Overturning ICB Decision

‘Carol’ (not her real name) instructed Farley Dwek to deal with appeal of her husband’s (Mr X) CHC assessment following his Decision Support Tool (DST) in September 2023. He has a diagnosis of Parkinson’s Disease, Dementia, brain atrophy and osteoporosis, with a history of fractures. He is cared for at home with support from his wife and a 24-hour live-in carer.

The DST provided by the NHS Integrated Care Board (ICB) to Carol, contained two conflicting recommendations with regard to eligibility. The first recommendation stated that Mr X WAS eligible for CHC Funding due to the nature, intensity, complexity and unpredictability of his needs – including challenging behaviour, nutrition, mobility, cognition and medication to manage his overall health. However, WITHIN THE SAME DST document, there was a second recommendation which stated that he was NOT eligible for CHC funding.

The ICB had clearly not noticed this major discrepancy when writing to Carol with the outcome and enclosing a copy of their DST!

We immediately identified this significant procedural issue and set about obtaining all care records from the live-in carer, including diary entries kept by Carol, and the GP records – which were reviewed, and relevant evidence collated.

We also lodged a Subject Access Request with both the ICB and Local Authority, to try and identify how the discrepancy in the DST had come about and what process the organisations had followed to address what appeared to be a split MDT decision as to eligibility. Both ICB and Local Authority indicated that they would need additional time to respond to our Subject Access Requests, over and above the usual timeframe permitted by the GDPR legislation.  The relevant documents had not been received by the deadline for lodging appeal and we therefore lodged the appeal request, followed by our detailed Appeal Submission in support.

Within a matter of three weeks, the ICB wrote to us to say that the decision of ineligibility had been overturned and it was agreed that Mr X was eligible for full CHC Funding. Carol was therefore not required to go through the Local Resolution Meeting and was understandably delighted with the outcome.

Nearly two months later, the documentation requested from the Local Authority has still not been disclosed to us. Although it is no longer relevant to the appeal which has already been successful, the documentation may be crucial in relation to further reviews or reassessments, and we are therefore pursuing the Local Authority to comply with our Subject Access Request. Conversely, whilst the ICB have provided disclosure of their documentation, this provides no information as to how the split MDT recommendation was addressed and how/by whom the decision of ineligibility was made and communicated to Carol.