If your relative has been assessed for NHS Continuing Healthcare funding, you may be finding it difficult to fully understand the assessment process or how you can appeal a negative decision. Here we explain the process for appealing a negative Continuing Healthcare decision focusing on the role of NHS England and Independent Review Panels (IRP’s).
If your relative has been assessed for NHS Continuing Healthcare and found not eligible you have the right to appeal this decision. The appeals process differs depending on whether your relative was assessed by a checklist assessment (an initial screening tool to determine if a full review is required) or by way of a full assessment in the form of a Decision Support Tool (DST).
If a checklist assessment has been undertaken which came back negative, then a full assessment of your relative’s needs will not be completed. If you decide to dispute this, you have the right to submit a complaint to the Clinical Commissioning Group’s (CCG) complaints department. Usually, this must be made within 12 months of you being informed of the decision.
If however, the checklist assessment was positive, a full assessment will be undertaken. This is called a Decision Support Tool (DST). However if the DST assessment then comes back negative, the process to appeal this is different.
In these circumstances there are generally two stages in the appeals process. Firstly an appeal should be made at local level, direct to the relevant Clinical Commissioning Group (CCG). You need to clearly explaining your reasons for appealing. Please note that you cannot appeal a decision simply because you disagree with it; you must be able to show that the correct process has not been followed or that the Patient’s care needs have not been properly assessed. (Please see our blog entitled NHS Continuing Healthcare: What Makes Someone Eligible for further information.)
If, following this appeal, the negative decision is upheld, a further appeal can be made to NHS England requesting that an Independent Review Panel (IRP) is held. This request must be made in writing within six months of the CCG’s decision being communicated to you.
NHS England will then review arguments made by both you and the CCG and will make a decision as to whether an IRP should be organised. Whilst in our experience the majority of appeals made to NHS England do proceed to IRP, if NHS England decides not to convene a panel, you should receive a full explanation as to why and be told of your right to complain about this decision.
What is the role of the IRP?
The role of the IRP is to review the decision made by the CCG focusing on whether the National Framework for Continuing Healthcare has been correctly applied.
The IRP will be made up of:
- An independent Chair;
- a representative nominated by a Clinical Commissioning Group (not involved in the case);
- a representative from a Local Authority (not involved in the case);
- and there may also be a clinical advisor in attendance.
Preparing for the IRP.
Prior to the IRP you should be provided with a panel pack including copies of the assessment undertaken and any records the CCG is seeking to rely on.
You will also be asked if you have any further written submissions to make about your relative’s needs. Whilst these submissions will be useful to the panel members, we strongly recommend that you also attend the IRP in person. As relatives of the patient, you will be in a unique position to provide the panel members with details of the patient’s needs which may not be included in their medical records. Further, as a client of ours, we will always offer you a representative from Hugh James Nursing Care to attend this panel with you, or on your behalf.
Proceedings on the day
Whilst the IRP is a formal review of the CCG’s decision they aim to be a non-intimidating experience for relatives. At the start of the IRP, the Chair will introduce the panel members and will set out the agenda for the meeting.
Both you (or your representative) and the CCG’s representative will then be invited to discuss your reasons for eligibility or non-eligibility. This involves a discussion of the assessment document and the areas of disagreement. Following this discussion, you will both be asked to leave the room in order for the panel members to discuss in private.
Decisions made at IRP
For claims registered in England, a report of the IRP’s findings will usually be sent to you around eight weeks following the meeting. Naturally we hope all decisions made at IRP are positive, nevertheless, if the decision remains that your relative is not eligible for NHS Continuing Healthcare funding you have right to contact the Parliamentary and Health Service Ombudsman in England to request that they investigate your case.