17. Before we decide whether we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any signs something went wrong when NHSE made its decision.
18. Whether or not an individual is eligible for CHC funding is a discretionary decision. It is our role to decide whether the NHSE IRP acted in line with the National Framework when it considered whether Mrs T was eligible for CHC. The National Framework sets out the principles and processes CCGs (now ICBs) and NHSE should follow when considering whether someone is eligible for CHC. Please note we refer to the CCG (rather than ICB) throughout this decision as it was a CCG at the time.
19. 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 clinicians’ opinions. We can only consider whether 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.
20. The IRP reviews whether the CCG should have found the person to have a primary health need and therefore be eligible for CHC. It also reviews the CCG’s procedures followed when coming to its eligibility decision to make sure it was acting in line with the National Framework. If the IRP finds the CCG made a mistake, it can:
• recommend the CCG reconsider whether the patient had a primary health need, and • recommend the CCG address any procedural faults the IRP identified.
21. When we look at a complaint about an IRP, we consider whether it considered all the relevant information when it made its eligibility decision. To help us make a decision, we consider four key areas.
Did the IRP get all the relevant evidence?
22. Paragraph 199 of the National Framework says that:
‘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.’
23. We have reviewed the information provided to us in the NHSE case file, and we can see the IRP had access to the following:
• a summary of Mrs T’s case, including a chronology of events • DSTs dated 10 November 2016 and 17 February 2017 • LRM minutes and letters • GP records • care home records and plans • a speech and language therapy (SaLT) referral • correspondence among between Mrs O, CCG and NHSE, including her request for an independent review • correspondence from the community psychiatric nurse (CPN) • a letter from the consultant physician, Dr U, dated 7 September 2015.
24. We also have a copy of the IRP’s report. The report includes the detailed notes of the IRP meeting held on 11 March 2021. The report documents the submissions Mrs O and her sister gave in person.
25. Mrs O says not enough evidence was collected. She says information was available at the hospital, but the family were told this could not be considered. She says the IRP did not obtain information from Dr U at the hospital. She says Dr U managed her mother’s condition for many years.
26. It is clear the IRP had access to all the information the CCG used to make its decision on 11 March 2021. It gave Mrs O an opportunity to provide verbal evidence during the meeting and had access to the family’s written submissions.
27. The IRP considered the available GP records, hospital records and care records, including the care plans. We can see the IRP file included Dr U’s letter dated 7 September 2015. The IRP said it was satisfied the CCG had obtained all the relevant evidence for the 2017 assessment. It was not satisfied the CCG had obtained the relevant clinical evidence for the 2016 assessment. We can see the IRP made enquiries with the CCG to check whether any further daily care records were available. The CCG explained there were no further records and it had included all the care records it had obtained. At the IRP, the CCG said it had difficulties obtaining evidence from the care home despite repeatedly asking for it.
28. We accept the daily care home records are limited. However, we can see the IRP took Mrs O and her sister’s views into account throughout its review of all the care domains. We are satisfied there is no sign of a failing in how the IRP established all the appropriate and relevant clinical facts. We think the IRP acted in line with the National Framework here.
Before it made its decision, did the IRP consider all the relevant evidence?
29. Mrs O says the IRP did not consider Dr U’s letter. She says Dr U managed Mrs T’s condition for many years.
30. 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 domains. The IRP noted on page 11 of its report the family were not happy Dr U’s letter seemed to have been disregarded. That letter is dated 7 September 2015. We would not have expected the IRP to draw its conclusions from the letter as it was dated outside the period being considered.
31. We can see the IRP also considered the information in Mrs T’s care home records, GP records and correspondence from the CPN. It referred to its consideration of the information available. It took the views of Mrs O and her sister into account throughout its review and in the care domains. This is detailed in section seven, section nine and in the notes in annexes one and two to the IRP report, which outlines Mrs O’s views on the domains and the four key indicators. We can also see the IRP had the National Framework in mind when it discussed its weighting of each domain and key characteristics.
Did the IRP clearly explain how it had reached its decisions?
32. Mrs O says she disagrees with how the IRP considered six of the domains the health service uses to determine a person’s care needs.
Mobility
33. Mrs O considered Mrs T’s needs in this domain were severe.
34. The DST sets out the descriptors for the weightings in each domain area. It says the descriptor for severe is:
• ‘Completely immobile and/or clinical condition such that, in either case, on movement or transfer there is a high risk of serious physical harm and where the positioning is critical.’
35. Mrs O says her mother was not mobile and was at high risk of falls. She says Mrs T had a history of falls and had broken her hip and thumb. She says her Mrs T needed help repositioning.
36. The CCG said Mrs T’s needs in this domain were high, and the IRP also weighted them as high.
37. The DST descriptor for high says:
• ‘Completely unable to weight bear and is unable to assist or cooperate with transfers and/or repositioning.
OR Due to risk of physical harm or loss of muscle tone or pain on movement needs careful positioning and is unable to cooperate.
OR At a high risk of falls (as evidenced in a falls history and risk assessment).
OR Involuntary spasms or contractures placing the individual or others at risk.’
38. We can see from the IRP report it discussed Mrs T’s mobility needs. The family gave its account of her needs. The IRP weighed up the concerns to see whether a higher weighting may be appropriate.
39. The IRP said Mrs T required the help of one to two carers for transfers and was able to weight bear to transfer only. It noted she was not mobile and her ability to help with moving was variable. Mrs T was at a high risk of falls, and the IRP said Mrs T had fallen three times over a five week period between 16 December 2016 and 22 January 2017. Mrs T experienced tremors due to her Parkinson’s disease and had a profiling bed, bed rails and a crash mat. She had a wheelchair for use when travelling distances but did not need a hoist. The IRP accepted Mrs T was not able to assess risk due to her declining cognitive impairment.
40. We think the IRP acted in line with the National Framework when it considered Mrs T’s mobility needs. Mrs O says her mother was not mobile and needed help repositioning. On 20 November 2016, the family sent an email to the CCG to say they had been informed by staff at the care home Mrs T had been found wandering the corridors at night looking for the toilet. The evidence shows Mrs T was at high risk of falls. On 4 November 2016, the care home records show Mrs T’s mobility had declined slightly so she may need a mobility aid.
41. On 12 February 2017, the health needs assessment record shows Mrs T was dependent on staff members, as she could not walk without help. She used a wheelchair and needed help with going to bed, the toilet and sitting in a chair. She needed monitoring and supervising by staff due to her kyphosis, which is a curvature of the spine. On 10 February 2017, the physiotherapy referral shows Mrs T was using a Zimmer frame. There is no evidence Mrs T was completely immobile or had a clinical condition with a high risk of serious physical harm and where positioning is critical, which is what the IRP would have needed to see to give a severe weighting in this domain.
42. We recognise Mrs O has a different opinion to that of the IRP. It appears the IRP considered this domain in line with the National Framework and the DST descriptors. We can see no sign of a failing.
Psychological and emotional needs
43. Mrs O considers Mrs T’s needs in this domain were high.
44. The DST descriptor for high says:
‘Mood disturbance, hallucinations or anxiety symptoms, or periods of distress, that have a severe impact on the individual's health and/or well-being.
OR Due to their psychological or emotional state the individual has withdrawn from any attempts to engage them in care planning, support and/or daily activities.’
45. Mrs O says Mrs T refused mental health support and was distressed a lot of the time. At the IRP, the family said Mrs T was delusional, had hallucinations, paranoid ideation and changes in mood, and she was low and sad.
46. The CCG said her needs in this domain were moderate, and the IRP also weighted them as moderate.
47. The DST descriptor for moderate says:
‘Mood disturbance, hallucinations or anxiety symptoms, or periods of distress, which do not readily respond to prompts and reassurance and have an increasing impact on the individual's health and/or well-being.
OR Due to their psychological or emotional state the individual has withdrawn from most attempts to engage them in care planning, support and/or daily activities.’
48. We can see from the IRP report it discussed Mrs T’s psychological and emotional needs. It took into account the family’s comments on the impact of her needs. It weighed up the family’s concerns to see whether these suggested that a higher weighting might be appropriate.
49. The IRP said Mrs T experienced hallucinations and became depressed at night. It accepted her sleep pattern and responses to reassurance were variable. Mrs T was prescribed medication to help with restless nights, but she was not prescribed antidepressants or anti anxiety medications. She was monitored for hallucinations and delusions but not treated for them. The IRP said care home staff helped to provide reassurance and distractions. The IRP noted a CPN was involved and would have been able to pick up on any mental distress.
50. We think the IRP acted in line with the National Framework when it considered Mrs T’s needs in this domain. The care home’s informal mental health and capacity assessment shows there were occasions between 1 October 2016 and 6 February 2017 when Mrs T appeared to have insight of her needs and was able to communicate them. She was agitated and confused at times. A letter from the CPN dated 8 November 2016 says Mrs T’s dementia was progressing and her care needs were best met in a care setting. The CPN also said Mrs T’s severe hallucinations needed to be managed rather than treated with prescribed medication.
51. The care plans for between 1 October 2016 and 23 January 2017 say Mrs T was confused and disorientated, and staff would provide reassurance and support. We can see entries in the records which show Mrs T sometimes responded to support and reassurance from staff members. The IRP said Mrs T’s deteriorating physical health made her withdraw slightly, and this was added to by her decreasing cognition due to her dementia and Parkinson’s disease. This does not suggest a severe impact on her health and/or well-being, as the IRP would have needed to give a higher weighting. The IRP looked at the available evidence and said why it could not say Mrs T’s needs in this domain were high.
52. We understand it can be upsetting when a family member experiences distressing symptoms. It appears the IRP considered this domain in line with the National Framework and the DST descriptors. We can see no sign of a failing.
Cognition
53. Mrs O considers Mrs T’s needs in this domain were severe.
54. The DST descriptor for severe says:
‘Cognitive impairment that may, for example, include, marked short-term memory issues, problems with long-term memory or severe disorientation to time, place or person. The individual is unable to assess basic risks even with supervision, prompting or assistance, and is dependent on others to anticipate their basic needs and to protect them from harm, neglect or health deterioration.’
55. Mrs O says Mrs T lacked capacity and had a deprivation of liberty safeguards procedure in place. She says Mrs T had no awareness of risk and orientation during the day or at night.
56. The CCG said Mrs T’s needs in this domain were high, and the IRP also weighted them as high.
57. The DST descriptor for high says:
‘Cognitive impairment that could include frequent short-term memory issues and maybe disorientation to time and place. The individual has awareness of only a limited range of needs and basic risks. Although they may be able to make some choices appropriate to need on a limited range of issues, they are unable to consistently do so on most issues, even with supervision, prompting or assistance. The individual finds it difficult even with supervision, prompting or assistance to make decisions about key aspects of their lives, which consequently puts them at high risk of harm, neglect or health deterioration.’
58. We can again see from the IRP report it discussed Mrs T’s cognition. We can see it asked the family to talk about the impact of Mrs T’s needs. It weighed up the family’s concerns to see whether these suggested a higher weighting might be appropriate.
59. The IRP said Mrs T had vascular dementia and Parkinson’s disease. She was prescribed a rivastigmine patch (used to treat dementia), which was changed daily. The IRP said Mrs T’s short- and long-term memory fluctuated. She could recognise her family, but this sometimes took time. She did not recognise staff members. She had periods of lucidity, but there was disorientation in terms of time and place. Mrs T was able to converse with the DST assessor.
60. We think the IRP acted in line with the National Framework here when it considered Mrs T’s needs in this domain. To give a severe rating in this domain, the IRP would have had to see Mrs T was unable to assess basic risks even with supervision, prompting or help. We can see from its discussions the IRP felt Mrs T was able to make basic meal choices but did not always know what she was given. She needed prompting to make sure her needs were met. She also needed general monitoring and visual checks to make sure she was safe.
61. It appears the IRP considered this domain in line with the National Framework and DST descriptors. We can see no signs of a failing.
Behaviour
62. Mrs O considered Mrs T’s needs in this domain were high.
63. The DST descriptor for high says:
‘Challenging behaviour that poses a predictable risk to self, others or property. The risk assessment indicates that planned interventions are effective in minimising but not always eliminating risks. Compliance is variable but usually responsive to planned interventions.’
64. Mrs O says managing Mrs T’s medication for Parkinson’s condition could be problematic and this affected her behaviour. She says her mother’s behaviour charts were not reviewed and there were no risk assessments in place or available.
65. The CCG said Mrs T’s needs in this domain were low. This was a change from its previous rating of moderate. The IRP weighted Mrs T’s needs in this domain as moderate.
66. The DST descriptor for moderate says:
‘Challenging behaviour that follows a predictable pattern. The risk assessment indicates a pattern of behaviour that can be managed by skilled carers or care workers who are able to maintain a level of behaviour that does not pose a risk to self, others or property. The person is nearly always compliant with care.’
67. We can again see from the IRP report it discussed Mrs T’s needs in this domain. It weighed up the family’s concerns to see whether these suggested a higher weighting might be appropriate.
68. The IRP noted Mrs T needed the help of one carer for personal needs and one or two carers for moving and with help going to the toilet during the day. It said she could be confused and would sometimes refuse personal care at night. The IRP said no medication had been prescribed to manage her behaviour. It said Mrs T was a risk to herself but not others. The IRP noted Mrs T was complaint with her medication, diet and fluid intake. She would sometimes walk unaided, but this led to falls.
69. We think the IRP followed the National Framework when it considered Mrs T’s needs in this domain. We can see from the behaviour charts that Mrs T could be unsettled and confused. Staff would help to provide reassurance and support. The IRP acknowledged Mrs T could be psychologically rather than behaviourally upset. There is no evidence Mrs T’s behaviour needed a skilled response beyond what the carers could provide. This is in line with the DST descriptor for moderate.
70. It appears the IRP considered this domain in line with the National Framework and DST descriptors. We can see no signs of a failing.
Drug therapies and medication: symptom control
71. Mrs O considers Mrs T’s needs in this domain were severe.
72. The DST descriptor for severe says:
‘Requires administration and monitoring of medication regime by a registered nurse, carer or care worker specifically trained for this 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. Even with such monitoring the condition is usually problematic to manage.
OR Severe recurrent or constant pain which is not responding to treatment.
OR Risk of non-concordance with medication, placing them at risk of relapse.’
73. Mrs O says administering medication to her mother was problematic and the care home asked for help with this. Mrs O says she disagrees with the IRP’s comment it did not see the Parkinson’s drug intake as time-specific. She says the medication had to be given on time. She says this showed a lack of understanding of the condition.
74. The CCG said Mrs T’s needs in this domain were high, and the IRP also weighted them as high. The IRP noted on 16 August 2017 the dispute panel found Mrs T to have a moderate level of need in this domain.
75. The DST descriptor for high says:
‘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 revision of care.’
76. The IRP sets out the discussions it had about Mrs T’s needs in this domain. It weighed up the family’s concerns to see whether these suggested a higher weighting might be appropriate. It also considered on 16 August 2017 the dispute panel had found Mrs T to have a moderate level of need in this domain.
77. The IRP noted Mrs T had a high level of pain and was receiving a wide range of medications. This required clinical judgement from her carers under the supervision of a registered general nurse (RGN). The IRP accepted there were some risks associated with Mrs T receiving timely medications for Parkinson’s due to her medication regime, but this did not appear to be an issue. The nurse (specialising in Parkinson’s disease) said Mrs T’s drug therapies were well maintained. The IRP said Mrs T was compliant with her medication intake.
78. We understand Mrs O’s view it was at times difficult to administer medication. We think the IRP acted in line with the National Framework when it considered Mrs T’s drug therapies and medication needs. Mrs T was prescribed many medications. These had to be administered and monitored, and a GP oversaw Mrs T’s medication. The IRP noted no changes were made during the enquiry period. Mrs T was compliant with her medication intake. There were no covert medications or difficulties in Mrs T swallowing her medication. Her medications were PRN (which means they are not required on a regular basis), but it would have been expected the nursing staff could manage this. This is in line with the DST descriptor for moderate.
79. It appears the IRP considered this domain in line with the National Framework and DST descriptors. We can see no signs of a failing.
ASC
80. Mrs O considered Mrs T’s needs in this domain were high.
81. The DST descriptor for high says:
‘Frequent episodes of ASC that require the supervision of a carer or care worker to minimise the risk of harm.
OR Occasional ASCs that require skilled intervention to reduce the risk of harm.’
82. Mrs O disagrees with the IRP’s decision because the care home plans and risk assessments were not updated.
83. The CCG said Mrs T’s needs in this domain were moderate, and the IRP also weighted them as moderate.
84. The DST descriptor for moderate says:
‘Occasional (monthly or less frequently) episodes of ASC that require the supervision of a carer or care worker to minimise the risk of harm.’
85. We can see the IRP discussed Mrs T’s needs in this domain. It weighed up the family’s concerns to see whether these suggested a higher weighting might be appropriate.
86. The IRP noted Mrs T had several transient ischaemic attacks (TIAs) (mini strokes) but did not require intervention from any other health care professionals. It accepted care home staff needed to monitor Mrs T for any signs of TIAs to make sure she was kept safe. It noted the TIAs were reported to the GP, who GP refused to attend. The family said at the IRP this could be because there was a DNAR (do not attempt resuscitation) order in place. The IRP could find no evidence of this in the file. To give a higher rating, the IRP would need to see there had been skilled intervention to reduce the risk of harm. It explained it could not see Mrs T required intervention from any other healthcare professionals.
87. It appears the IRP considered this domain in line with the National Framework and DST descriptors. We can see no signs of a failing.
Did the IRP apply the eligibility tests properly and reach an evidence-based conclusion about them?
88. The IRP applies an eligibility test to help it decide 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 whether the quantity or type of an individual’s care needs are more than what the local authority can provide. This shows they have a primary health need, which in turn shows they are eligible for CHC.
89. The National Framework sets out questions for the IRP to consider when establishing 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 to look at whether the IRP properly considered the four key characteristics of Mrs T’s needs.
90. The four key indicators are fundamental to the decision making, so we have looked at how the IRP considered these. Mrs O disagrees with the IRP’s rationale in considering the four key characteristics. She disagrees with the IRP’s comments about the intensity indicator being evidence-based because it did not look at the care plans. We can see the family gave its views on each key characteristic at the IRP, and their views are recorded in the annex to the IRP report.
Nature
91. Section 3.3 of the practice guidance in the National Framework describes nature as ‘the characteristics of both the individual’s needs and the interventions required to meet those needs’.
92. In line with paragraph 59 of the National Framework, in the IRP’s consideration of nature we would expect to see analysis of: ‘The particular characteristics of an individual’s needs (which can include physical, mental health or psychological needs) and the type of those needs. This also describes the overall effect of those needs on the individual, including the type (quality) of interventions required to manage them’.
93. Section 3.3 also lists question prompts for factors that should be considered (though not specifically and individually answered) for the nature indicator:
• How does the individual or the practitioner describe the needs (rather than the medical condition leading to them)? What adjectives do they use?
• What is the impact of the need on overall health and well-being?
• What types of interventions are required to meet the need?
• Is there particular knowledge/skill/training required to anticipate and address the need? Could anyone do it without specific training?
• Is the individual’s condition deteriorating/improving?
• What would happen if these needs were not met in a timely way?
94. The IRP shows the panel considered Mrs T’s needs and how they impacted her. Its decision on the nature indicator is clear and presents a full picture of how Mrs T’s needs were met. The IRP focused on Mrs T’s individual needs rather than her diagnosed medical conditions. The IRP noted that, due to Mrs T’s heart condition, she was prescribed a salbutamol spray (used to relieve asthma and breathlessness) and had a glyceryl trinitrate spray to treat her angina (chest pain). The IRP said it found no evidence these sprays were used during the period it was looking at.
95. The IRP said Mrs T’s needs arose from her deteriorating mental health, significant cognitive impairment and poor physical health. These impacted her ability to undertake daily activities. It said Mrs T was dependent on others to make sure she had a safe environment, as she had a deteriorating ability to recognise and assess risks and hazards. She had difficulty retaining and processing information, so she could not manage her daily living activities.
96. The IRP noted a SaLT referral had been made, but this was after the enquiry period. The IRP said Mrs T was initially continent but had issues with frequency of urinating and diverticulitis (inflammation or infection of the pouches formed in the colon), which she had medication for.
97. The IRP also looked at the types of care Mrs T needed to keep herself safe and well. The IRP report sets this out in detail, including needs such as help at mealtimes to make sure she was upright, due to kyphosis of the spine, and ate enough to eat. Carers needed to cut up her food so she could eat and drink independently. The report also sets how Mrs T was initially continent and outlined the help she needed to maintain a regular toilet regime, otherwise she would have occasional accidents and wore a pad. She had two urinary tract infections (UTIs) during the period considered, and these were treated with antibiotics.
98. The IRP noted carers needed to monitor and give preventative interventions to maintain Mrs T’s skin integrity. She did have a history of sacral sores (ulcers on her lower back), but this was not during the period it was looking at. The IRP accepted Mrs T’s Parkinson’s disease and kyphosis meant she was at high risk of falls, and it noted she fell three times during the enquiry period. There is evidence of referrals to physiotherapy and the falls team. The IRP said Mrs T was nursed in a profiling bed with bedrails and a crash mat at the side of her bed. It said there was no evidence she had contractures of her limbs. It also said her carers needed to give ongoing physical support and reassurance to enhance Mrs T’s well-being, as she would become agitated and paranoid.
99. The IRP said carers needed to take a calm and sensitive approach to care interventions due to Mrs T’s significant cognitive impairment. The report shows carers would need to monitor for signs of challenging behaviour, but the evidence of such behaviour was minimal. Mrs T needed help with monitoring and administration of her medication. Mrs T had vascular dementia, and carers needed to observe for any changes in levels of consciousness. The IRP accepted there was evidence of two TIAs, but Mrs T appeared to recover without any ill effects. The evidence available was enough for the IRP to decide the nature of Mrs T’s needs did not show a primary health need.
100. We think the IRP considered all the relevant factors, including the family’s evidence, when it decided the nature of Mrs T’s needs did not suggest she had a primary health need. We are satisfied it acted in line with the National Framework.
Intensity
101. Section 3.4 of the practice guidance in the National Framework says intensity ‘is about the quantity, severity and continuity of needs’.
102. In line with the National Framework, we would expect the IRP’s consideration of the intensity indicator to ‘relate both 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”)’.
103. Section 3.4 also lists question prompts for the intensity indicator:
• How severe is this need?
• How often is each intervention required?
• For how long is each intervention required?
• How many carers / care workers are required at any one time to meet the needs?
• Does the care relate to the needs over several domains?
104. Mrs O disagrees with the IRP’s comments about the intensity indicator being evidence-based because it did not look at the care plans.
105. We can see the IRP looked at the right things. It had a detailed discussion about the intensity of Mrs T’s needs. It recognised Mrs T had some high levels of needs and pain due to her Parkinson’s, cognitive impairment and physical ailments. However, her needs were not severe and could be met by one carer. One carer was required to change her, monitor her skin and anticipate her needs. She required two carers for transfers. Mrs T was generally compliant, with some resistance to person care, but this did not require special interventions. The IRP said there was no evidence her care was problematic or time consuming. There was no evidence she required additional staff or they needed additional training to meet her needs.
106. We can see the IRP considered Mrs O’s concerns her mother’s needs were of a nature or at a level of intensity suggesting a primary health need. The IRP weighed these needs up before making its decision about the intensity indicator. It acknowledged Mrs T needed daily interventions and monitoring. The IRP considered the available evidence and decided Mrs T’s care needs did not require care or intensity of interventions over and above what a local authority could provide.
107. We think the IRP considered all the relevant factors when it decided the intensity of Mrs T’s needs did not suggest she had a primary health need. We are satisfied it acted in line with the National Framework.
Complexity
108. Section 3.5 of the practice guidance in the National Framework says complexity ‘is about the level of skill/knowledge required to address an individual need or the range of needs and the interface between two or more needs’.
109. In line with the National Framework, in the IRP’s consideration of the complexity indicator we would expect to see analysis of: ‘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 interaction 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 where a physical health need results in the individual developing a mental health need’.
110. Section 3.5 lists the question prompts for the complexity indicator: • How difficult is it to manage the need?
• How problematic is it to alleviate the needs and symptoms?
• Are the needs interrelated?
• Do they impact on each other to make the needs even more difficult to address?
• How much knowledge is required to address the needs?
• How does the individual’s response to their condition make it more difficult to provide adequate support?
111. Mrs O disagrees with the IRP’s consideration of the complexity indicator. Mrs O says the evidence clearly shows Mrs T’s clinical condition. She says her mother had multiple conditions which made it harder and labour intensive for staff to manage her conditions.
112. We have again looked at whether the IRP considered Mrs O’s concerns. Mrs O and her family gave verbal and written evidence for the IRP to consider. The IRP looked at the evidence provided. It said Mrs T had Parkinson’s, dementia and other health needs which were interrelated. The IRP recognised the interaction of Mrs T’s needs in the domains of cognition, skin, nutrition and mobility. It said Mrs T needed ongoing management of her continence by trained carers, but this did not show it was complex in the period under review.
113. The IRP noted Mrs T needed monitoring in several domains but said this was not at a high enough level of complexity to make the interaction difficult to manage. It agreed Mrs T had high levels of need due to her Parkinson’s and cognitive impairment, but these needs were not severe and could be met by one carer. She needed two carers for transfers. The IRP noted the care plans were not reviewed but said they would have been had her needs changed. The IRP said there was no evidence Mrs T’s care across the domains was complex, problematic, excessively time consuming or more frequent than what care staff would expect or manage.
114. The IRP considered and weighed up the evidence before making its decision. We consider the IRP considered all the relevant factors when it decided the complexity of Mrs T’s needs did not suggest she had a primary health need. We are satisfied it acted in line with the National Framework.
Unpredictability
115. Section 3.6 of the practice guidance in the National Framework says unpredictability ‘is about the degree to which needs fluctuate and thereby create challenges in managing them. It should be noted the identification of unpredictable needs does not, of itself, make the needs “predictable” (i.e. “predictably unpredictable”) and they should therefore be considered as part of this key indicator’.
116. Section 3.9 lists the question prompts for the unpredictability indicator:
• Is the individual or those who support them able to anticipate when the needs might arise?
• Does the level of need often change? Does the level of support often have to change at short notice?
• Is the condition unstable?
• What happens if the need is not addressed when it arises? How significant are the consequences?
• To what extent is professional knowledge/skill required to respond spontaneously and appropriately?
• What level of monitoring/review is required?
117. Mrs O disagrees with the IRP’s consideration of the unpredictability indicator. She says her mother had several unpredictable conditions. She says Mrs T had delusions and hallucinations, TIAs and chest infections, and she needed prompting to eat.
118. The IRP report shows it considered the unpredictability of Mrs T’s needs. The IRP recognised Mrs T had Parkinson’s disease and she was on the dementia pathway where her deterioration over time was predictable. It accepted she sometimes resisted personal care interventions, but this was predictable and mitigated by having two carers if needed. The IRP said Mrs T usually required only one carer. The IRP accepted Mrs T had ASCs and TIAs which could have created some instability. It noted Mrs T had unstable hypo/hypertension which carers needed to be aware of and monitor. However, the IRP said this did not require any further interventions or one-on-one care. The IRP noted Mrs T had UTIs and chest infections which were treated by a GP. This care was routine and was reviewed by the care staff. The IRP acknowledged there was no involvement from the CPN or any increased levels of GP intervention. Mrs T’s needs were addressed and supported by carers daily.
119. There was no evidence staff needed additional training to provide necessary care. For a person with unpredictable needs, we would expect to see frequent or sudden changes to their care. That was not the case for Mrs T. The IRP clearly described why her needs were not unpredictable.
120. We think the IRP considered all the relevant factors when it decided the predictability of Mrs T’s needs did not suggest she had a primary health need. We are satisfied it acted in line with the National Framework.
Well-managed needs principles
121. Mrs O says the IRP marginalised Mrs T’s needs.
122. Paragraph 188 of the National Framework says:
• ‘When undertaking CHC reviews, care must be taken not to misinterpret a situation where the individual’s care needs are being well managed as being a reduction in their actual day-to-day care needs. This may be particularly relevant where the individual has a progressive illness or condition, although it is recognised that with some progressive conditions care needs can reduce over time.’
123. We can see the IRP took Mrs O and her family’s evidence about Mrs T’s needs into account. There is no evidence it marginalised Mrs T’s needs. The IRP described how Mrs T’s behaviour, cognitive impairment, nutrition, ASC, skin integrity, drug therapy, medication, psychological and emotional needs were managed to make sure she was safe, as it must do to make a decision about the four key indicators. It detailed how Mrs T’s care could be met with care and monitoring. It did not downplay or suggest any need did not exist because of how it was managed. The IRP report shows the IRP’s application of the well-managed needs principle was supported by the evidence available and in line with the National Framework.
Other issues
124. Mrs O says the IRP report incorrectly referred to her mother by another name. We appreciate it would have been upsetting for Mrs O to see her mother had been incorrectly referred to by someone else’s name in the IRP report. We can see this was an administrative error. We cannot say this affected the IRP’s eligibility decision.
CCG concerns
125. Our role is to look at how NHSE considered Mrs O’s concerns and not the actions of the CCG directly. This is because we would expect the IRP to have accepted any errors made by the CCG the complainant raised with NHSE, considered the impact and made recommendations.
126. We can see Mrs O raised concerns at the IRP about the CCG’s process, details of which are found in annex 2 to the IRP report. We have looked at these concerns to see whether the IRP has addressed them. The IRP considered Mrs O’s concerns and recommended the CCG consider whether they wished to respond to the details provided in the family submission in annex 2. The CCG has confirmed it has considered this and provided its response to the panel in the blue section on page 34 of the IRP report.
127. Mrs O complains the CCG has not, in line with the IRP’s recommendations, considered whether it should carry out a retrospective review from February 2017 to the date of Mrs T’s death. We contacted the CCG to ask whether it had considered this and was able to provide an update. The CCG says it has considered this and does not consider a retrospective review for the period from February 2017 to the date of death would be appropriate. It says this is not an unassessed period of care as a review took place on 16 March 2018 which recommended funded nursing care. As a result, it says this period is not eligible for the retrospective review process.
128. We understand how important these issues are to Mrs O. We can see the IRP considered and addressed Mrs O’s concerns at the IRP. We are satisfied the process issues found by the IRP would not have made a difference to the eligibility decision. It would not have changed its overall decision Mrs T was not eligible for CHC. This is because the IRP fully considered the evidence presented about the domains of care and the nature, intensity, complexity and unpredictability of those needs. This is how it weighs up all the evidence to determine whether a person has a primary health need.
Summary
129. The IRP showed it applied the National Framework when it considered Mrs T’s CHC eligibility.
130. We recognise Mrs O’s account and that she disagrees with the IRP’s decision. We do not wish to take away from her account or what she has told us about her mother’s needs.
131. We have not found any reason to question the decision the IRP reached. There is nothing to suggest the IRP recommendations were not based on the evidence or were clinically unsound. It explained in detail how it weighed up all the evidence and came to its decision in line with the National Framework.
132. We thank Mrs O for bringing the complaint to us for consideration.