Introduction

The DH has brought in some much welcome guidance relating to time limits for CHC eligibility reviews. Dealing with redress claims has become big business for some, with companies being set up specifically to help patients challenge the NHS about previous eligibility decisions made. Making redress payments to previous patients and their families sometimes based on very limited and old information has become an increasing burden on PCTs especially in these days of efficiency savings. Equally patients and families are more likely to challenge decisions on eligibility in these years of austerity when the financial consequences of becoming eligible for NHS CHC can be so significant. Let’s hope that this new guidance from the Department of Health goes some way to assist the NHS in making the efficiency savings that Sir David Nicholson requires by 2015.  

Old cases

New cut off dates for a “new” request for assessments of eligibility

Sir David’s letter of 15 March 2012 states that the intention is (it is unclear on that basis if further Guidance is anticipated for the future) that there will be final dates for requests for assessments for CHC for previously unassessed periods between 1 April 2004 and 31 March 2012.

In summary, he states that where there is evidence that there should have been an assessment of eligibility for CHC funding in the past PCTs should only carry out new assessments for the periods between 1 April 2004 to 31 March 2011 if the request for the assessment is received from the patient or their representative before 30 September 2012. For the period 1 April 2011 to 31 March 2012 the DH proposes to allow individuals a further year to request an assessment; the cut of date being 31 March 2013.

Of course all cases prior to 1 April 2004 were closed off previously in 2007.  

Although not specifically mentioned in the letter, requests for an assessment of CHC for past periods where there is no evidence that a previous assessment should have been performed, in our view, should be rejected in any event

In the “Frequently Asked Questions” document on this issue (see link below) it is clear that the intention is that the cut off dates for notification for each period are final. Notification in respect of an unassessed period between 1 April 2004 and 31 March 2011 must be received by 30 September 2012, even if the period requested for assessment extends after this date (see FAQ number 7).

The letter makes it clear that the dates set out should be seen as ‘cut off dates’ but that there may be “exceptional circumstances” that would persuade PCTs to accept cases outside the deadlines.  

In order to limit the need to allow cases to fall within this ‘exceptional’ category we suggest that great efforts are made to communicate these deadlines to local communities at the earliest point possible. Although the Department of Health has involved stakeholder groups when drafting this guidance it will be important for PCTs to evidence the steps that have been taken to publicise these cut off periods locally. Local newspaper adverts, flyers in nursing homes, engagement with local patient advocacy services etc would be very useful in communicating these changes. We understand that the local SHA leads are working on this. It will also be vital that these steps are recorded so that there is evidence to support a decision to refuse to accept cases in the future, if PCTs or new CCGs are challenged.

New Cases

Guidance on time limits for individuals to request a review of eligibility decision for NHS CHC

This separate guidance relates to review following an initial eligibility decision – presumably which said “no”.

In essence, for cases from 1 April 2012 the time limits are as follows:  

  • An individual patient or their representative has 6 months from the date of notification of the eligibility decision to request a review.
  • The NHS body responsible must deal with the request within 3 months of receiving this.
  • An independent review should be no later than 6 months from notification of the responsible body’s decision (it is not clear if the guidance relates to the local review process decision or the original eligibility decision however we expect that it must relate to the latter).
  • The independent review should be conducted within 3 months of the request.

Again, the DH accepts that there may be cases where there would be good reason to accept a request outside the timeframes. It also provides limited grounds for extending the time a PCT/CCG or SHC/NCB has. Local publicity and communication relating to the changes will again be important. However, it should be noted that at paragraph 2.2 of the guidance it states that if a patient or their representative has not requested a review within 6 months of notification there must be “good reason” and that it must be still possible for the responsible body to access all the information to make the review possible. No definition of “good reason” is given and this will depend on local interpretation. Again, the extent and proof of the notification to individuals will be important to justify decisions made.

Conclusion

This guidance goes someway to providing clarity to both patients and the NHS for those cases where a request for an assessment for CHC relating to past care can now be refused and the time frames that need to be complied with for requests for reviews.

However, some may say that the new guidance is not far reaching enough as it does not deal with retrospective reviews of CHC decisions that were made between 1 April 2004 to 31 March 2012, as opposed to cases where no assessment was carried between these periods. With this pocket of cases, it seems that no time limits have been set for patients to request a review.

The outcome initially with respect to this guidance may be that there are more requests for assessments before 31 March 2012 because of the publicity that will be necessary. However, we would hope that in the future the guidance will allow PCTs to make clear decisions that certain requests for assessments and reviews are outside the time limit and therefore cannot be taken forward. This will be welcome news for incoming CCGs as they will no doubt be reluctant to spend time unpicking old CHC decisions where the evidence no longer exists.