need.
44. Having considered the evidence, our view is the IRP acted in line with the National Framework when it considered the nature of Mrs M’s needs.
Intensity
45. The National Framework says intensity ‘relates to 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”)’.
46. Ms L states her mother’s needs were severe. As Mrs M was unable to manage her needs, she required increasing levels of ongoing care.
47. The IRP considered all evidence presented for this case when making its comments about the intensity of Mrs M’s care needs. While there was some connection between the areas, influenced by Mrs M’s underlying conditions, her care was delivered by carers following a care plan that was assessed, planned and monitored by a registered nurse. There is no evidence showing her care was difficult and complex to manage, nor did she require regular, intensive input from a specialist team.
48. We can see the IRP has weighed up all the evidence before they decided the assessment of this key characteristic did not show Mrs M had a primary health need. It sets out why it thinks the level of skill needed to manage the connections between Mrs M’s needs was not intense, or that any of the connections presented significant barriers to the carers looking after her.
49. Having considered the evidence, our view is the IRP acted in line with the National Framework when it considered the intensity of Mrs M’s needs.
Complexity
50. The IRP has carefully considered the complexity of Mrs M’s level of need. The National Framework says:
‘[Complexity] 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. This may arise with a single condition, or it could include the presence of multiple conditions or the interactions between two or more conditions. It may also include situations where an individual’s response to their own condition has an impact on their overall needs, such as when a physical health need results in the individual developing a mental health need.’
51. Ms L states her mother’s needs were extremely complex. The management of her diabetes was different day to day, and she required a registered nurse to be present at all times. Ms L also states that her mother’s unstable blood sugar levels caused her weight loss, which in turn had an effect on her nutrition, skin integrity and mental health.
52. The IRP considered all evidence presented for this case when making its comments about the complexity of Mrs M’s care needs. While there was some connection between the areas, influenced by Mrs M’s underlying conditions, her care was delivered by carers following a care plan that was assessed, planned and monitored by a registered nurse and GP. There is no evidence to support that her care was difficult and complex to manage, nor did she require regular, intensive input from a specialist team.
53. We can see the IRP has weighed up all the evidence before they decided this key characteristic did not show Mrs M had a primary health need. It sets out why it thinks the level of skill needed to manage the connections between her needs was not complex, or that any of the connections presented significant barriers to the carers looking after her.
54. Having considered the evidence, the IRP acted in line with the National Framework when it considered the complexity of Mrs M’s needs.
Unpredictability
55. The final key characteristic used to determine a person’s level of need is unpredictability. The National Framework defines unpredictability as ‘the degree to which needs fluctuate and thereby create challenges in managing them. It also relates to the level of risk to the individual’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’.
56. Ms L states her mother’s blood sugar levels would go up and down rapidly and she was constantly at risk of becoming hypoglycaemic (when the blood sugar level becomes too low). Her insulin dosage had to be changed day to day by a trained nurse.
57. The IRP has provided a detailed review of the unpredictability of Mrs M’s needs in its report and we can see it had PG3 in mind to inform its discussions. The report accepts Mrs M had varying levels of needs. Her condition did not change excessively daily. Her care plans did not require amendment and her care did not need to change suddenly. Mrs M’s care followed a natural format that was appropriate for her underlying conditions. There is no evidence to show her care was unpredictable to manage.
58. Having considered the evidence, our view is the IRP acted in line with the guidance set out in the National Framework when it considered the unpredictability of Mrs M’s needs.
59. We are satisfied there are no failings in how the IRP considered the four characteristics of Mrs M’s needs.
60. This does not take away from the account Ms L has given us. We appreciate Mrs M was entirely reliant on the care she received and we are pleased to hear she had a well-trained, dedicated team caring for her.