14. Before we decide if we should do 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 went wrong when NHS England made its decision.
15. It is our role to decide whether NHS England’s IRP acted in line with the National Framework when it considered whether Mrs B was eligible for CHC. The National Framework sets out the principles and processes ICBs and NHS England should follow when considering if someone is eligible for CHC.
16. 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.
17. 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 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.
18. 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.
Key characteristics
19. The IRP applies an eligibility test to help it make a decision about a person’s CHC eligibility. This is called the four key characteristics – the nature, intensity, complexity and unpredictability of their needs. 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.
20. 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 key characteristics of a person’s needs.
21. Mr A has told us he disagrees with the IRP’s consideration of the four key characteristics.
22. He says the IRP stated his mother has health needs, but that there is not primary health need. He does not understand how it reached this conclusion. He does not feel that the skills and knowledge of the carers and family would be fully reflected in the care notes, so should not be assumed.
23. We acknowledge his concerns. A person may have had a number of needs that required both social care and healthcare input; however, it is evidence of a primary health need that indicates eligibility for CHC. A primary health need is determined by whether a person's care needs are primarily for healthcare as opposed to social care and accommodation. In the case of a person meeting the criteria for full CHC funding, their care needs are identified as being above and beyond what can be provided routinely by appropriately trained staff due to their care needs being complex, intense or unpredictable, therefore requiring a higher level of skilled interventions. We look at this in more detail below.
24. We note Mr A feels the skills and knowledge of the carers and family is not fully reflected in the care notes. The IRP could only make its decision based on the evidence available to it. This is the same for us. If Mr A feels the care records are not as comprehensive as they should be, he will need to raise this directly with the care agency.
Nature
25. Mr A says without his and the carers’ proactive, consistent and knowledgeable input, his mother would have rapidly deteriorated, significantly effecting her quality of life and life span. Her combination of needs evidence a primary health need and eligibility for CHC funding. This is because the main aspects of her care and support are focussed on addressing and preventing health needs.
26. His mother required prompts, support and assistance to maintain her activities of daily living which was provided by carers, who visited three times a day and her family who visited her daily. The GP and other health services monitored her condition and adjusted her treatment as clinically indicated. The district nurses monitored her blood glucose levels, administered her insulin daily, monitored her tumour and changed her dressings as required.
27. Mr A says this demonstrates she did have needs of a nature that required daily interventions four-five times a day to prevent her health from deteriorating.
28. The National Framework says nature should ‘describe the particular characteristics of an individual’s needs (which can include physical, mental health or psychological needs) and the overall effect of those needs on the individual, including the type (‘quality’) of interventions required to manage them.’
29. The nature section of the IRP report gives a detailed explanation of Mrs B’s needs. It acknowledged she had a number of medical conditions such as diabetes and diagnosis of breast cancer which impacted her day-to-day care needs. She was dependent on her family and carers and needed support with activities of daily living within her own home.
30. We can see the IRP presented a clear picture of how Mrs B’s needs were met. They described the nature of her condition. The report sets out a consideration of the types of care Mrs B needed across each of the care domains to keep her safe and well. It noted these were routine interventions, including insulin injections and wound care from district nurses.
31. There was no risk of harm to others around daily care interventions. Carers would not need to leave and return to fulfil the care. Her care needs were met with care support.
32. We looked at the levels of training Mrs B’s carers needed. They were knowledgeable and well-trained in older person’s care for physical and mental health needs. We know Mrs B needed support because of her significant diagnoses. Care staff, along with her family, would monitor her needs. There was access to her GP and specialist hospital-based services if needed.
33. Mr A feels the range, interaction and frequency of his mother’s needs and the frequency of her need for assistance required knowledgeable and skilled carers, without which she could not cope. We can see the evidence supports the IRP’s conclusion. They show Mrs B did need care to ensure her needs were met. But it was routine interventions that did not take a long time to complete.
34. We think the IRP weighed up the things the National Framework PG3 says it should. It is very clear Mrs B needed a lot of care with daily living activities, as Mr A says. But we cannot see she needed any specific knowledge, skill or training beyond that which a local authority carer could provide. She was able to carry out personal care tasks independently, participate in activities within her home and garden and go out with her friend.
35. The IRP acknowledged the nature of Mrs B’s care changed between February and March 2020 (a later review period) when her breast cancer related wound deteriorated and felt that a primary health need was then indicated.
36. We think the IRP’s decision about the nature of Mrs B’s needs was in line with the guidance set out in the National Framework.
Intensity
37. Mr A says his mother had health needs relating to her diabetes and breast cancer. These were maintained by the health services who monitored her condition and provided input as necessary.
38. She required sustained care several times a day to ensure that her food intake and hydration was correct to manage her diabetes. This prevented her conditions from worsening. Otherwise, there would have been a risk to her life if her blood glucose levels were incorrect. Mr A says this care was not just for support with activities of daily living, it was to manage health needs.
39. The National Framework says this characteristic ‘relates both to the extent (‘quantity’) and severity (‘degree’) of the needs and to the support required to meet them, including the need for sustained/ongoing care (‘continuity’). It sets out that assessors should look at how severe a person’s needs are, how often an intervention is needed and how long it takes, how many carers are needed, and whether the care is needed over several domains.
40. The IRP’s report shows a good account about the intensity of Mrs B’s needs. It set out the domains where her needs were greatest and that the combination of these required consistent care throughout a 24-hour period. It set out that earlier in the review period she needed help with her impaired cognition function (including forgetfulness) and continence (responding to loose stools/constipation). She was monitored for pressure damage, with barrier creams applied and pressure relieving conditions for her skin.
41. Mrs B also needed support with her nutrition and prescribed medication (this included monitoring her blood glucose levels) which was administered by her family and carers. She was compliant with care interventions. Her blood glucose levels did not represent a sudden or urgent risk/changes in her insulin dose and could be managed by the district nurses. Her diabetes and breast cancer responded to treatment and remained stable.
42. There were no barriers to providing the care. Her support and interventions were managed successfully, with oversight from the GP and district nurses when needed.
43. The evidence shows the IRP acknowledged she needed supervision and monitoring with her general health and daily activities. It noted Mrs B’s care could be delivered with no increase of frequency of support during the earlier review period. She needed care 24 hours a day, as Mr A says, but this alone does not indicate a primary health need. At different times of the day, she needed more or less help.
44. The IRP recognised Mrs B had a level of need in many of the care domains. We note it concluded the levels of care required in these domains were what local authority carers could be expected to provide and were not intense enough to determine a primary health need. There is no indication that the majority of her interventions took a long time. They were straightforward to meet with one or two family members and/or paid carers visits three times per day.
45. The IRP acknowledged the nature of Mrs B’s care changed between February and March 2020 when her diabetes and breast cancer related wound had a significant impact and felt that a primary health need was then indicated. The extent of her interventions increased within her skin integrity and drug therapies and medication with considerable change in her clinical presentation, treatment plans and input required.
46. The IRP acknowledged she had increased dressing changes by the district nurses during the later review period for the leakage of her wound which impacted on her skin integrity. She also had an emerging ulceration from the breast cancer which led to a referral to palliative care services, tissue viability nurses and charcoal dressings to manage odours from the deteriorating wound (which was likely to be a fungating tumour).
47. We think the IRP’s decision about the intensity of Mrs B’s needs during the period we are looking at here was in line with the guidance set out in the National Framework.
Complexity
48. Mr A says there was inter-relation between his mother’s needs across the domains. She had a number of health conditions which interacted to add to her complexity.
49. She had memory difficulties, confusion, loss of balance, vertigo, side effects of medication, increasing risk of falls and episodes of loose faeces. This affected her appetite, blood glucose levels and urine infection. Heart issues were also dominant in her health needs affecting all aspects of her health. Her family and carers were very skilled in observing her behaviours. This required action to prevent a risk to her life. The skills of the district nurses were also required in checking blood glucose levels and administering medication.
50. If her diet was not monitored, she would choose foods that would have put her health at risk as they would have had a detrimental effect on managing her diabetes. So, this had to be carefully managed by her family and carers. He says her care was provided by a small group of carers who knew her needs very well. They were able to provide consistency were skilled in their care. This allowed them to pick up on small signs that her health was deteriorating could address any issues that may cause problems with interacting health conditions.
51. The National Framework says this characteristic is ‘concerned with how the needs present and interact to increase the skill required to monitor the symptoms, treat the condition(s) and/or manage the care.’ It sets out that assessors should think about how difficult it is to manage the need and alleviate the symptoms, how the needs impact on each other, how much knowledge and skill is needed, and whether the person’s response makes it difficult to provide support.
52. The IRP report shows the panel discussed the complexity of Mrs B’s needs. It noted her care was not difficult to deliver. It recognised her level of cognition and nutrition. She would forget to take medication at times and her low blood glucose levels led to episodes of increased confusion. It noted the interactions Mr A raised impacted her balance, risk of falls and continence needs. This did not become difficult or need adjusting on a regular basis. It noted she had experiences of loose stools and loss of appetite, but this was not problematic.
53. The IRP thought about the knowledge and skill needed to care for Mrs B. Carers and Mr A anticipated her needs through familiarity and understanding of her care. It thought about whether the needs combined to create complexity and set out why it thought they did not.
54. We think IRP considered the factors PG3 says it should. It saw Mrs B’s care interventions were not difficult to manage and did not need specific skill or knowledge beyond that which a well-trained carer would have. There were no interactions or difficulties with Mrs B’s response that meant it was more complex to provide her care. Her needs were not difficult to plan or provide for. She did not require intervention from specialist care teams, such as speech and language therapy (SALT), around the time of the assessment.
55. The IRP recognised during the later review period the progression of Mrs B’s breast cancer, subsequent wound, odour and bleeding interacted with the need for pain control and her psychological and emotional needs. She had episodes of low mood. She could not get out and about much. This had an impact on the intensity of her needs and led to a primary health need.
56. We think the IRP’s decision about the complexity of Mrs B’s needs during the period we are looking at here was in line with the guidance set out in the National Framework.
Unpredictability
57. Mr A says inputs from his mother’s GP and other health services were ‘episodic’ as described in the DST because of the skills of her family, carers and the district nurses in managing her needs. Her diabetes was unpredictable in the changes of blood glucose levels. There were challenges in managing this, such as how the diabetes interacted with her other conditions and the ability to control her diet when she had less awareness about her condition. If timely and adequate care was not provided the level of risk was grave, leading to a risk to her life.
58. The final key characteristic of a person’s level of need is unpredictability. The National Framework defines it as ‘the degree to which needs fluctuate and thereby create challenges in managing them. It also relates to the level of risk to the person’s health if adequate and timely care is not provided. An individual with an unpredictable healthcare need is likely to have either a fluctuating, unstable or rapidly deteriorating condition.’
59. The National Framework says an assessor should think about whether it is possible to anticipate the person’s needs, whether the needs or support change at short notice, if the person’s condition is stable, what level of knowledge or skill is needed for a spontaneous response, and what would happen if the need was not met.
60. The IRP report shows the panel considered the unpredictability of Mrs B’s needs. It noted that her needs were stable during the period. There were some fluctuations in her blood glucose levels and continence needs (loose stools and constipation at times). But Mr A and the care staff knew what to expect and the appropriate actions to respond. There was no difficulty in meeting those needs. Additional support was provided as required by the diabetic specialist nurse and district nurses.
61. The IRP noted Mrs B required regular observation, but her health needs did not fluctuate and did not present a high level of risk. Her care interventions were routine. There was no rapid deterioration or sudden change in the level or type of support Mrs B required in the earlier review period. She did not need unplanned district nursing visits due to unexpected changes in need. These are key pieces of evidence in this characteristic. If a person had unpredictable needs, we would expect to see frequently changing care plans, or the family or carers having to take action outside of the care plans to meet those needs.
62. She did not require constant 1:1 supervision, nor did she require the completion of behaviour charts. There was no safeguarding alerts raised. On the occasions when there were specific concerns, Mrs B attended A&E for further assessment and treatment as needed. She did not have frequent emergency interventions.
63. The IRP recognised during the later review period the increased unpredictability of need arising from the deterioration of Mrs B’s breast cancer related wound. This led to unexpected changes in need and a primary health need.
64. We think the IRP’s decision about the unpredictability of Mrs B’s needs was in line with the guidance set out in the National Framework.
Well managed needs
65. Mr A says the IRP marginalised his mother’s needs because they were often successfully managed. The monitoring, supervision and investigations she required for her needs were beyond what the local authority could provide. This is evidenced by the fact that she had daily district nurse visits for these purposes, as well as input from other health specialists.
66. The IRP concluded that even though Mrs B’s needs were well managed, they did not constitute a primary health need.
67. The National Framework says, ‘care must be taken not to misinterpret a situation where the individual’s care needs are being well-managed as being a reduction in their actual day-to-day care needs.’
68. We can see why Mr A was concerned about the IRP’s consideration of the well managed needs principle. Mrs B had a variety of needs which he felt the IRP did not recognise.
69. We have considered if the IRP did misinterpret Mrs B’s needs because of the level of care she received. We think the IRP correctly applied this principle. The IRP has detailed in its report the level of care Mrs B needed in each domain and the key characteristics, and how the care she was receiving met this need. It had to do this to properly consider her needs.
70. The IRP discussed Mrs B’s needs in totality and there was evidence that they considered the need for skilled intervention. It recognised she received good quality care from family members, carers, district nursing staff and specialist hospital services. It acknowledged she needed a degree of skilled oversight and input but did not deem it as a skilled response outside of routine provision within her home. She had trained staff input, but this was generally to oversee the care. It detailed her deterioration arising from her breast cancer and diabetes. Within the cognition and drug therapies domains, it determined a higher level of need than that which may have been evidenced.
71. Mrs B’s needs were managed by one carer visiting to assist her in getting up and her activities of daily living, this included meal preparation. She was able to remain independent with activities of daily living throughout most of the review period.
72. We cannot see that the IRP misapplied the well managed need principle. There is no evidence that the IRP marginalised Mrs B’s needs. It referred to how staff managed her needs, which it must do to make decisions about the four key characteristics. The report shows the IRP’s application of the well managed need principle was supported by the evidence available and in line with the National Framework.
Conclusion
73. Our decision does not take away from the account Mr A has given us, or the challenges Mrs B faced. We appreciate she was reliant on the care she received at home. The IRP’s conclusion that her care did not indicate a primary health need and fell within the remit of the local authority appears to be in line with the National Framework.