Elsewhere we explain the system of NHS continuing care, which, if your physical condition meets certain criteria, funds your medical care regardless of your own financial circumstances.

Obviously this is of huge importance to many people and sometimes individuals may believe they or a relative deserve continuing care funding, but the assessment process leads to refusal.

In these circumstances it is important to make sure the decision is correct since this financial support can make a world of difference.  So what options are available to you?

Seek Professional Advice

Any challenge is more likely to be successful if you are supported by a solicitor or specialist in this area.  Unfortunately these challenges are complex and can rely on fine details and a sound working knowledge of the funding criteria. 

Essentially, these challenges are legalistic in nature, assessing whether the national framework and guidance have been properly applied to the individual’s case. 

This is why you should consult a professional who will be able to give objective advice about whether a challenge is worthwhile and can help with preparing written submissions.

The process of appeal is referred to as Dispute Resolution and it falls into several stages.

Primary Care Trust Review

The first stage is local and asks the Primary Care Trust (PCT) which rejected the initial application to look at the decision again.  You should apply for a review in writing, specifying exactly why you believe the decision to be incorrect.  This may include details of how the condition of you or your relative has deteriorated since the original judgement.

Decisions about continuing care funding are based on specific areas, so you should offer detail and evidence where appropriate.  The following can all help clarify the need for review and add weight to your argument:

• Specify any mistakes, misunderstandings or omissions in the assessment of the individual’s medical needs.
• Provide evidence of healthcare needs from a recent hospital assessment or from a GP who did not contribute to the original assessment.
• Use the care plan devised by social services to demonstrate specific care needs.
• Use your own records detailing conditions and incidents which demonstrate the need for continuing care.

Whilst the PCT is supposed to deal swiftly with review requests, be aware this can take several months.  You should follow up your request for a review regularly.  If you feel the process has dragged on for too long you can try to bypass this stage altogether and apply to the Strategic Health Authority to initiate the next stage.

Strategic Health Authority Referral

If the PCT does not believe there is sufficient evidence to reverse the original decision you can move to the next stage and request referral to the Strategic Health Authority’s Independent Review Panel (IRP).

The IRP is made up of three people, usually including a nursing advisor.  It works in a relatively informal way, assessing the documentation and interviewing both you and the PCT representatives separately.  They will pass the documents being used for the decision-making process to you and it is important to review these with a professional before preparing your written submission.

You should note the IRP works in an advisory capacity.  Its decision is not actually binding, but it is extremely rare for PCTs to reject any IRP ruling against them.
If the IRP decides in your favour then payments should be made retrospectively, covering the period of the dispute.  If the decision has been reached because the condition of the individual has deteriorated since the original application then back-payments will only cover the time from which this deterioration merited continuing care.

Healthcare Commission Referral

If the IRP does not decide in your favour then this exhausts the options at a local level.  Now you can take the matter to a national body, the Healthcare Commission.  The Commission can review decisions made at a local level and intervene if it judges the decision to have been in error.  Note that you can also involve the Healthcare Commission if your case has not been resolved through the previous local stages for six months.

Health Service Ombudsman

The Parliamentary and Health Service Ombudsman is there to ensure fairness and consistency in NHS procedures, providing a last resort for anyone who has been through the full review process and is still unsatisfied by the decision.

It is unlikely the Ombudsman would agree to review a case before all the previous options have been exhausted.

The Ombudsman doesn’t have the power to overturn decisions but can refer them back to the PCT or Healthcare Commission if it is believed the application for funding was unreasonably refused, the proper processes weren’t followed or the decision was not clear or based on the appropriate evidence.

You can visit the website of the Parliamentary and Health Service Ombudsman.

Honest Advice in Challenging Circumstances

Dealing with the healthcare problems of an elderly parent can be stressful and wearing.  There are so many options and such a confusing mass of information. That’s why we have created this user-friendly information library.

Nobilis provides trusted in-home care services for the general Hampshire area and we understand the challenges faced by the elderly and their families.  If you have any questions or worries about your elderly parents you are very welcome to give us a call.  Whether you are interested in our homecare services or not, we’ll be happy to share our experience with you and we promise not to subject you to any sales pitch!

Telephone – 0845 8620647