3. Mr B complains about North East and North Cumbria Integrated Care Board’s (the ICB) decision that his son, Mr S was not eligible for NHS continuing healthcare (CHC) funding following its decision support tools (DST) between June 2019 to May 2023.
4. Mr B says as result his son was found not eligible for NHS CHC funding. This has caused the family stress, upset and it has affected their health.
5. Mr B wants the ICB to reconsider its eligibility decision.
8. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong when the ICB made its decision.
9. Mr B complains about the ICB’s decision that his son was not eligible for NHS continuing healthcare (CHC) funding following its decision support tools (DST) between June 2019 to May 2023. A DST is a document which helps to record evidence of an individual’s care needs to determine if they qualify for CHC funding.
10. We understand Mr B disagrees with the ICB’s DST decisions between 2019 and 2023. The ICB have said the issues he raised going back to 2019 onwards would not be investigated as these are out of time. The ICB said they are out of time under the NHS complaints process and there is evidence he was aware of the issues at the time. It said it would only be looking at issues from 2023 onwards under the complaint process. It referred Mr B to us.
11. The ICB have declined to consider Mr B’s concerns prior 2023 as it is out of time. Where an NHS organisation does not consider a complaint because it is out time, we are also unable to form a view on the complaint concerns. What we can do is look at whether it was appropriate for the organisation to say the concerns are out of time out for it to consider. This is what we have considered below.
12. On 4 June 2019 the ICB completed a DST. On 13 June 2019 it sent its outcome letter, Mr S did not have a primary health need. He was not eligible for CHC funding and not eligible for funded nursing care. Mr B appealed the decision. On 6 November the ICB held a meeting to discuss his concerns. It agreed to hold a further DST.
13. On 14 January the ICB held the DST. The panel could not reach an agreement. On 5 February a panel was held and the outcome was Mr S did not have a primary health need and he was referred for shared cared (joint funding). On 3 March 2020 Mr S was offered a joint funding package. The package was for one carer for 35 hours per week. We understand Mr S was in receipt of joint funding until 16 December 2024 when he was found to be eligible for CHC funding. We can see annual care reviews of the joint funding package took place between 2021 to 2024.
14. We understand during the period of June 2019 to December 2024 the following occurred:
• 4 June 2019 – DST • 14 January 2020 – DST • 19 February 2020 – Mr B appeals the January 2020 DST.
• 21 October 2021 – DST • 8 December 2021 -October DST outcome letter sent. Not eligible for CHC. The family were advised it had six months to appeal its decision.
• 22 December 2021 the ICB updated Mr B. It said his previous appeal was awaiting allocation. It advised he cannot appeal the outcome of the current DST until the outcome of the registered appeal is communicated.
• 23 May 2022 – appeal meeting took place for January 2020 DST.
• 4 July 2022 – the ICB sent its appeal outcome letter to his January 2020 DST appeal. Mr S did not have a primary health need. He was not eligible for CHC funding. The family were informed of their right to appeal to a CHC review panel and were told they had 14 days to lodge its appeal.
• We understand on 23 July 2022 Mr B submitted his appeal. This is outside the 14 day time limit.
• On 24 July 2022 Mr B sent a further email to the ICB with his additional comments.
• Mr B says he did not receive a response to his appeal until several months later.
• On 22 February 2023 Mr B says the ICB acknowledged his appeal.
• On 27 February 2023 Mr B says he had a call with the ICB and it offered a nurse assessor to review his son’s situation.
• On 24 March 2023 – joint funding review – no evidence of change in need.
• On 27 March 2023 Mr B sent an email to the ICB with his complaint on the DSTs since 2019.
• 17 May 2023 – local resolution meeting.
• On 15 September 2023 Mr B sent the ICB an email with his formal complaint. He set out the timeline of the DSTs from 2019 to 2023. He set out 11 questions which he said forms the basis of his complaint • On 12 March 2024 – joint funding review – refer to a DST. On 20 March 2024 the ICB sent its outcome letter. It said following the review on the 12 March the nurse assessor could find no evidence in change of needs that required further consideration for NHS CHC funding. It said joint funding remained appropriate.
• On 13 May 2024 Mr B sent an email to the ICB setting out his additional questions to part of his original complaint he sent on 15 September 2023.
• On 24 May 2024 the ICB sent Mr B an email. It said the issues he raised going back to 2019 would not be investigated as they are out of time. It said it would only investigate issues from 2023 onwards under its complaints process.
• On 17 June 2024 the ICB sent Mr B its response letter. It referred him to NHSE to request and independent review panel (IRP) for its 12 March 2024 decision. It referred Mr B to us.
• On 19 June 2024 Mr B sent NHSE his IRP request.
• On 5 July 2024 NHSE sent a letter to Mr B. It said it was not appropriate to set up an IRP as it did not feel the ICB had taken sufficient action to resolve the concerns at a local level.
• On 23 September 2024 the ICB completed a checklist. It recommended a full CHC assessment.
• On 6 November 2024 DST completed – eligible for CHC funding.
• On 20 December 2024 the ICB sent its outcome letter. Mr S was eligible for CHC funding from 16 December 2024.
• Mr B says on 22 January 2025 the ICB told him funding had been awarded from 30 October 2024.
15. The ICB have said Mr B’s complaint to them is out of time. It says its issues relating to 2019 to 2022 have been responded to previously as part of its local resolution process. This included the appeals of the various DSTs.
16. We have carefully considered Mr B’s date of awareness of when he first became aware of the problem. Looking at the chronology of events we consider Mr B first became aware of the problem in January 2020 when his son was not eligible for CHC funding. However, we can see he was going through the ICB’s local resolution process. We do not criticise him for not complaining about his concerns in January 2020. On 4 July 2022 the ICB sent Mr B its appeal outcome letter. It said his son did not have a primary health need and he was not eligible for CHC funding. The family were informed of the right to appeal within 14 days. We think 4 July 2022 is Mr B’s date of knowledge, at this point he knew the ICB’s outcome of his appeal.
17. On 23 July 2022 Mr B says he sent his appeal to the ICB. On 24 July he sent a further email. This was out of time. Mr B says he did not receive an acknowledgement to his appeal for several months. He says he had to chase a response and send the emails again. He says he then received a response on 22 February 2023. It appears Mr B may have sent his appeal to an incorrect email address. The email address he sent his emails to is ‘ntcc.chc@nhs.net’. The email address on the ICB response letter is ‘ntccg.chc@nhs.net’. This may explain why Mr B says he received no response to his appeal.
18. We can see Mr B did not formally complain to the ICB about its DST decisions until September 2023. This is out of time under section 12 of the NHS regulations which says you have one year in which to raise a complaint from the date of the event occurred or when you first became aware of the problem. Therefore, the ICB were correct when it made its decision not to consider his concerns for the DSTs between 2019 and the end of 2022. There is no indication of failings in its decision to not consider complaints relating to 2019 to the end of 2022.
19. Mr B says he is also complaining about the ICB’s DST decision in May 2023. The available information show no DSTs took place in May 2023. The records show in March 2023 a joint funding review took place. The ICB have also confirmed no DSTs took place in 2023. As a result, we will not consider this part of the complaint further.
20. We recognise Mr B’s account and that he disagrees with the ICB’s decision. We do not wish to take away from his account or what he has told us about his son’s needs.
21. In summary, we will not consider this complaint further. We understand how important Mr B’s complaint is to him and we thank him for bringing his concerns to us for consideration.
1. We have carefully considered Mr B’s complaint about North East and North Cumbria Integrated Board (the ICB) looked at his NHS continuing healthcare claim for his son, Mr S. We have seen no indication that anything went seriously wrong when it made its decision that his complaint to it was out of time.
2. We are sorry to hear the ICB’s decision that Mr S was not eligible for CHC funding left the family stressed, upset and it affected their health. We recognise the stress and frustration they felt by the CHC process.