19. CHC describes care provided over an extended period of time to meet physical or mental health needs arisen as a result of disability, accident or illness. If someone meets the criteria to receive funding, their care will be funded by the NHS.
20. It is our role to decide whether NHSE’s IRP acted in line with the National Framework when it considered whether Mrs U was eligible for CHC. The 2018 National Framework sets out the principles and processes ICBs and NHS England should follow when considering if someone is eligible for CHC.
21. 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.
22. The IRP reviews if the ICB should have found the person to have a primary health need and therefore be eligible for CHC. It also reviews the ICB’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 • recommend the CCG addresses any procedural faults the IRP identified.
23. When we look at a complaints 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. We also consider any procedural issues raised at the IRP.
Did the IRP get all the relevant evidence?
24. Paragraph 199 of the National Framework says the following:
‘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.’
25. We have reviewed the information provided to us in NHSE’s case file. The IRP has access to: • the family’s authority to act on Mrs U’s behalf and the family’s statement material • summary of Mrs U’s case, including a chronology • decision support tool (DST) dated 16 December 2021 • correspondence between Miss U, the ICB and NHSE • local resolution minutes and letters • relevant sections of Mrs U’s GP records • relevant sections of Mrs U’s care home records • local authority records • NHS funded nursing care assessment.
26. The National Framework also sets out the IRP should have access to the views of key parties involved in the case, including the individual or their family.
27. We have carefully considered the IRP report. The report shows Miss U was invited to contribute to the panel. Her submissions are documented for each domain throughout the period. The IRP received Mrs U’s medical records, care home records and social services records from the ICB which demonstrated her needs during the review period.
Before it made its decision, did the IRP consider all the relevant evidence?
28. Paragraph 199 of the National Framework is also relevant to this part of the IRP’s considerations.
29. 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. We can see the IRP discussed Miss U’s written and verbal evidence. This is clearly detailed in section 5, 6 and 7 of the IRP report where it outlines her views on the nutrition, continence, skin, psychological and emotional needs, behaviour, drug therapies and medication and altered states of consciousness domains, and key characteristics.
30. The report shows the IRP considered the information in Mrs U’s medical, social services and care home records. The IRP outlined how it weighted each domain and key characteristic. It drew extracts from the evidence and explained the reasons for its decision making clearly. Where it made a different decision, it provided its rationale in line with the National Framework. We are satisfied the IRP acted in line with the National Framework here.
Did the IRP clearly explain how it had reached its decision?
31. We are focusing on Mrs U’s needs when she was assessed on 16 December 2021. We appreciate her needs may be different now, but our role here is to look at how the IRP considered her needs at the time of the assessment.
32. Miss U has told us she disagrees with how the IRP considered several of the domains the health service uses to determine a person’s care needs. We will consider Miss U’s concerns about the domains in turn.
Nutrition
33. Miss U feels her mother’s level of need in this domain was severe. The ICB considered the level of need in this domain as high. The IRP disagreed with both and considered the need in this domain was low.
34. The DST defines severe level of need in nutrition as: ‘unable to take food and drink by mouth. All nutritional requirements taken by artificial means requiring ongoing skilled professional intervention or monitoring over a 24 hour period to ensure nutrition/hydration or being unable to take food and drink by mouth, intervention inappropriate or impossible.’
35. Mrs U told us the care home had asked the family to visit the home to feed Mrs U, during a period when she was not eating. The family said that she could only have a soft diet. Miss U told us Mrs U’s care need was outside the care home’s capabilities, and that they could not adequately feed her.
36. The DST defines a high level of need in the nutrition as: ‘significant weight loss or gain due to identified eating disorder.’
37. The DST defines a low level of need in nutrition as: ‘needs supervision, prompting with meals, or may need feeding and/or a special diet.’
38. The IRP report noted that Mrs U had no significant weight loss. She had lost significant weight, but this was prior to the review period and her BMI hovered between 29, 30 and 31. The IRP noted there was contradictory evidence about feeding. It also noted she ate foods she liked, such as sandwiches and crisps. She did not require pureed food. The IRP noted the care home records showed Mrs U ate at ‘odd’ times, such as having cornflakes at 10.30pm and tea and sandwiches at midnight.
39. The IRP considered the care home records that said it did take a long time for Mrs U to eat, but she did not need feeding. The IRP said she needed supervision and prompting to eat.
40. The IRP noted she did push food away but would take food at different times. It acknowledged there was evidence to show she would eat good portions. The IRP further noted that evidence showed carers offered food at different times throughout the day.
41. The family stated that Mrs U could only eat a soft diet, but the IRP could find no evidence of this. If she had, this would still have aligned with the descriptor for low needs.
42. We reviewed the care home records, which included details of Mrs U’s nutritional intake. The records often record her eating well and independently. They also show on some occasions she refused to eat what the care home offered. On other occasions, care home staff encouraged and assisted her to eat, which sometimes she complied with and sometimes she did not.
43. We recognise there is a very big discrepancy between Miss U’s and the IRP’s view on the appropriate weighting here. Miss U’s account of the family going into the home at mealtimes for a period demonstrates she needed supervision and prompting, possibly help to actually eat. This aligns with the low descriptor. We do not know why the home asked the family to go in to help Mrs U, rather than its own carers doing this. But this does not have a bearing on the level of need.
44. There was no indication her mother experienced significant weight loss or was unable to take food and drink by mouth, which is what the IRP would have had to see to say she had a higher level of need.
45. We think the evidence supports the IRP’s weighting and rationale for this domain. The IRP report shows how the IRP weighed up the evidence in terms with what the descriptors say. We are satisfied NHSE acted in line with the National Framework and have seen no indications of failings here.
Continence
46. Miss U feels her mother’s level of need in this domain was high. The ICB and IRP considered the level of need in this domain as moderate.
47. The DST defines high needs as: ‘continence care is problematic and requires timely and skilled intervention, beyond routine care (for example frequent bladder wash outs/irrigation, manual evacuations, frequent recatheterisation).
48. Miss U told us that Mrs U’s care was problematic and her Waterlow score (a measure of whether she was at risk of pressure sores) was underscored.
49. The DST defines moderate needs as: ‘continence care is routine but requires monitoring to minimise risks, for example those associated with urinary catheters, double incontinence, chronic urinary tract infections and/or the management of constipation or other bowel problems.’
50. Mrs U was doubly incontinent and wore pads day and night. She was not able to indicate her need to use the toilet or recognise when she had been incontinent. Staff had to monitor and anticipate her needs.
51. One staff member was usually required to meet her personal hygiene needs. Two staff could be required dependent on Mrs U’s compliance. She was not always accepting of care and could be aggressive. Miss U told us that on occasion, care home staff would leave Mrs U to settle and return to attempt to meet her continence needs. This meant she was sometimes left in a soiled pad or clothing.
52. Mrs U had a history of urinary tract infections. Her non compliance with medications meant these could sometimes take longer to resolve. She also had a history of constipation and was prescribed docusate and senna (laxatives) regularly.
53. There is nothing in Mrs U’s medical records to show anything problematic in her continence care and she did not need skilled intervention such as washouts. There was nothing to show she needed a catheter. This is what the IRP would have needed to see to say she had high needs.
54. Miss U’s account demonstrates a need for routine continence care, that needed monitoring to minimise risks. This aligns with the descriptor for moderate needs.
55. We think the evidence supports the IRP’s weighting and rationale for this domain. The IRP report shows how the IRP weighed up the evidence in line with what the descriptors say. We are satisfied NHSE acted in line with the National Framework and have seen no indications of failings here.
Skin
56. Miss U feels her mother’s level of need in this domain was high. The ICB and IRP considered the level of need in this domain as moderate.
57. The DST defines high needs as where the person has pressure damage or an open wound (serious that is responding to treatment or less serious that is not), or a specialist dressing regime and is responding to treatment.
58. Miss U told us she felt Mrs U’s Waterlow score was underscored and that the DST was inaccurate. From what we have seen, we cannot see she gave any further evidence to the IRP.
59. The DST defines moderate needs as where the person is at risk of skin breakdown needing several times daily intervention to avoid that, less serious pressure damage or open wound that is responding to treatment, or an identified skin condition needing at least daily treatment or daily monitoring/reassessment.
60. Mrs U was reported to have skin that was at risk and dry. She was prescribed emollient cream, which care home staff applied daily. Her skin required monitoring. Her skin was intact. Her pressure areas were intact.
61. Mrs U was prescribed a barrier cream to support her skin integrity and supplement drinks were also provided. The care home nursed her on a level one foam mattress. She did not have a pressure relieving cushion in place. She was self moving and did not need to be repositioned by staff. This aligns with the descriptor for moderate needs.
62. We reviewed the care home records. We can see it identified Mrs U was at high risk of developing pressure damage. The care home records tissue viability plan shows that her Waterlow score was to be reviewed monthly, or sooner if there was a change in her condition. The care home had a clear plan in place to monitor Mrs U’s skin integrity. We have seen no evidence to show that Mrs U had pressure damage, an open wound or any specialist skin dressings or treatment. This is what the IRP would have needed to see to award a high weighting.
63. We think the evidence supports the IRP’s weighting and rationale for this domain. The IRP report shows how the IRP weighed up the evidence in terms of what the descriptors say. We are satisfied NHSE acted in line with the National Framework and have seen no indications of failings here.
Psychological and emotional needs
64. Miss U feels her mother’s level of need in this domain was high. The ICB and IRP considered the level of need in this domain as moderate.
65. The DST defines high as: ‘mood disturbance, hallucinations or anxiety symptoms, or periods of distress, that have a severe impact on the individual’s health and/or wellbeing.’ Alternatively, the person has withdrawn from any attempts to engage them because of their psychological or emotional state.
66. Miss U and the care home staff reported that Mrs U could be upset several times throughout the day. They reported that personal care, continence hygiene and being prompted to eat and drink could trigger her to become upset. It was also reported that Mrs U suffered with episodes of low mood for no obvious reason.
67. Miss U said that Mrs U had experienced visual hallucinations, but this was only evidenced once.
68. The DST defines moderate as: ‘mood disturbance, hallucinations or anxiety symptoms, or periods of distress, which do not respond to prompts, distraction and/or reassurance and have an increasing impact on the individual’s health and/or wellbeing.’ Alternatively, the person has withdrawn from most attempts to engage them because of their psychological or emotional state.
69. Mrs U had a history of depression and had been prescribed antidepressants for many years. The evidence we have seen says Mrs U’s antidepressant medication was increased just before the DST. Additionally, the evidence says Mrs U was prescribed additional diazepam (medication to help relax people). This was on a twice daily basis, to be taken when needed. It is unclear as to whether the extra dose was ever administered to Mrs U.
70. Mrs U’s care home records show that there was an altercation with another care home resident, which may have been about the same time as the extra diazepam was introduced. However, this is not clear. We acknowledge that this incident may have been difficult for her family to recognise.
71. Both the moderate and high descriptors capture that the person has mood disturbance, hallucinations, anxiety or periods of distress, and that they are not engaging well. The difference is how these are affecting the person and how much they have disengaged. The IRP could not see a severe impact on Mrs U.
72. Having reviewed Mrs U’s care home records, we can see that she did not readily respond to reassurance. Care home staff used a retreat and return approach with Mrs U, which is noted to be successful. There is nothing to suggest care home staff could not provide necessary care.
73. While we can see that Mrs U did not readily respond to prompts from care home staff, the evidence is in line with the moderate descriptor for this domain. We can see the IRP weighed up the impact of her mood disturbance. It could see that she did not always engage with care staff, but would do on further attempts.
74. We think the evidence supports the IRP’s weighting and rationale for this domain. The IRP report shows how the IRP weighed up the evidence in terms of what the descriptors say. We are satisfied NHSE acted in line with the National Framework and have seen no indications of failings here.
Behaviour
75. Miss U feels her mother’s level of need in this domain was priority. The ICB and IRP considered the level of need in this domain as high.
76. The DST defines priority needs as: ‘challenging behaviour of a severity and/or frequency and/or unpredictability that presents an immediate and serious risk to self, others or property. The risks are so serious that they require access to an immediate and skilled response at all times for safe care.
77. The DST defines high as: ‘challenging behaviour of type and/or frequency 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 risk. Compliance is variable but usually responsive to planned interventions.
78. We recognise there is a very big discrepancy between Miss U’s and the IRP’s view on the appropriate weighting here. Miss U did not provide any specific evidence to support her view that Mrs U had a priority need.
79. We have already said the care home used a retreat and return approach to providing Mrs U’s care, when this was needed. There is no evidence to show that she displayed any challenging behaviour not outside of what could be expected within this care placement.
80. The IRP found no evidence that Mrs U was seen by the mental health team, during her stay in the care home, before the DST.
81. We acknowledge Mrs U did have a history of a mental health section admission, as highlighted by Miss U.
82. We can see the care home was able to anticipate her daily behaviour, and this followed a pattern. This is in line with the descriptor for high needs. We have reviewed Mrs U’s care home records. They show she displayed several behaviours that were challenging. They also show that there were several triggers before the challenging episodes which usually centred around personal care, nutrition and hydration, continence care, medication administration, invasion of personal space and asking Mrs U to do something that she did not want to do, or lacked capacity to understand why she needed to do something. This is also in line with the descriptor for high.
83. It is noted that she was often reluctant to accept personal care and interventions. She could be physically aggressive and verbally angry towards staff during care interventions. She could push and hit staff and be very abrupt with her language.
84. The care home records show that Mrs U usually required assistance from one member of staff. During times when she was displaying challenging behaviours, she required two staff to meet her needs safely.
85. We think the evidence supports the IRP’s weighting and rationale for this domain. The IRP report shows how it weighed up the evidence in terms of what the descriptors say. We are satisfied NHSE acted in line with the National Framework and have seen no indications of failings here.
Drug therapies and medication
86. Miss U feels her mother’s level of need in this domain was severe. The ICB and IRP considered the level of need in this domain as high.
87. The relevant part of the severe descriptor is: ‘non compliance with medication, placing them at severe risk of relapse.’
88. Miss U said the family frequently found Mrs U’s medications on the floor, when they visited. They felt this suggested Mrs U spat the medication out after staff had administered it. We acknowledge that is must have been very concerning for Mrs U’s family to see. We understand why Miss U feels this aligns with the severe descriptor, as there was evidence of Mrs U’s non compliance with her medication.
89. The DST defines high 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 medical 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.
90. Mrs U’s medication regime was routine and non-complex. She needed all her medications to be administered by a trained member of staff at the care home. The medication was administered because of her cognitive impairment. It is noted in Mrs U’s care home records that her compliance with her medication could be variable, and her records indicated there were three refusals. The care home notes show staff were to stay with Mrs U while she took her medication, to ensure she did not hide the tablets. They needed to make sure she took a drink and swallowed her medication.
91. The evidence indicates that while there were odd occasions when Mrs U would refuse her medication, this did not reflect her day to day needs. The IRP would have needed to see non compliance was the usual situation. From what we have seen, Mrs U’s drug therapies and medication need was in line with the descriptor for high need.
92. We think the evidence supports the IRP’s weighting and rationale for this domain. The IRP report shows how the IRP weighed up the evidence in terms of what the descriptors say. We are satisfied NHSE acted in line with the National Framework and have seen no indications of failings here.
Altered states of consciousness (ASC)
93. Miss U feels her mother’s level of need in this domain was high. The ICB and IRP considered the level of need in this domain as low.
94. The DST defines high as: ‘frequent episodes of ASC that require the supervision of a carer or care worker to minimise the risk of harm’.
95. The DST defines low as: ‘History of ASC but it is effectively managed and there is a low risk of harm.’
96. Miss U did not provide any evidence in support of this domain.
97. Mrs U had a history of ASC and a previous stroke. She also has a diagnosis of cerebral amyloid angiopathy, which increases the risk of a stroke.
98. The IRP noted that while Mrs U required supervision and support there was no evidence of any other faints, blackouts or seizures.
99. Having reviewed Mrs U’s care home records, we have not found any evidence to show she had any further issues. Her needs align with what the low descriptor says for this domain.
100. We think the evidence supports the IRP’s weighting and rationale for this domain. The IRP report shows how the IRP weighed up the evidence in terms with the descriptors say. We are satisfied NHSE acted in line with the National Framework and have seen no indications of failings here.
Did the IRP apply the eligibility tests properly and reach an evidence-based conclusion about them?
101. The IRP also applies an eligibility test to help it decide on a person’s CHC eligibility. 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 of a person’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.
102. The National Framework sets out questions for the IRP to consider helping establish 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 U’s needs.
103. Miss U disputes how the IRP considered the four key characteristics. We will address how the IRP considered the four key characteristics in turn below.
Nature
104. Section 3.3 of the practice guidance within the National Framework describes nature as ‘the characteristics of both the individual’s needs and the interventions required to meet those needs.’
105. 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.’
106. The National Framework includes the prompt questions, and we have looked at whether the IRP report indicates the IRP had these in mind.
107. Miss U disagrees with the IRP’s consideration of the nature indicator. She has not given any specific reasons why, other than overall her mother’s needs are high.
108. The IRP report shows it considered the nature of Mrs U’s needs, looking at the characteristics of her needs and the impact this had on her. The IRP focused on Mrs U’s individual needs rather than her diagnosed medical conditions.
109. The IRP recognised Mrs U had dementia which had progressed to a level which caused severe agitation and aggression, where she was previously admitted to hospital on a section 2. This is when a patient is admitted to hospital under the Mental Health Act 1983, for an assessment, lasting no more than 28 days. It further acknowledged Mrs U was severely cognitively impaired. She had no insight or understanding of her needs, and she was unable to identify any potential risks. She was fully dependent on staff to maintain her safety and wellbeing.
110. The IRP thought about the types of interventions Mrs D required, and the knowledge, skill and training staff needed to meet her needs. The IRP could see the care was the type that local authority carers could manage. It was interventions like changing her continence products, managing her pressure areas with cream to stop them breaking down, interpreting her communication from non-verbal cues, giving her medication, providing personal care and feeding her, and generally keeping her safe. There were some challenges relating to her behaviour, but carers could manage these within her care plans. She was also independently mobile.
111. There is no indication staff needed a high level of expertise to manage Mrs U’s needs. This could be done by care home staff with support from nurses and her GP. There is no evidence to show that the care home could not provide her with the care she needs.
112. We recognise Mrs U did need access to constant support and supervision to help keep her safe. We do not dispute she needed help and recognise the importance of what Miss U has told us. Our decision is not intended to take away from the help she needed. We can see the care home staff were able to manage Mrs U’s needs without requiring any special training or skills. They had simple measures to address Mrs U’s cognitive impairment, mobility, incontinence, and skin integrity.
113. We think the IRP considered the nature of Mrs U’s needs in line with the National Framework when it decided it did not indicate she had a primary health need. We have seen no indication of failings here.
Complexity
114. Section 3.5 of the practice guidance within 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.’
115. In line with the National Framework, in the IRP’s consideration of 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.’
116. The National Framework includes the prompt questions, and we have looked at whether the IRP report indicates the IRP had these in mind.
117. Miss U says her mother’s severe cognitive impairment meant she could not understand or appreciate the staff’s requests when managing her personal care needs. She said that her mother became aggressive when staff needed to provide this care, and it took several attempts and staff to get her to comply.
118. The IRP report notes there were interactions between some of the care domains in relation to Mrs U’s needs. It said Mrs U’s needs were interrelated due to her cognitive impairment and known behaviours.
119. The IRP considered how difficult it was to manage Mrs U’s needs, if they were problematic and if they impacted on each other. It said the interrelation of needs did add an additional depth to the needs and interventions she needed, but that her needs could still be met.
120. It concluded there was a requirement for additional knowledge and skill, but that this could be met with support from existing NHS services, that is the community mental health team. The IRP considered the various interactions between the domains and if this created any problems. The IRP found Mrs U’s needs were not complex.
121. The IRP looked at the areas where Mrs U did need assistance. It did not find this created any problems in managing any of her needs.
122. There is no indication Mrs U’s care was problematic to manage. The records show her needs could be planned for and anticipated. Staff did not need to respond outside of what was set out in Mrs U’s care plans or make regular or emergency changes to meet her needs. She did not have any complex care plans in place.
123. As set out above, the records support that Mrs U’s condition was generally stable. We acknowledge she could have episodes of non compliance, but staff were able to calm her down and provide reassurance.
124. We recognise Mrs U needed access to care and support and recognise Miss U’s reasoning for feeling this was complex. The complexity characteristic is about whether staff needed knowledge or skills beyond what would be expected of a care professional. We do not doubt that Mrs U needed a lot of support, but she did not receive complicated or complex care interventions.
125. The IRP’s consideration of the complexity of Mrs U’s needs was consistent with the evidence. We think its decision is in line with the National Framework and we have seen no indications of failings.
Unpredictability
126. Section 3.6 of the practice guidance within the National Framework says unpredictability ‘is about the degree to which needs fluctuate and thereby create challenges in managing them. It should be noted that the identification of unpredictable needs does not, of itself, make the needs ‘predictable’ (that is ‘predictably unpredictable’) and they should therefore be considered as part of this key indicator.’
127. The National Framework includes the prompt questions, and we have looked at whether the IRP report indicates the IRP had these in mind.
128. Miss U said that her mother’s behaviour was completely unpredictable and dangerous to others. Issues arising from her personal care were often unpredictable and required immediate, controlled, and skilled response. She could also show dangerous behaviour at mealtimes and had previously thrown plates.
129. The IRP report considered Mrs U’s needs and highlighted they were largely known and expected. It said there were no sudden changes or rapid deterioration to Mrs U’s presentation during the review period. For her day-to-day needs, there were no changes or unpredictable requirements.
130. The records show Mrs U did not need regular changes or adjustments to her care. She did not appear to present significantly different on a daily basis.
131. The unpredictability key indicator is about the degree to which needs fluctuate creating difficulty in managing them on a daily basis. Unpredictability is not about nothing unexpected ever happening or predicting every health episode. It may not be possible for carers to know when health incidents would happen, but if they knew they would happen at some point and, importantly, they could manage them in line with existing care plans, this meant the needs were predictable. This is what the evidence shows was the case for Mrs U.
132. There is no indication Mrs U’s condition was unstable or there was a rapid or unexpected deterioration.
133. The IRP’s consideration of unpredictability and rationale was consistent with the evidence. We think its consideration is in line with the National Framework and we have seen no indications of failings.
Summary
134. We have considered if the IRP looked at the appropriate evidence when reaching its view that the CCG’s decision was sound. We appreciate the helpful evidence Miss U has given to us. We thank her for sharing this with us. We recognise how important her complaint is to her. We hope she is reassured by our view that NHSE acted in line with the National Framework when it reached its decision.