Facilitating treatment plans
14. In September 2018, Ms T saw consultant A who suggested four different treatment options for her damaged teeth.
15. Ms T’s dentist wrote to consultant A at an NHS Trust in April 2019. They explained Ms T did not fit criteria to have NHS consultant treatment locally, and they were only able to provide advice and guidance. The Trust noted Ms T was caught between hospital and primary care treatment. It advised her to pursue this with NHSE.
16. In May 2019, NHSE emailed several restorative dental consultants and staff noted there had been problems with her pathway and referrals. Restorative dentistry focusses on repair of damaged and missing teeth. NHSE noted the challenges in providing her care due to a lack of resources in the area. It arranged a second opinion appointment with consultant B.
17. In June, Ms T saw consultant B. They suggested the same treatment options as consultant A. They were also unable to provide treatment as Ms T did not meet the local referral criteria. They wrote to NHSE asking it to advise what would be available on the NHS.
18. Consultant B suggested Ms T’s dentist submit an IFR (individual funding request) to NHSE. An IFR is an application to NHSE, to fund treatment that would not normally be available on the NHS.
19. In August 2019, Ms T’s MP wrote to NHSE explaining her situation and asking it to ensure the treatment suggested by both consultants was delivered on the NHS. NHSE noted in an internal email that she would need a referral to a specialist in prosthodontics (specialists in creating replacement teeth) but this was not available locally.
20. NHSE contacted a prosthodontic consultant to review Ms T and confirmed it would meet the costs for a referral and treatment. Ms T attended five appointments with consultant C between October 2019 and February 2020 and was given a new denture. NHSE met the costs of these appointments.
21. In March 2020, Ms T explained she was finding it very difficult to eat her normal diet, was gagging and finding it difficult to tolerate the denture. She was due to attend an appointment, but this was cancelled due to COVID-19 and rescheduled for October 2020. Consultant C discharged her in October. They confirmed that as they had provided one course of IFR treatment, they could not provide anything further.
22. In November 2020, following contact from Ms T, consultant A wrote to NHSE with a letter of support to ask them to re-consider the IFR panel’s initial decision on her treatment.
23. We have not seen any evidence NHSE acted on this letter, and a different consultant later confirmed to Ms T that no action was taken. NHSE has been unable to provide any documentation in relation to the IFR panel process.
24. Ms T was confused about the situation with her funding, had intolerance of her denture and did not yet have treatment for UR2. She contacted NHSE in November 2020 for further information. As she had not received a response, she followed up with another email in January 2021. In March, NHSE responded apologising as her emails had gone into their spam folder.
25. In April 2021, NHSE spoke to Ms T and discussed referring her to consultant D. Consultant D agreed to see Ms T but explained this would be for an opinion only and not for treatment. They explained they needed a written referral.
26. Ms T chased NHSE for the outcome of this referral regularly. She contacted consultant D’s secretary directly who confirmed they had not received it. In June, Ms T chased NHSE again and staff told her they would call consultant D to arrange this.
27. At the end of July, consultant D’s secretary confirmed they still did not have a referral, so Ms T raised her concerns with a director at NHSE. In September, they responded and confirmed the referral was made on 4 August 2021. We have seen evidence that when this referral was made, it was incomplete. Consultant D had to write back to NHSE requesting further information before they would offer Ms T an appointment.
28. Ms T saw consultant D in November 2021. They made some changes to her denture, but this was a temporary solution. They made further treatment suggestions and asked her dentist to complete an IFR application. This letter was not sent until January 2022 due to the consultant’s ill health.
29. In February 2022, Ms T saw consultant E. This was as a result of remaining on consultant A’s waiting list and not organised by NHSE. They told her that consultant A’s letter to the IFR panel in November 2020 had never received a reply and had not been chased.
30. Consultant E submitted a new IFR application in May 2022, but we understand no action was taken on this application. NHSE has been unable to provide any documentation in relation to this, so we are unable to understand what happened at this time.
31. By June 2022, Ms T had received multiple opinions for treatment plans, but only one course of treatment. We can see how frustrating it must have been for her to see consultants on an advice only basis and not receive treatment.
32. We recognise the difficulties in this case as Ms T felt she was moving no further forward in obtaining treatment, while NHSE felt it was facilitating multiple consultant reviews. In a case such as this, where treatment is outside of usual NHS commissioning and there are limitations due to resources, it is difficult for us to say what should have happened reflecting standards and guidance. We can look at our principles of good administration which sets out how public bodies should act.
33. Our principles say, ‘good administration by public bodies means getting it right, being customer focused, being open and accountable, acting fairly and proportionately, putting things right and seeking continuous improvement.’
34. Between April 2019 and February 2020, we can see staff liaised with restorative consultants for Ms T to obtain first and second opinions in 2019. It then approved an IFR and arranged for her to receive treatment by way of a denture. We find it acted in line with our principles, in particular ‘responding to customers’ needs flexibly’, and ‘taking reasonable decisions’.
35. In November 2020, when consultant A wrote to NHSE regarding Ms T’s initial IFR request, we cannot see it took any action. Consultant E later confirmed this. NHSE has been unable to share any documentation in relation to the IFR panel and actions it took.
36. We find this failure to act did not meet the expectations in our principles. In particular, the principles that state bodies should ‘handle information properly and appropriately’ and ‘keep proper and appropriate records’.
37. In April and June 2021, NHSE told Ms T it had referred her to consultant D. This did not take place until August, after she had escalated her concerns. There is no set timescale in which we would expect these actions to be taken. However, our principles say bodies should keep to their commitments and inform customers what they can expect. We find NHSE failed to meet these principles as it did not make the referral when it said it would.
38. Ms T told us the impact of NHSE’s actions has led to a prolonged period without treatment for her teeth. She told us of the significant impact this has had on her physical, financial and mental wellbeing. She said she has lost income as she was told her appearance was not professional enough to teach face to face. She told us she lacks confidence, and this has led to depression and weight gain.
39. It is difficult to say what would have happened without the administrative failures set out above, as we cannot say what the IFR panel outcome may have been. We are aware Ms T continued to have problems accessing treatment after the period we are investigating.
40. We find there was a missed opportunity for earlier treatment. We also find that NHSE’s actions have led to significant frustration and administrative burden for Ms T as she had to chase up her referrals.
Complaint handling
41. Ms T submitted a formal complaint to NHSE on 10 June 2022. NHSE acknowledged her complaint and asked for some further information. We have seen there was a lot of correspondence between Ms T and NHSE to create a Complaint Investigation Plan (CIP). This was agreed and signed in November 2022.
42. NHSE’s complaint policy states it aims to respond within 40 working days. The CIP indicated the response would exceed this due to increased volume of complaints, capacity within the team and the complexity of Ms T’s complaint due to the time period and multiple providers.
43. The policy says if NHSE has not provided a response within six months, it will write to the complainant to explain the reasons for delay and when they can expect to receive a response. It also says it will notify the complainant of their right to approach PHSO.
44. The expected resolution date for Ms T’s complaint was 13 December 2022. On 9 December the complaints team wrote to Ms T to advise her it would not meet this deadline and would endeavour to respond by the end of January.
45. In January, the complaints team wrote again and advised her they would provide an update in February. They explained the delays were due to not receiving responses from the hospital trusts involved, and due to staff sickness. In April, the complaints team notified Ms T of a further delay and advised they would respond in May.
46. In May 2023, Ms T contacted PHSO as she still did not have a response. We contacted the complaints team, and they advised us the providers wished to wait for an outcome of an IFR panel in order to provide a comprehensive response. They aimed to respond by the end of June.
47. In August, the complaints team had still not responded so Ms T chased them. PHSO sent chaser letters to NHSE in July, September, October, November and December 2023.
48. In December 2023, NHSE informed Ms T she could approach PHSO due to the delays in her complaint being answered, advising she would get a response by the end of January 2024. This was the first date of response she had been advised of since June 2023.
49. NHSE finally responded to Ms T’s complaint on 24 July 2024, over two years since her formal complaint. This response did not address the agreed points in the CIP. The response referenced events from 2023 which post-dated her complaint letter. It did not include details from the Trust involved, which was one of the reasons cited for the long delay in responding.
50. We contacted NHSE with concerns around the lack of comprehensive response and it agreed to look at this further. It provided a final response on 24 December 2024.
51. In this response, neither of the hospital Trusts involved were able to give comprehensive responses to her concerns. NHSE was unable to answer her specific question on IFR panels, signposting her to one of the Trusts. However, that Trust had already indicated it would not provide any further responses.
52. Our NHS complaint standards say organisations should give an open and honest answer as quickly as possible, considering the complexity of the issue and ensure complainants are kept updated.
53. Overall, it took NHSE two and a half years to provide a final response to Ms T. Both responses failed to address all aspects of her CIP.
54. There was a failing to keep her updated with its reasons for delays and likely timescales for its response. The reasons for delay it gave were due to issues at the Trusts. However, these are not reflected by the complaint responses as the Trusts have not provided anything substantive.
55. In addition, it did not signpost to PHSO until one and a half years after the complaint was submitted, which is not in keeping with NHSE’s own complaint policy.
56. We understand the frustration of the delayed complaint handling has added to Ms T’s distress from her treatment delays and caused further administrative burden.