September 2022
16. Mrs A complains the ICB should have completed a full DST assessment in September 2022 following a material change to her mother’s needs.
17. We have reviewed the records.
18. A decision support tool was completed on 10 November 2020. It concluded Mrs I was not eligible for CHC funding. It did recommend Mrs I should receive NHS FNC.
19. NHS-funded Nursing Care Practice Guidance Published December 2018 says:
‘81. Where an individual has been found eligible for NHS-funded Nursing Care, a review should be undertaken within 3 months of the eligibility decision being made. After this, further reviews should normally be undertaken on at least an annual basis.’
20. We have not seen a three month review was carried out. The records show a review took place on 16 June 2021 and a another on 14 September 2022. For context, we have seen the assessors carrying out the assessments have used different approaches and documents. Our advisor said this may have contributed to confusion in the scoring.
21. We will now consider the DST and FNC assessments.
22. In comparison to the DST completed in November 2020, the June 2021 FNC assessment shows a change in needs in two domains. The behaviour domain was considered high in the DST, in the FNC June 2021 review it was scored as no needs. The drug therapies and medication domain was scored high at the DST in November 2020. In June 2021 FNC assesment it scored as no needs.
23. We have not seen an appeal was made regarding the outcome of this FNC assessment.
24. On 14 September 2022 a further FNC review was carried out. A change in need in the nutrition and altered state of consciousness domain was noted compared to the original DST. The behaviour and drug therapies and medication domains were scored both as high. This score was in line with the DST completed in November 2020.
25. The 14 September 2022 FNC review stated overall there had been no material change.
26. By the time of the FNC review in September 2022, the NHS-funded Nursing Care Practice Guidance had been updated. We will now refer to the updated version. It says:
‘88. When reviewing the need for NHS-funded Nursing Care, potential eligibility for NHS Continuing Healthcare must always be considered. This will normally be achieved by completing a Checklist and where necessary a full assessment for NHS Continuing Healthcare using the DST.
89. However, where: • a Checklist and/or DST has previously been completed (with the result that the individual was not found eligible for NHS Continuing Healthcare), and • it is clear that there has been no material change in need then it will not be necessary to repeat the Checklist and/or DST and this should be recorded. The individual should be informed of this outcome and the reasons for it.’
27. Both NHS-funded Nursing Care Practice Guidance and the National Framework does not define what a material change is. We asked our advisor if there has been a material change in need. They explain the evidence presented by the ICB demonstrated no significant material change in Mrs I presentation and no indication there was a primary health need.
28. We acknowledge Mrs A complains a new DST should have been completed in September 2022. It is agreed there were changes in domain scores. A change in domain scores does not necessarily amount to a material change. In line with NHS-funded Nursing Care Practice Guidance, as there had been no material change in need a new full assessment using the DST was not needed.
13 January 2025
29. Mrs A complains on 13 January 2025 the ICB incorrectly refused to carry out a retrospective review of the period 14 September 2022 to 20 September 2023 for her mother, Mrs I.
30. The ICB explained it would only carry out a retrospective review if a Previously Unassessed Period of Care (PUPoC) had been identified. As Mrs I has been assessed during the period June 2021 and September 2022 it would not carry a retrospective review.
31. Department of health and social care, dealing with requests for assessments of previously unassessed periods of care from 1 April 2012 guidance, says:
‘Definition of a previously unassessed period of care A request for a PUPoC assessment refers to a request for an ICB to consider NHS CHC eligibility where the ICB had responsibility for an individual, for a specific past period of care, where: • there was no consideration of NHS CHC eligibility by the relevant ICB for that individual during the past period of such care’
‘If there was a consideration of eligibility for NHS CHC during the past period of care If an ICB finds evidence that the individual had been previously considered for NHS CHC - for example: • via NHS CHC checklist • where a decision was made not to undertake an NHS CHC checklist or assessment then the period was considered at that time and no further assessment is necessary.’
32. We will now consider the records to see if an unassessed period of care exists.
33. A decision support tool was completed on 10 November 2020. It concluded Mrs I was not eligible for CHC funding. It did recommend Mrs I should receive NHS FNC. The records show a second review took place on 16 June 2021. Mrs I continued to be in receipt of FNC.
34. On 14 September 2022 a further review was carried out. Mrs I continued to be in receipt of FNC. A DST assessment was carried out by the ICB on 14 November 2023. This assessment found Mrs I was eligible for CHC funding.
35. NHS Continuing Healthcare, dealing with requests for assessments of previously un-assessed periods of care, says:
‘4.1.6 The PCT (primary care trusts, now known as ICB’s) should make sure that the request relates to a previously ‘un-assessed’ period of care as set out in paragraph 3.0 above. The closing date does not apply to reviews of decisions that have already been made. The PCT should check its records to consider the following: (i) Has the person been considered for continuing healthcare previously for the period for care being requested? This may be either by the use of the Checklist process (or equivalent if before October 2007), or a full continuing healthcare assessment. If a Checklist was carried out, it should: • have been completed appropriately; • be clinically sound • reflect the patient information known at the time; • relate to the relevant period(s).
(ii) Was the individual in receipt of either Registered Nursing Care Contributions (RNCC) (pre October 2007) or NHS Funded Nursing Care (FNC) (post October 2007). An RNCC / FNC assessment should have only taken place once it had been established that the individual was not eligible for NHS CHC.
Providing a proper consideration of the need for NHS CHC was made prior to the RNCC / FNC assessment or annual review, then a further assessment of the past period of care is not necessary.’
36. We consider A DST was completed on 10 November 2020 and Mrs I was ineligible for CHC funding. As outlined in 4.1.6 (ii), a consideration for NHS CHC was made prior to a FNC review on 14 September 2022. In line with guidance the period 14 September 2022 to 20 September 2023 cannot be considered previously unassessed. We have not seen the ICB got anything wrong here.
37. We understand Mrs A is of a different opinion about her mother being assessed for funding. We thank Mrs A for bringing her complaint to us.