13. Mrs K has brought other concerns to us about the IRP decision. We considered these and gave our views on them earlier this year. We are not looking at those again here.
14. Mrs K asked us to look again at two domains where she disagreed with the weighting the IRP decided upon in its report. These were the breathing and mobility domains.
15. Before we set out our decision, we would like to explain how an IRP reaches its decision and what this means for how we look at it.
16. An IRP is a panel set up by NHS England that completes a review of:
a) the primary health need decision made by an integrated care board (ICB); or b) the procedure followed by an ICB in reaching a decision as to that person’s eligibility for CHC.
17. The IRP then makes a recommendation to NHS England in light of its findings.
18. Whether or not an individual is eligible for NHS continuing healthcare funding is a discretionary decision. It is our role to decide if the IRP made its decision in line with the National Framework. We are looking here at disputed weightings in the care domains.
Breathing
19. Mrs K disputes the IRP’s weighting of this domain. She says it should be high, but the IRP weighted it as moderate.
20. Mrs K says her mother got tired and upset easily, which caused her distress. She says this made her very breathless and that she sometimes panted because of this. Mrs K also says her mother would get breathless when she completed activities such as washing items or going to the bathroom.
21. The IRP said there was clear evidence of Mrs E being breathless and this limiting some aspects of her daily living activities. It said she could get panicky and breathless, especially after exertion. It recognised that Mrs E would try to do things independently (such as washing her clothes) which made her breathless. But it said it had not seen evidence Mrs E’s breathing difficulties were due to a condition which was not responding to treatment and which limited all her daily activities.
22. The DST gives the following descriptor for a high weighting in this domain:
‘Is able to breathe independently through a tracheotomy that they can manage themselves, or with the support of carers or care workers.
OR Breathlessness due to a condition which is not responding to treatment and limits all daily living activities.’
23. Its descriptor for a moderate weighting in this domain says:
‘Shortness of breath or a condition which may require the use of inhalers or a nebuliser and limit some daily living activities.
OR Episodes of breathlessness that do not consistently respond to management and limit some daily living activities.
OR Requires any of the following: low level oxygen therapy (24%).
room air ventilators via a facial or nasal mask.
other therapeutic appliances to maintain airflow where individual can still spontaneously breathe e.g. CPAP (Continuous Positive Airways Pressure) to manage obstructive apnoea during sleep.’
24. When we look at the records, we can see Mrs E’s care plans said care staff should check on her breathing. We can see they did that. This indicates Mrs E did have an issue with her breathing, although the records for those checks say things like ‘breathing safely and well’.
25. Both Mrs E’s GP and hospital records confirm her family had raised concerns with them about Mrs E panting when she was breathless. We can see the records say she sometimes coughed after eating. The GP records on her discharge to the care home do not mention Mrs E’s breathlessness and her discharge from the hospital’s emergency department in November 2021 says she had no shortness of breath.
26. We can see from the records Mrs E would often take herself to the toilet, or be taken there with help from her carers. She sometimes tried to wash her own clothes. The records do not indicate Mrs E had specific medication for her breathlessness or needed to visit her GP or a hospital about this during the period the IRP reviewed.
27. The records show Mrs E had issues with her breathing which needed monitoring by her carers. These were clearly a concern for her and her family. In order for the IRP to decide on a weighting of high for this domain, we would need to see evidence Mrs E needed to breathe through a tracheotomy or with the support of her carers. We have not seen indications this was the case.
28. We can see Mrs E often became breathless due to conditions (her anxiety) which were not improving. The records also show she undertook many daily living activities, such as taking herself to the toilet and back to bed. The IRP would only have been able to award a weighting of high for this if her breathing difficulties had limited all of her daily activities.
29. We can understand how distressing it was for Mrs K to see her mother struggling with her breathing. When we weigh up the evidence, it appears the IRP acted in line with the National Framework and DST guidance when it considered Mrs E’s needs in this domain. Its weighting of moderate captures the needs Mrs E described and what the records show. There is no indication of what the IRP would have needed to see to give a higher weighting. We have not seen indications of a failing here.
Mobility
30. Mrs K says the IRP should have weighed her mother’s needs in this domain as high. She says the ICB had assessed it as high at both its DST and the local resolution meeting. The IRP weighed it as moderate.
31. Mrs K says her mother’s heart condition meant she could tire easily when mobilising, and that she had fluctuating blood pressure and postural hypotension (a drop in blood pressure when someone stands up which can make them feel dizzy). She had fallen three times in the previous year and had a high falls risk assessment. She said she had a reveal tracker (which alerts others if you fall) but often took this off, putting her at risk.
32. The IRP said Mrs E’s carers had to monitor when she mobilised and had moved Mrs E to a room which was more visible for carers. It said she mobilised with a stick and noted she had a degenerative spinal condition and walked on ‘bent’ legs. It also said carers had made sure Mrs E’s room was cleared of items which might have caused trip hazards because of her falls history and risk. It also said Mrs E’s risk assessment had been recorded in November and December as her being at a medium risk of falls. It said she had not fallen during the period under review.
33. The decision support tool document gives the following descriptor for a high weighting for this domain:
‘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.’
34. Its descriptor for a moderate rating is:
‘Not able to consistently weight bear.
OR Completely unable to weight bear but is able to assist or cooperate with transfers and/or repositioning.
OR In one position (bed or chair) for the majority of time but is able to cooperate and assist carers or care workers.
OR At moderate risk of falls (as evidenced in a falls history or risk assessment).’
35. It also says ‘Where mobility problems are indicated, an up-to-date Moving and Handling and Falls Risk Assessment should exist or have been undertaken and the impact and likelihood of any risk factors considered. It is important to note that the use of the word ‘high’ in any particular falls risk assessment tool does not necessarily equate to a high level need in this domain.’
36. When we look at the records, we can see both Mrs E’s GP and hospital records say she was at risk of falls. This was also recognised in her care plan. The care plan also says Mrs E had a reveal tracker and a call bell, but was not able to understand what to do with either. This meant staff had to monitor her carefully in case she had fallen. The records also show Mrs E was able to alter her position (for example, in bed) if she felt uncomfortable,
37. We can see she was able to mobilise independently, using her stick. For example, she often took herself to the toilet. The records also show she was able to sit and balance independently. She had a falls diary when at the home, but no examples of her falling were recorded in it. Her discharge to the home did not specifically mention mobility issues.
38. The records do not show Mrs E fell during the period the IRP reviewed. The records say the care home changed her falls risk to moderate and produced a new falls risk assessment in December 2021 which confirmed this. The records also say Mrs E was not showing evidence of postural drop in December 2021. They suggest this, and also her previous falls, may have been related to how hydrated she was, with her now drinking sufficient liquids.
39. We can see Mrs E had a falls risk and a history of falls. We can also see the IRP changed the weighting for this domain from that decided by the ICB, which was frustrating for Mrs K. In order for it to award a weighting of high, it would have needed to see evidence that Mrs E’s needs met the relevant descriptor.
40. The records show Mrs E could weight bear and was able to help with her positioning, being able to move herself if she was uncomfortable. The records do not indicate she was at risk when being moved and we have not evidence she needed specialist care for her mobility issues. The records do not show Mrs E fell during the period in question and we can see her carers reduced her falls risk assessment to a medium risk.
41. We understand how distressing Mrs E’s fall history was for Mrs K and how worrying it was that she may fall again in the future. When we weigh up the evidence, it appears the IRP acted in line with the National Framework and DST guidance when it considered Mrs E’s needs in the mobility domain. Its weighting of moderate captures the needs Mrs E described and what the records show. We have not seen evidence the IRP got something wrong when it made its decision here.
42. We understand why Mrs K thinks her mother had a primary health need. She was clearly not well. When we weigh up the evidence, the records do not indicate she had needs beyond those which could be provided by the local authority. It appears the IRP considered Mrs E’s needs in line with the National Framework. We have not seen an indication of a failing here.