The Public Services Ombudsman for Wales and the Health Service Ombudsman for England have issued a joint report recommending that the Health Commission Wales (HCW) reimburse a mother and daughter some £31,000 for fees paid for medical care for the daughter in a private eating disorders unit, following a finding of maladministration and service failure connected with a refusal to fund treatment on the NHS.
The daughter (S), though living in South Wales, developed depression and anorexia nervosa while staying with a friend in the south west of England, where she came under the care of Plymouth PCT (the PCT), initially as an out-patient but later as an in-patient. Although the PCT approached a consultant employed by Cardiff and Vale NHS Trust, he declined to take over her care. As S’s condition deteriorated further, she was referred to a specialist eating disorder unit in Devon. Although the referral was accepted subject to funding, HCW declined to fund on the basis, principally, that S had never been assessed by the service in Wales and because no post-discharge plan had been put in place. S’s mother accordingly had S admitted to a private eating disorders centre, the placement being funded by mother and daughter from their savings.
S’s mother complained to the Ombudsmen about the refusal of the NHS to fund her daughter’s care, saying it was unreasonable to have expected S to travel back to Wales for assessment given the gravity of her condition.
Maladministration was found in the following respects:
- HCW adopted an excessively inflexible approach to the request to fund S’s care by failing to take account of S’s geographical situation, failing to consider the valid opinion of the referring consultant, insisting on the existence of a detailed discharge plan when it was unreasonable to do so and failing to communicate adequately its reasons for refusing to fund;
- Cardiff and Vale NHS Trust unreasonably refused to take over S’s care when asked; and
- the PCT failed to provide short-term funding for S’s treatment and thereby placed her at clinical risk.
The Ombudsmen recommended that HCW reimburse S and her mother the money paid out for her care (with interest) and that all three bodies pay a nominal sum to both women for the distress caused. A recommendation was also made to the Welsh Assembly Government to consider carrying out a Wales-wide review of the adequacy of provision for eating disorder treatment in Wales.
Although the case was decided specifically on its own peculiar facts, in terms of the daughter’s geographical location, commissioners should be alert to the potential of this alternative avenue for reclaiming the cost of private care, albeit of course that the Ombudsman has no powers of compulsion and can merely make recommendations.