Overview: Retrospective Welsh Case
This case illustrates the drastic failures of Health Boards to accurately apply the national framework, such that they grossly undermined the care needs of the patient to the extent that Compass CHC successfully appealed 8 disputed care domains and secured Continuing Healthcare funding.
Details of the case:
This was a retrospective case concerning a patient with vascular dementia, frequent agitation and challenging behaviour. Compass CHC were instructed by the patient’s son, who was seeking to recover the cost of six months of care fees.
As this was a Welsh case, it had been assessed by Health Boards prior to it reaching the appeal stage. Specifically, three separate Health Boards had assessed the patient’s needs and concluded that the patient did not have a primary health need and therefore, did not qualify for Continuing Healthcare funding. Each Health Board that reviewed this case had significantly and grossly undermined the care needs of the patient. The third and final Health Board that reviewed the case had awarded 4 High levels of need, 4 Moderate levels and 3 Low levels of need. When appealing the decision, Compass CHC submitted that the patient had 4 Severe levels of need, 4 High levels, 2 Moderate levels and 1 Low level of need. As such, 8 care domains were disputed, illustrating the extent to which the Health Boards had dramatically undermined the patient’s care needs and failed to conduct an objective and accurate assessment.
While Compass CHC successfully appealed 8 care domains, we wish to outline the arguments for 3 of the care domains that encapsulate the frequent misapplication and oversight of the national framework that takes place at Continuing Healthcare assessments.
The care domains:
The most notable failures of the Health Boards related to the Mobility domain, the Psychological & Emotional domain and the Communication domain.
Mobility domain:
The Health Boards had each maintained that the patient had a Moderate level of need in Mobility, whereas Compass CHC submitted that a High level of need was satisfied. The Advocate from Compass CHC that attended the appeal noted that the Health Boards had misapplied the national framework in a way that frequently transpires at assessments nationally.
The dispute was concerning the patient’s falls history, risk assessment, and subsequent level of need; with the Health Boards awarding a Moderate level, whereas Compass CHC submitted a High level of need. In this domain, a High level of need relates to a patient who (a) has been assessed as being at high risk of falling, and; (b) has a history of falls. Often, assessors will attempt to apply their own broad, unsupported interpretation of the national framework, force a comparative approach and attach artificial brackets to descriptors by alleging, as they did so in this case, and attempted to maintain at the appeal, that an individual that is frail and cognitively impaired will always have a high falls risk assessment, but that it does not necessarily mean they are at a high risk of falling. Further, it was alleged by assessors in this case that the falls were not frequent, severe, did not cause significant injury and so do not satisfy a High level of need.
This unsupported, broad, comparative approach at assessments leads to significant disparity and variation across England and Wales in terms of how the national framework is applied. There is no provision in the national framework, practice guidance or any other form of supplementary documentation encouraging assessors to neglect risk assessments. Similarly, there is no provision that states a patient must be falling monthly, weekly or daily or must have sustained significant injury. Rather, a falls risk assessment assessing a patient as being at high risk of falls, coupled with a history of falls, is all that needs to be satisfied for a patient to qualify as having a High level of need.
Psychological & Emotional domain:
In this care domain, the Health Board had supported their contention that a Low level of need was satisfied by stating that the patient did not “require anything other than general support and reassurance”. Compass CHC disputed the Low level of need in this domain and submitted that a High level of need was satisfied. The Health Boards had blatantly disregarded that this patient was prescribed Lorazepam on an ‘as required’ basis to manage agitation and care staff were required to provide close supervision when the patient was experiencing periods of distress. The evidence of the medication for agitation and the care plan relating to the management of the patient’s mood disturbance was outlined clearly in the care records. Yet, these records were disregarded by the Health Boards. As such, Compass CHC submitted at appeal that the Health Boards rationale for the level of need in this domain was unjustified and contradicted the records that illustrated that the patient rarely responded to reassurance.
Communication domain:
This care domain was significantly disputed, given that the Health Boards had maintained that a Low level of need was satisfied, whereas Compass CHC were successful in submitting that a High level of need should have been awarded in this domain.
The Communication domain is frequently misinterpreted at local level. Communication, for the purposes of the Continuing Healthcare assessment, seeks to assess an individual’s ability to “reliably” communicate their “needs”. Instead, as was the case in this appeal, assessors had concluded that because the individual was able to speak, in that they could say words, albeit out of context, and referred to their long-term memories, the patient was able communicate, but just required some support. At appeal, Compass CHC disputed this on two points. Firstly, that there is a very clear and important distinction between speech and reliable communication. While the patient could speak, the patient did not communicate any basic care needs, including pain, hunger or thirst, in a way that was or could have been deemed reliable.
Our second point when disputing this level of need related to the Cognition domain. Specifically, at this stage of the appeal, it had been agreed that the patient had a Severe level of need in the Cognition domain. Accordingly, we highlighted that an individual with severe cognitive impairment is deemed, by the national framework, as being “dependent on others to anticipate their basic needs”. As such, we made the submission that a patient considered to be severely cognitively impaired is unable to communicate reliably for the purposes of the national framework, given that they have no insight into or awareness of their basic needs. Both of our points in this domain were accepted at appeal.
Summary:
This case highlights the unfortunate reality wherein numerous separate Health Boards repeatedly upheld an unjustified, procedurally incorrect decision, illustrating the necessity to have expert knowledge of the national framework and eligibility criteria to ensure that an objective, thorough and accurate assessment of a patient’s care needs is completed
