Case studies & success stories
Successful Appeal Outcome
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CHC Appeals
Dear Farley Dwek have recently achieved a successful appeal outcome at Local Resolution stage for our client, on behalf of her Mother who was admitted to a Nursing Home in October 2022.
The patient was assessed initially in February 2023, but that assessment was aborted as additional information was required in relation to challenging behaviour and response to medications prescribed by the Mental Health Team. The Multi-Disciplinary Team (MDT) was therefore rescheduled in June 2023 when it was concluded that the patient did not meet the eligibility criteria for CHC funding but was eligible for Funded Nursing Care (FNC). A three-month review was subsequently undertaken in October 2023, also concluding that FNC remained appropriate.
We appealed the outcome of the DST/MDT assessment and also challenged the outcome of the three-month review. The patient was continuing to present with challenging behaviour despite prescribed medication and the Mental Health Team had concluded there was no further input they could offer.
It was noted that there was a significant disparity between the verbal evidence provided during the MDT assessment and the written records, particularly with regard to the nature and frequency of challenging behaviour. Staff were reporting significant behaviour concerns but, sadly, the written records were insufficiently robust to reflect this.
The NHS’ Integrated Care Board Assessor (ICB) had been insistent that the decision would be based on written evidence, despite strong verbal evidence to support the frequency and severity of behaviour – although a ‘Severe’ level of need was awarded in both Behaviour and Cognition domains (would normally be an indicator of eligibility). The MDT’s analysis of the key characteristics was exceptionally poor.
Farley Dwek obtained all relevant records and produced a detailed Appeal Submission Document, running to 100 pages. The Appeal Submissions Document was lodged with the ICB in support of the appeal and the ICB confirmed the Local Resolution appeal process would be instigated.
In September 2024, somewhat unexpectedly, the ICB advised that following a “peer review” of our Appeal Submission and the DST, it was agreed that the patient was eligible for full NHS Continuing Healthcare funding from the date of the DST on an ongoing basis. There was no need for a Local Resolution Meeting to take place, and it was further accepted by the ICB that the three-month review outcome from October 2023, should also be overturned.
This is an excellent outcome for the family as it has saved them the time, stress and anxiety of having to go through the Local Resolution appeal meeting.
We have now had several cases where the ICB has considered our Appeal Submission Documents and decided to overturn the eligibility decision, without proceeding to full Local Resolution meeting or appeal panel.
We are now progressing the reimbursement with the ICB which is likely to result in a significant repayment to the patient, expected to be in excess of £110,000 before interest is added.
Contact us if you want advice on the merits of your appeal or robust advocacy representation at appeal or, visit our website, or call 0161 272 5222 / 0800 011 4136 or email your enquiry to enquiries@farleydwek.com.
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