17. It is our role to decide whether NHS England’s IRP acted in line with the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care when it considered whether Mrs Y was eligible for CHC. The National Framework sets out the principles and processes the ICBs and NHS England should follow when it considered if someone is eligible for CHC.
18. 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 think the IRP did not follow the National Framework when it made its decision.
19. 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 made its eligibility decision to make sure it was acting in line with the National Framework. If the IRP does find the ICB made a mistake, it can:
• recommend the ICB reconsiders if the patient had a primary health need, and • recommend the ICB addresses any procedural faults the IRP identified.
20. When we look at a complaint about an IRP, we consider if it took into account all the relevant information when it made its eligibility decision. Mr Y has told us he did not feel his wife’s needs had changed from when the ICB agreed she was eligible for fast track CHC. He does not agree with the IRP’s overall conclusion she was not eligible for CHC, so we will look at how it considered the ‘primary health need test’.
The ’primary health need’ test
21. The IRP applies an eligibility test to help it make a decision about 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 or 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.
22. The National Framework sets out questions for the IRP to consider to help 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 considered the key characteristics of a person’s needs.
23. Mr Y has told us he disagrees with the overall outcome his wife did not have a primary health need. He has not been specific on what he disagrees with for each of the key characteristics but has told us her nursing needs were an indication of eligibility.
24. Mrs Y was discharged from hospital to the care home with a very short prognosis. The fast track documents said the hospital thought she had less than three months to live, and it would likely be a matter of weeks rather than months. Mrs Y’s needs stabilised, and fast track CHC was found to no longer be appropriate.
25. The IRP considered the nature of Mrs Y’s needs and the report presents a clear picture of them and how they were met. It sets out the types of care Mrs Y needed across each of the care domains to keep her safe and well. The report explains her needs could be managed by her carers with the oversight of a registered nurse.
26. When the IRP looked at the impact Mrs Y’s needs had on her, and the types of interventions her care staff needed to employ to keep her safe, it saw it was not particularly challenging for them beyond what they would routinely carry out. This should not downplay how reliant Mrs Y was on her care staff, and how dedicated they were at providing her care.
27. The intensity of Mrs Y’s needs relates to the amount of care she needed to keep her safe and well. The IRP report outlines its discussions on this key characteristic. It shows where her needs interacted across several domains, such as how her poor cognition impacted on her communication.
28. The IRP looked at how often Mrs Y needed intervention from her carers, how long the activities took and how many carers were needed each time. It recognised Mrs Y did not need an increased number of carers and they did not need to spend an extended amount of time providing each intervention. These are key indications her needs were not of the intensity of a primary health need.
29. The IRP had a concise discussion about the complexity of Mrs Y’s needs. It had already established Mrs Y’s carers did not need any particular specialist skill or training to keep her safe and well. This is something it considered when it looked at the nature of her needs.
30. The report briefly shows the IRP looked at whether the interaction between her needs resulted in complexity, and it saw Mrs Y’s needs could be safely managed through the routine interventions from a team of skilled care staff. This was alongside nursing oversight, funded via her FNC, with support from community services such as Mrs Y’s GP.
31. Unpredictability relates to how much Mrs Y’s needs fluctuated, making them more difficult to manage. The IRP saw the interventions did not vary around the time the ICB assessed her. The report acknowledges Mrs Y relied on her needs being anticipated. The needs were consistently in line with planned interventions.
32. We do not think the IRP made a mistake in how it considered the four key characteristics of Mrs Y’s needs. It has provided a detailed overview of Mrs Y’s needs and the report shows it had the guidance in PG3 in mind. This does not take away from how reliant she was on the care she received. Her carers employed interventions which they had been trained to provide and benefitted from the oversight of a registered nurse. We think the IRP considered how Mrs Y’s needs were managed in line with the National Framework.
The IRP’s panel members
33. Mr Y has asked us to look at how NHS England convened its IRP. He has told us the chair of the IRP was previously employed by the NHS, and therefore was not truly independent.
34. The National Framework provides NHS England with guidance for the establishment and operation of its IRPs. It says:
‘Selection of the right people as chairs – people who are capable of gaining the confidence of all parties – will be a crucial factor in the success of the IRP. Current NHS staff, board members of NHS organisations, LA (local authority) staff and LA elected members should not be considered but people who have formerly held such a position are eligible. NHS England is advised to involve lay people in the selection process.’
35. Mr Y has told us the chair was a former NHS employee. This is in line with the National Framework’s guidance on convening an IRP. We cannot see NHS England made a mistake here. We do understand Mr Y’s concerns here, and his reasons for asking us to look at this.