Can CCGs overturn NHS Continuing Healthcare eligibility?

Published 23/04/2014

Please note: This article was published prior to July 2022, and some information may be outdated.

CCG decision-making panel. Can CCGs overturn NHS Continuing Healthcare eligibility recommendations? Let’s assume your relative has got through an assessment for NHS Continuing Healthcare. The assessors recommend funding. Great news.

Then you receive a letter in the post from the local CCG saying funding has been refused. Can CCGs overturn NHS Continuing Healthcare eligibility recommendations?

(CCGs are local Clinical Commissioning Groups, formerly Primary Care Trusts.)

Reading that your relative’s NHS Continuing Healthcare funding has been declined can be bewildering, frustrating and downright maddening, especially when you know the original Continuing Healthcare recommendation of eligibility was correct.

If you don’t know any different, you may take the outcome at face value and assume the letter is right. But be careful. Look carefully at who has actually made this decision.

NHS Continuing Healthcare is NHS funding for full time care and it covers all care fees. A full assessment for NHS Continuing Healthcare funding involves a multi-disciplinary team, and the lead assessor will make a recommendation about eligibility. This recommendation is then put to a CCG panel, who make the final decision.

This also happens in retrospective claims for care fees previously wrongly charged.

Can CCGs overturn NHS Continuing Healthcare eligibility recommendations?

The National Framework for NHS Continuing Healthcare – the formal guidelines for Continuing Healthcare assessments – sets out in black and white that CCG panels can only overturn an eligibility recommendation in exceptional circumstances. There are clear guidelines to this effect – and about what should happen next.

Needless to say, a CCG panel cannot arbitrarily throw out a recommendation of eligibility without following these rules and without being able to justify their actions. Predictably, reports from families show that this is exactly what some CCG panels try to do.

If this happens to you, be sure to read the guidelines. The blog http://chcfunding.wordpress.com contains a useful page of information about what the guidelines actually say in this respect. It will help you appeal, should you need to.

Tagged Categories: After your assessment, CHC eligibility, CHC essentials, CHC funding, NHS Continuing Healthcare

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12 Comments

Carol Chesborough March 22, 2017 at 7:51 pm

Hello,
My mum is currently in care after having a severe stroke. She was initially Fast Tracked by the hospital in August 2016 and granted Continuing Healthcare (CHC). Mum was re-assessed at the Multidisciplinary Team Meeting (MDT) in early January 2017 and we were told she didn’t meet the criteria for CHC funding but the report would go to the CCG and we would be informed in writing after their meeting, but it was made clear that their decision would be accepted. Today, 21st March 2017, my dad received a letter from CCG group stating mum is eligible for CHC but the report from MDT was included in the correspondence stating that they didn’t recommend it. I just want to set my mind at rest as I’m still uncertain. Does the CCG ever go against an MDT decision in this way? I would be most grateful for help here. Many thanks, Carol

David Armstrong April 28, 2014 at 2:49 pm

My daughter is almost 24 now and has deteriorated rapidly since the onset of a condition akin to Parkinson's from when she was eleven. In 2008 the Panel Decision was unambiguous, quote… "Panel discussed all care domains and agreed unanimously that Helen meets the criteria for NHS Continuing Health Care due to the complexity and intensity of her care needs and her deteriorating condition." Since then her condition has indeed deteriorated a lot.
A surreal assessment took place in 2012 during which the rest of us in the meeting became aware of an unusually cosy relationship between the social services representative and the nurse assessor. They chuckled their way at speed through the DST as a double-act and informed us, before the DST had even been completed, that my daughter's NHS funding was to be transferred to Social Services! When I objected and reaffirmed that Helen's Primary Need was still a Health Need I was patted (inappropriately) on the arm by the nurse assessor and told in a patronising way, "Don't worry, pet, nothing is going to change, she will still have her funding."
A few months later the acquiescence of the social services representative was explained… they had mistakenly believed another county would be responsible for the funding. The other county were given a deadline of less than two months before the NHS would cease their funding to allocate for my daughter.
The current situation is that the second county are correctly denying that they have ever had any responsibility for my daughter. The CCG are trying to deflect attention from their 'dodgy assessment' by claiming the outcome of an earlier assessment in 2010 (but kept secret until now) had rendered Helen ineligible for NHS CHC way back then… and what of the first county social services?
Despite their enthusiasm in the assessment meeting they have been in hiding and refused all communication for the last year since they realised they had unwittingly accepted responsibility for Helen's funding for themselves! The only correspondence comes from the CCG and although their plausible statements serve their purpose to deflect criticism from themselves they bear scant resemblance to the facts. Every time I send them written proof that they have not told the truth they ignore my request for an explanation and suggest a 'meeting' instead. A 'meeting' is OK by me, but only if we have to give our evidence under oath and are subject to the usual penalties for perjury!
Check out 'NHS England' and 'Monitor'… no effort has been spared creating logos, mission statements and layers of on-message jargonese (sorry for that one!) but where amongst this lot… can you complain about the CCGs and hold them to account?

Chris Gallagher May 2, 2014 at 4:40 pm

Sorry David,

I forgot to mention that I discovered forgeries of my mother's first Decision Support Tool. 5 of the 11 domains were altered by a Panel, that is not permitted to alter the document. Framework says not to.

Then it was sent to us in its forged form as if it was the evidence. As such it was the false basis for an appeal. So all correspondence from then on was based upon lies and it could be proved.

Police are investigating due to the fact that it is forgery under the 1981 act. It is also evidence of fraud under the 2006 act. They carry criminal convictions if guilty.

Under The Tort of Deceit one has the ability to sue without proving the matter of dishonesty. (Which would usually need a Police investigation).

Any statement of fact or law that is recklessly made as to it's truth from anyone in the process, that risks any kind of loss to another, by persuading them to act or not to act; is evidence of guilt under this Tort.

Chris Gallagher May 2, 2014 at 4:26 pm

Hi David:
Except for your loved one's circumstances, DITTO.
I too have recently experienced a very cosy relationship between organisations and was even warned by the L.A assessor that the NHS Nurse would need to leave in less than 2 hours so that she could collect her children, so would I please not try to muddy the waters with precedent from the past 6 years so that she could get away on time.

It seems that she had been reading my complaints to her bosses that case law requires precedent to be included in decision making processes or in the words of a Judge, "only random outcomes could occur.

Not to mention that it is impossible to review a patient that is already in receipt of funding without knowing what their previous condition was. Otherwise it is always an assessment as if it were the first time and that is also a breach of the rules. Especially when the Framework insists that extra care and explanation is warranted when removing funding from a previously eligible patient.

I consider (as does law), that it is prima facie evidence of misfeasance in a public office, to permit random outcomes in decision making.

All the best.