Overview:
The patient, who had been diagnosed with Parkinson’s Disease and Dementia, had a number of severe health issues and required constant supervision during waking hours. She lived at home with full-time care provided by live-in carers and paid for privately by the family.
BaNES (Bath & North East Somerset) Clinical Commissioning Group outsource their services to external company Sirona Care & Health to undertake clinical assessments for continuing healthcare funding.
Compass CHC was brought in by the family to oversee the appeal process after BaNES Clinical Commissioning Group deemed that the patient didn’t have primary health needs and denied the family access to NHS continuing healthcare funding
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The family of the patient thought her needs were sufficiently complex, intense and unpredictable in their nature to be considered a ‘primary health need’ which would have entitled her to NHS continuing healthcare funding to pay for the cost of her care in full. This is entirely separate to social care funding and the fact that she had assets over the threshold of £23,250 was irrelevant.
Accordingly, the patient’s family requested that an assessment of their relative’s care needs be undertaken. These services are commissioned to an external company, Sirona Care & Health, in Bath.
An assessment took place in the spring of 2015 following an initial checklist assessment 3 months earlier.
The first issue here is that the National Framework for continuing healthcare funding states that the entirety of the process should be completed within 28 days of the date of the initial checklist. In this instance, it was some 3 months before the secondary assessment, the Decision Support Tool (DST) assessment, was undertaken.
Secondly, and separately, there was not a representative from the local authority in the form of a social worker in the DST assessment, it is set out in the National Framework that there must be a multi-disciplinary team panel of individuals involved in the assessment to look at matters from both a clinical and social care perspective. Clearly the absence of the social care representative meant this was not possible in this case.
Despite the recommendations of the nurse assessor present at the Decision Support Tool assessment, Sirona Care & Health – the company acting on the CCGs behalf – down scored and downgraded the levels of need the nurse assessor had awarded at the initial assessment and the patient was deemed ineligible for funding.
It was at this point that the family contacted Compass CHC who instigated an appeal of this assessment.
As part of the appeal process an independent panel must be convened to review the initial recommendation and afford the family an opportunity to explain why they disagree with the outcome and how the evidence contradicts the negative decision. This took place in early 2016 (a year after the initial checklist assessment) and Tim Davies of Compass CHC represented the family’s interests as the advocate.
From the outset, the appeal meeting was farcical in that the ‘independent’ chairperson was a Director of Sirona Care & Health. The attitude of the chairperson was unprofessional and bordering on aggressive and the whole process was entirely unsatisfactory from the perspective of the family. Despite presenting the panel with clear evidence of the incorrect scores in relation to levels of need provided throughout the initial assessment and the clear primary health need that warranted the funding, the outcome of the appeal panel was that the initial decision stood.
Therefore, the family advanced through Compass CHC to an appeal at NHS England level. This took place in late 2016 where Mr Davies again represented the families’ interests and presented matters to the NHS England panel.
Examples were provided of issues which occurred when the CCG scored the patient’s needs as merely moderate in rather than high across a number of domains (or categories).
The evidence and the view of Compass CHC was that as a minimum the level of need for the behaviour domain was in fact high because the restless behaviour and the need for constant supervision presented a predictable risk of harm to the patient. In the domain of nutrition, the level of need was recorded as being ‘moderate’ by the BaNES Clinical Commissioning Group but the evidence, in Compass’ view supported a higher classification. It was highlighted that the patient satisfied the requirement of being nutritionally at risk given that she was on a fortified diet requiring dietary supplements to keep her weight at a stable level. Further, there was a risk of aspiration of food associated with the Parkinson’s Disease and the fact she had swallow function issues. In light of the fact the patient had a BMI of less than 18 and a malnutrition universal screening tool scoring of 2 which indicated she as at high risk of malnutrition, the only conclusion which could be reached was that the patient was at high risk of malnutrition and a high – not moderate – level of need was the appropriate assessment.
In the domain of drug therapies, the Clinical Commissioning Group scored the level of need as being moderate whereas Compass CHC thought the evidence supported a high domain. Indeed, the nurse assessor at the original assessment recorded a high level of need and this was downgraded by Sirona and BaNES CCG to ‘moderate’. Due to the Parkinson’s medicine needing to be administered at very set timeframes and monitored for its effectiveness and symptom control, Compass CHC reviewed that these potential fluctuations of condition meant that the only sensible outcome was a ‘high’ level of need. Further, Compass CHC argued that in light of these increased issues the needs were sufficiently complex, intense and unpredictable in their nature to warrant the consideration that the needs were primarily health needs and there was a funding entitlement.
The NHS England panel agreed and continuing healthcare funding was awarded and backdated to the date of the original Decision Support Tool assessment 21 months previously. In totally Compass CHC managed to secure c£90,000 for the family.
This goes to show that unfortunately when the National Framework is ignored, incorrect decisions can be made at every stage of the continuing healthcare funding process and even when the initial appeal process has been exhausted there is justification to pursue matters further to ensure that an individual receives the funding they should be entitled to.
