4. Mr R complains that Hertfordshire and Worcestershire Integrated Care Board (the ICB) refused to do a previously unassessed period of care (PUPoC) assessment of his mother, Mrs P’s eligibility for continuing healthcare (CHC) from August 2012 to November 2017.
5. Mr R tells us he has been financially disadvantaged because he paid for his mother’s care.
6. Mr R would like the ICB to reconsider its decision.
7. CHC is a package of health and social care that is fully funded by an integrated care board (ICB) for a person who has a primary health need. There is a two-stage assessment process to decide if they have a primary health need. The first stage is a screening checklist. If this is positive, the ICB arranges a full assessment. An individual or their representative can ask an ICB to consider if they were eligible for CHC during a past period, if that period has not already been assessed. This is called a previously unassessed period of care, or PUPoC.
8. After Mrs P died in July 2019, Mr R, via his representatives, Compass Continuing Healthcare, requested a PUPoC assessment for her, for the period August 2012 to 14 July 2019. The ICB only agreed to assess her from 18 November 2017, as it said there had been CHC assessments before this.
9. Compass submitted a formal complaint to the ICB on 19 August 2022. It said the family had not been invited to these previous assessments.
10. The ICB issued the final response to the complaint on 17 January 2023 and upheld its decision not to review the entire period.
11. ICBs were created in July 2022. Before that, clinical commissioning groups (CCGs) were responsible for CHC. And before April 2013, this was primary care trusts (PCTs). We refer to the responsible organisation throughout as ‘the ICB’ for ease of reference.
14. The 2012 PUPoC guidance, which was in place at the time Compass made the claim, says the ICB should make sure a request is related to a previously unassessed period of care. A previous assessment could be either by a checklist or a full CHC assessment. The guidance also says the ICB should check any previous assessments related to the claim period, had been completed appropriately, were clinically sound, and reflected the patient information known at the time.
15. The guidance also says the ICB should check if the individual had NHS funded nursing care (FNC). This is a contribution to the nursing element of a person’s care who lives in a care home with nursing provision. If there had been consideration of CHC before the FNC assessment or annual review, then the ICB would not need to do a further assessment.
16. We have considered evidence the ICB provided to decide whether it acted in line with the 2012 PUPoC guidance.
17. Mrs P was receiving FNC. We have seen a letter informing her that she would have a review of her FNC on 8 October 2012. This letter was sent to Mrs P at her care home. This letter says the ICB would consider whether she was eligible for CHC or FNC.
18. The ICB also sent the decision letter from this assessment, to Mrs P care of Mr R at his home address. It stated a checklist indicated she was not eligible for CHC but would continue to receive FNC. It also informed Mrs P that if she disagreed with the decision she could write to the ICB with her reasons. We have not seen evidence that either Mrs P or her son contacted the ICB to say they disagreed with the decision at this time.
19. We have also seen a letter the ICB sent to Mr R, at his home address, on 27 August 2013 telling him a review of his mother’s health needs would take place on 12 September.
20. We have also seen the decision letter the ICB sent to Mr R’s address on 28 October. This letter says Mrs P had a full assessment of needs on 30 September. The ICB found she was not eligible for CHC but would continue to receive FNC. This letter also detailed Mr R’s right to appeal this decision and how to do this. We have not seen evidence he appealed this decision at this time.
21. We have seen a letter the ICB wrote to Mr R, at his home address, to tell him his mother would have an assessment on 10 November 2014.
22. The decision letter, sent to Mr R’s home address, dated 5 December says a full assessment took place on 22 November 2014. Again, the ICB found Mrs P was not eligible was for CHC funding, but would continue to receive FNC. This letter also explained that Mr R could request a review of this decision and how to do this. We have not seen evidence he did this.
23. Based on the evidence we have seen, the ICB was right to say Mrs P had been considered for CHC between 2012 and 2014. We have not seen evidence that the ICB checked whether the assessments from 2012 to 2014 had been done appropriately when considering the PUPoC request. And Compass says Mr R had not been present at the previous assessments. But it is clear Mr R had received all the decisions and details of how to challenge them. The PUPoC process is a safety net for people who may have been missed for assessment previously. It is not a further chance to raise concerns about previous assessments if there was an opportunity to do that at the time, as was the case here. We would not have expected the ICB to do anything more for this part of the PUPoC claim period.
24. However, the ICB has provided no evidence of any CHC consideration in 2015 or 2016. Based on the information we have seen, Mrs P did not have a consideration of her possible eligibility for CHC during this part of the period.
25. The next time the ICB considered CHC eligibility for Mrs P was November 2017. The ICB agreed to do a PUPoC assessment from November 2017 until the date of Mrs P’s death, on the basis there were no further assessments before she died.
26. We have found a failing in the ICB’s actions. We have not seen sufficient evidence to support the ICB’s view that the period 2015 to 2016 was already assessed. We next thought about the impact of this.
27. We understand the November 2017 CHC assessment also found Mrs P not eligible for CHC. A person’s health will often deteriorate, and their needs will increase, gradually as time goes on. However, that is not always the case. A person can experience peaks of need. So they may be found eligible for CHC and then at a later date, they no longer are.
28. So the fact that Mrs P did not have needs that made her eligible for CHC in November 2017 is not proof in itself that she was not eligible for CHC between the previous CHC consideration in 2014 and this point.
29. Mr R believes his mother should have been eligible for CHC between 2012 and 2017. He says he paid for her care. He does not think he should have had to do this and he wants the ICB to reimburse him.
30. The only way to know if Mrs P was eligible for CHC funding would be for the ICB to do a full CHC assessment. We have no grounds to ask the ICB to look back at the period 2012 to 2014, as this period is already assessed, and Mr R had the right to challenge those decisions at the time. We do have grounds to ask the ICB to go back and consider the period between then and the next CHC consideration in November 2017. This does not mean the outcome will be different – we have not taken a view on this. But we have found Mr R has not yet had a fair consideration of his PUPoC claim for this part of the period.
1. We have found a failing in this complaint. The ICB declined to consider whether Mrs P was eligible for continuing healthcare (CHC) between August 2012 and November 2017 on the basis she had already been assessed during this period. The evidence indicates this was true for the period 2012 to 2014. But the ICB has not provided sufficient evidence to support its view that the period 2015 to 2016 has already been assessed. Mr R paid for his mother’s care. We cannot say whether Mrs P was eligible for CHC in 2015 and 2016, so we cannot say if he should be reimbursed. But we think the ICB needs to do more to ensure he has had a fair consideration of this.
2. We partly uphold this complaint.
3. We ask the ICB to reconsider Mr R’s PUPoC claim for the period there is no evidence his mother was already assessed. We also ask the ICB to write to him to acknowledge what it got wrong and that this means he has not yet had a fair consideration of part of his claim.
31. In considering our recommendations, we have referred to the ‘NHS Complaint Standards’. These say NHS organisations should be open and honest when things have gone wrong, recognise when this has had an impact on people, and identify suitable ways to put things right. It says organisations should give meaningful and sincere apologies.
32. We recommend the ICB should consider the period for which there is no evidence Mrs P was considered for CHC. We think it should do this in line with the 2023 PUPoC guidance. The intention of both versions of the guidance is the same – to capture people who should have been considered for CHC in the past but were not. The current guidance clarifies that intention and some ambiguities in the previous version. It is a more robust standard to show how the PUPoC process should work.
33. We recommend the ICB writes to Mr R within one month of the date of our final report, to explain what information it needs from him to do this, and a timeline for its consideration and when he will receive its decision.
34. In that letter, the ICB should also acknowledge what it got wrong and apologise that it has not yet given Mr R a fair consideration of part of his claim.
35. The ICB should send us evidence that it has complied with all our recommendations.