The BBC have reported (https://www.bbc.co.uk/news/health-48555199) that it is claimed that ‘thousands of vulnerable patients in England are missing out on NHS funding for care that they are legally entitled to’. It goes on to state that many are dying before getting the funding for care or are forced to sell their homes to pay for care that should be free.
What is a Primary Health Need?
Unfortunately many people do not realise that there is funding available for certain people who have what is described as a ‘primary health need’. This means that if somebody is assessed as having a primary health need then the NHS should meet the full cost of their care irrespective of that person’s means.
Clinical Commissioning Groups assess a person’s needs using a Decision Support Tool which assesses their needs in a range of domains (for example, behaviour, continence, nutrition) and scores them from ‘no needs’ to ‘priority’.
A priority need or two severe scores indicate that a person is automatically eligible. Otherwise a range of needs in the severe/high/moderate categories indicates that a person may have a primary health need but the CCG would need to consider the totality of that person’s needs, the intensity, complexity and unpredictability of the needs and whether that amounts to a primary health need.
It is important that when these assessments are carried out the Clinical Commissioning Group has all the information that they need to make an informed decision regarding that person’s eligibility. This means that they should have input from the person’s family and healthcare professionals involved in their care. They should also consider the person’s medical records.
Appealing Against the Decision
If the person being assessed or a family member on their behalf feels that the assessment has not been completed correctly then it is possible to challenge this. A challenge can either be brought on the basis that the correct procedure was not followed (for example, they did not have the information needed to complete the assessment) or that the needs have not been accurately assessed (i.e. the person should have scored higher than they did in the domains).
If an appeal is made then the Clinical Commissioning Group should review the decision and give the person and their family the chance to explain why they felt the assessment was not completed correctly. Sadly it can take Clinical Commissioning Groups a long time to consider these appeals during which period the person will have to make alternative arrangements to pay for their care.
Instructing a Solicitor
A solicitor can help to alleviate this pressure by obtaining the relevant records and drafting the appeal on the person’s behalf. They can also advise on alternative funding options in the interim for example Local Authority funding or Deferred Payment Agreements.