An introduction to the processes involved in this complex area of healthcare services

Although the claims process can be drawn-out and laborious, many people are finally beginning to hear the outcomes of their retrospective claims for previously unassessed periods of care under the NHS Continuing Healthcare regime.

Unfortunately, a high number of people are being told that they, or their relatives, have been found ineligible for retrospective funding.  The rationale behind these decisions is not always correct and, more worryingly, is sometimes reached without reference to the required guidelines.

It is important that anybody claiming retrospective funding is aware of the way in which the process should work. If you require assistance in a claim, it is advisable to approach a legal expert with experience in this field.

So, what should have happened?

  • First, the claim should be assessed by an NHS Nurse Reviewer. He or she will review all relevant care notes, health reports and records for the person for whom the claim is being made. You should be involved in this process and be invited to submit your opinion.
  • The first stage of the assessment is based on an Initial Checklist.  This is a 21-page long document with 12 different healthcare 'domains' to assess.  
  • These domains are: behaviour, cognition, psychological/emotional condition, communication, mobility, nutrition, continence, skin integrity, breathing, drug therapies and medication or symptom control and altered states of consciousness.  Each of these domains is given a grading on the checklist – either A, B or C, and each grade provides a brief synopsis of the kind of requirements that are needed to meet that grade.  The grading will be made with reference to the domains listed above.  
  • Once the Nurse Reviewer has been through the Checklist, he or she will tally up the total grades of all of the domains and decide whether the applicant requires a full assessment of NHS Continuing Healthcare.  

 The full assessment

  • This is one of the points at which the decision-making process becomes very complex – it can become overwhelming for non-professionals. A person is considered to warrant further investigation where there are either two or more domains selected in column A, five or more domains selected in column B, or one selected in A and four in B, or one domain selected in column A in one of the boxes marked with an asterisk, with any number of selections in the other two columns.  The domains which are marked with an asterisk are, behaviour, breathing, and altered states of consciousness. Certainly, this is far from easy to understand to the layperson.
  • If the application passes the Checklist, then the Reviewer will complete a document known as the Needs Portrayal document. He or she will also complete the Decision Support Tool form.

The Decision Support Tool

  • The Decision Support Tool is a 57-page document, which is laid out in a similar format to the Checklist.  It contains the same health domains, although they are graded slightly differently, ranging from no needs to priority needs, as opposed to categories of A, B and C.  Additionally, the applicant is then graded on the basis of the nature, complexity, intensity and unpredictability of his or her primary healthcare needs. This is a very subjective test, with much of the outcome depending on the assessor, although it is often based on available records of that individual.  
  • Unlike the Checklist, there are no definitive criteria as to what makes someone eligible or not for NHS Continuing Healthcare. The Decision Support Tool is used as an indicator as to whether that person should be eligible or not.  
  • Once the Reviewer has completed the Decision Support Tool and made reference to that individual's nature, complexity, intensity, and unpredictability of needs, he or she will make a recommendation about eligibility.  This should be sent to the individual's representative for comment before a final decision is made by the Clinical Commissioning Group panel.  The applicant will then receive the actual funding eligibility decision, this should include a copy of the Needs Portrayal and Decision Support Tool documentation; if this is not supplied, you are entitled to ask for it.

Challenging the panel's decision

  • If you disagree with the panel's final decision, you have a right to appeal that decision. You do so by writing to the Continuing Healthcare Team at the Clinical Commissioning Group that provided you with that decision, stating that you disagree with the outcome and that you will be appealing the decision. Unfortunately, the Clinical Commissioning Group's decision is still heavily influenced by budgetary constraints which can, in some cases, lead to a postcode lottery, even though this should have no part in their decision making process.
  • The claim will then go through to an appeal panel, you will be invited to attend the appeal panel in order to give your evidence.  You should then receive the outcome of the appeal shortly thereafter.
  • If you are rejected again, the Clinical Commissioning Group should provide you with the information on the next stage of the appeals process.  This is an independent panel review by NHS England.  You should be provided with the address to write to in the event that you disagree with the appeal panel decision of the Clinical Commissioning Group involved.  

Where do I go for further information?

  • There is plenty of literature available on the internet, most of which is provided by charitable organisations such as Age UK.  
  • You can also contact the Clinical Commissioning Group that is charged with assessing the retrospective claim, especially with regard to further information on their appeals process.