Rejected for CHC Funding? Part 2: How to appeal the Local Resolution Decision
This is the second part of an article relating to appealing a decision following an initial Multi-Disciplinary Assessment.
First a quick recap of the previous article, “Rejected for CHC Funding? Part 1: How To Appeal The MDT Decision” which provides helpful information and guidance on appealing the decision of a Multi-Disciplinary Assessment to the Local Resolution stage.
If your appeal to the Local Resolution Panel (LRP) is then rejected, don’t give up!
Read on to find out how to appeal to the next level.
Step 1:
The CCG will provide you with a letter setting out the Local Resolution Panel’s decision to reject funding. The letter should have detailed reasons and tell you how to appeal if you still remain dissatisfied with the outcome.
If not, you must ask for the LRPs rationale so that you can understand their reasoning why they found your relative was ineligible for CHC Funding.
Timescale: You only have 6 months from being notified of the outcome to lodge an appeal.
Advice: Do not delay! The sooner you get the ball rolling – the less care home fees you may have to continue paying.
We strongly recommend that you diarise forward as you cannot afford to miss this deadline. Without very good reason, an appeal lodged after 6 months will be out of time. Once time-barred you will not be able to pursue your appeal further.
IMPORTANT: Look at the advice in our previous blog which is summarised below:
- Write a simple letter to the CCG immediately you get the rejection letter telling the CCG that you are going to appeal their decision.
- Get proof that your letter appealing the decision has been sent to the CCG (eg send it by Recorded Delivery) in case there is an argument that you didn’t reply in time;
- Check that it has been received in time by them to give you peace of mind.
- For the avoidance of doubt, it also a good idea to email your letter to the CCG as well, confirming your intention to appeal.
Chase the CCG for their formal acknowledgement and appeals process. They should set out their appeals process and tell you that your appeal has to be made to NHS England for an independent review. A correspondence address will be provided with contact details of your regional NHS England team.
Step 2:
Next, write a formal letter to NHS England advising that you did not agree with the LRPs decision and that you want to pursue an appeal. You can adapt the template set out in the previous blog.
Again, chase an acknowledgement. NHS England will usually send you a form (or questionnaire) to complete setting out your reasons for appeal. Your appeal will go to an Independent Review Panel (IRP).
You will need to correspond with NHS England from now on, and not the CCG. Remember to quote their reference on your correspondence to avoid unnecessary delays.
NHS England will contact the CCG directly to obtain all the relevant files, records and information that was previously available when the earlier decisions were made. No new evidence is generally obtained at this stage. There is no set timescale for this, and so this can often take some weeks to process.
Step 3:
Once the CCGs papers have been obtained, the matter will be allocated to an independent Chair to conduct a preliminary review of the evidence and to check whether there are any other outstanding issues or other missing information required. Only if the case is suitable for the appeal to proceed, will NHS England then set up an Independent Review Panel meeting. A hearing date to consider the evidence at the IRP appeal will then be notified to you. However, due to lack of resources, this could be some months away.
Make sure the date is convenient and that you can attend.
The Independent Review Panel will consist of the following people:
- 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
- at times there is also a clinical advisor in attendance.
It is vital to present the IRP with your detailed written reasons (or submissions) for your appeal in writing, together with any new helpful evidence you have obtained. A deadline for doing so will usually be notified to you in advance.
Step 4:
Preparing your written appeal submissions can be quite a daunting process. To really do the job properly, ideally you too need to get hold of all care home, GP and hospital records, consider them carefully line by line, to find areas of challenge to support your appeal, and cross-reference them against the Decision Support Tool and previous LRP outcome. Be under no illusion, preparing detailed written submissions is a skill, and can be extraordinarily time consuming if done properly. It involves spending a lot of time reviewing the evidence in each of the Care Domains, looking for discrepancies, factual errors or omissions, and drawing on evidence from all the various assessments and records to try and present your appeal.
Step 5:
It is preferable to attend in person at the IRP to argue your case for appeal. The meeting is formal and you will be given your chance to speak and address the Panel. This is not an opportunity to rant, but to calmly present your case in a professional manner before the Panel. The CCG will be represented too, and will endeavour to put their case forward in support of their previous decision to reject CHC Funding.
If you do not feel confident that you can give it a ‘good’ go, then get support, but do not leave it until the 11th hour. A skilled professional advocate will need time to collate the necessary records (which can often many weeks whilst waiting for care homes, GP surgeries and hospitals to copy records!), consult with you, draft the written appeal submissions for your prior approval before lodging them with NHS England; nearer to the IRP hearing date they will need time to prepare as your advocate. Having an advocate means that you don’t have to speak at the IRP unless you want to.
Your appeal to the IRP can be thought of as ‘your last chance saloon’ and is one area where we really do recommend you get professional advice both to prepare your written submission and to help with advocacy.’
If all fails, what next…
Appealing the Independent Review Panel outcome…
If your appeal fails at the IRP stage, your only other and final route of redress is to apply to the Parliamentary and Health Service Ombudsman (PHSO).
However, they will not consider an appeal if you merely disagree with the IRPs decision – even if you find it perversely wrong.
The PHSO will only intervene if there is an evident abuse of process, and even then, the chances of success are unfortunately quite slim. They won’t simply overturn a decision just because you don’t agree with the IRPs findings.
Following an unsatisfactory LRP last October I applied for an IRP. My CCG has still not forwarded the relevant notes to them. What can I do?
Hi, We, like everyone else have had an horrendous experience to date. Non adherence to the NF, omissions of relent information, verbal & passive aggression and intimidation. We have an appeal meeting on Tuesday and have asked to audio record the meeting. The CCG have said that we can’t but they will if all attendees agree (we are expecting them to refuse last minute) they have said they will provide us with a written transcript. The reason we want to record is to ensure they follow process, and behave in an appropriate manner towards us, a written transcript will not give us tone of voice or context (if they do record, we expect they will lose the recording, tactics they have used previously).
Does anyone know if we have a legal right to audio record the meeting?
Thanks very much
H x
Thanks Judy x
It is now almost 12 months since since the Local Resolution meeting and I have had no decision. I have written and emailed but have had no response whatsoever. It seems I am just being ignored and treated with disdain. What do I do next? Any help would be greatly appreciated.
The best thing to do is raise a formal complaint to the CCG. They then have to answer your complaint (which they will do indirectly, probably from stating their policy which they haven’t followed!). Quote the National Framework if it states a timeframe. Then if they don’t answer your complaint to your satisfaction you can respond and ask again (this is the complaint process). Once they have had two chances at answering your complaint you can escalate the complaint to the PHSO.
Officially the Parliamentary & Health Ombudsman (PHSO) can’t get involved until you have gone through appeal or complaint process, but i have found that they will open a case reference and guide you through.
I refused to continue with my mother’s LRP because they were not following NHS guidelines and the DST were not present so I could not question them. We reconvened on Nov 15th 2018 – again they were not following NFD to the letter and admitted that they had still not produced their own guideline to the appeals process. I decided to continue, challenged the DST decision on points of law / process / needs then left them to make their decision. Three months later I have still not heard. They are still paying – least the care home have not asked for extra payment so I assume that is the case.In mid-December mum left unattended had a bad fall and suffered a gruesome procedure in A&E without anesthetic so I did relay this to CCG who have yet to respond. I am not going to chase them ! Adult Care have found the care home ‘guilty’ of abuse and neglect with regard to the fall so solicitors are now involved.
Hi I’ve just received notification of outcome from IRP review 1 severe 3 high 5 moderate 1 low 2n/a. Whilst they reinstated cognition back from high to severe & one other from low to moderate after LRP had downgraded 4 agreed domains behind closed doors so denying us a chance to put our case fwd. However they are justifying CHC funding refusal re 4 key indicators have not been met even tho evidence to contrary was provided. However it looks like I’ll have to go to ombudsmen with this appeal any pointers would be most helpful towards hopefully a successful outcome. Also from feedback how likely is successful outcome with ombudsman. My mother had severe dementia was doubly incontinent with high risk of falls.
I was successful with my late mother’s claim for NHS continuing care for all but the first six months. It wasn’t easy, but it is possible so don’t give up no matter how difficult and frustrating it can be at times. I’m currently fighting the refusal of the initial six months and attended a Local Review Panel six months ago and to date have heard nothing further. Does anyone know if there is a timescale they have to keep to inform me of their decision. I have emailed them twice without success. It seems to me that rigid deadlines are set but do not apply to the CCG, unless anyone know differently.