13. 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.
14. It is our role to decide whether NHS England’s IRP acted in line with the National Framework when it considered whether Mrs I 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.
15. 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.
16. 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.
17. 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
18. 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.
19. 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.
20. We can see during the IRP meeting Mrs X did not dispute any of the domains other than ‘Nutrition- Food and drink’. The IRP changed this weighting from moderate to high, therefore agreeing with Mrs X’s weighting.
21. Mrs X also raises concerns that the IRP failed to take into account previous periods when Mrs I was found eligible for CHC funding. We can see on page six of the IRP report, the IRP considered this. We can see the IRP noted that prior to November 2023, Mrs I had been in receipt of CHC funding and regular reviews took place. It noted that in November 2023, there were some changes in the presentation of her needs and so a full CHC assessment was carried out.
22. Based on this we are satisfied the IRP has taken consideration Mrs X’s concerns. We can see the IRP considered the relevant evidence for the period specifically relating to the DST completed on the 2 February 2024. We therefore do not find any indications of failings.
23. Mrs X has told us she disagrees with the IRP’s consideration of the four key characteristics.
Nature
24. 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.’
25. The nature section of the IRP report gives a detailed explanation of Mrs I’s needs and considered the way in which those needs were met. It acknowledged she had a number of medical conditions such as malignant glioma (brain tumour), breast neoplasm (breast cancer) and dementia (decline in brain function affecting memory and language) which impacted her day-to-day care needs. She was dependent on her husband and family to support her with the help of carers.
26. We can see the IRP presented a clear picture of how Mrs I’s needs were met. They described the nature of her condition. The report sets out a consideration of the types of care Mrs I needed across each of the care domains to keep her safe and well. It noted that Mrs I’s cognitive impairment meant that she did require full support to ensure that all her care needs were met. There were no noted risk of harm to others around daily interventions and her care needs were met with care support.
27. We looked at the levels of training Mrs I’s carers needed. They were knowledgeable and well-trained in older person’s care for physical and mental health needs. We can see for example with the administration of medication, her husband took on this responsibility and where he was unavailable, care staff would administer this. She did not require a long standing medication regime, or a requirement for her medicine to be closely monitored or observed. There was access to her GP, district nursing service and specialist hospital-based services if needed.
28. The IRP also considered the interaction and frequency of her Mrs I’s needs. We can see the IRP noted that she was non-verbal and was unable to communicate her needs reliably. She was totally dependent on others to anticipate the majority of her needs. The IRP noted Mrs I’s husband’s concerns at the panel that he was unsure how much information his wife understood. We appreciate how difficult this must have been for him to witness. We can see the IRP considered this and reviewed the evidence to see how care interventions were met. The evidence concluded that there were no noted concerns, and all care were successfully met.
29. We think the IRP weighed up the things the National Framework PG3 says it should. It is very clear Mrs I needed a lot of care with daily living activities. But we cannot see she needed any specific knowledge, skill or training beyond that which a local authority carer could provide. Although she had variable needs including the need for medication to be administered via a PEG tube (directly into the stomach), her care interventions could be planned and were not unusual.
30. We think the IRP’s decision about the nature of Mrs I’s needs was in line with the guidance set out in the National Framework.
Intensity
31. 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.
32. The IRP report shows there was a discussion about the intensity of Mrs I’s needs. It considered 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 because of her cognitive needs these affected her communication and nutrition.
33. There were no barriers to providing the care. Her support and interventions were managed successfully, with oversight from the GP and carers when needed.
34. The evidence shows the IRP acknowledged she needed supervision and monitoring with her general health and daily activities. It noted Mrs I’s care could be delivered with no increase of frequency of support. She needed care 24 hours a day, but this alone does not indicate a primary health need. At different times of the day, she needed more or less help based on her needs at the time, such as when medication needed to be administered.
35. The IRP recognised she 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 a family member and/or paid carers visits.
36. We think the IRP’s decision about the intensity of Mrs I’s needs was in line with the guidance set out in the National Framework.
Complexity
37. 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.
38. The IRP report shows the panel discussed the complexity of Mrs I’s needs. It noted her care for her physical frailties was not difficult to deliver. It recognised her level of cognition and communication were linked. But overall, there is no evidence of that this interaction was problematic. There is no evidence to suggest that skilled interventions were required which supports the IRP’s view that her care needs were not complex. We can also see there is no evidence of frequent changes in her care plans which evidences that her care needs were being met.
39. The IRP thought about the knowledge and skill needed to care for Mrs I. Carers and her husband 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.
40. We think IRP considered the factors PG3 says it should. It saw Mrs I’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, which in this case was her husband and the carers. There were no interactions or difficulties with Mrs I’s response that meant it was more complex to provide her care. Her needs were not difficult to plan or provide for.
41. We think the IRP’s decision about the complexity of Mrs I’s needs was in line with the guidance set out in the National Framework.
Unpredictability
42. 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.’
43. 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.
44. The IRP report shows the panel considered the unpredictability of Mrs I’s needs. It noted that Mrs I was cared for in her own home looked after by her husband and daughter with the support of carers. It noted this arrangement had been in place for a number of years. Her care was organised using a programme of planned care, with the evaluation of her needs and amendments when appropriate.
45. The IRP noted that Mrs I’s planned care did not change in the years before the November 2023 review which is what triggered the complained of DST to be completed. We can see the IRP noted that there was no evidence to suggest that care staff and the family could not effectively anticipate her needs and the risks involved. This is supported by no changes in the interventions or care she required.
46. The IRP noted the family and the care staff knew what to expect and the appropriate actions to respond on each respond. There was no difficulty in meeting those needs.
47. The IRP noted Mrs I did have care needs, 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 I required. 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 act outside of the care plans to meet those needs.
48. We can see she did not require constant 1:1 supervision, nor did she require the completion of behaviour charts. There was no safeguarding alerts raised. She did not have frequent emergency interventions.
49. We think the IRP’s decision about the unpredictability of Mrs I’s needs was in line with the guidance set out in the National Framework.
Conclusion
50. Our decision does not take away from the account Mrs X has given us, or the challenges Mrs I 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.