Client secures CHC funding for future care and recovers £125,000 in paid care home fees
Farley Dwek were instructed to seek NHS Continuing Healthcare Funding for ‘John’ (not his real name, for confidentiality purposes). NHS Continuing Healthcare Funding is a fully-funded package of free care provided by the NHS where the primary reason for care is a ‘health need’.
A ‘primary health need’ is explained in the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care (revised October 2018), and in simple terms, can be thought of as care needs which are over and above what a Local Authority are legally obliged to provide.
To start the assessment process for CHC Funding, the family arranged with the care home for a Checklist screening assessment to be carried out. The Checklist (completed on 05/09/2016) was positive, and so triggered for a full assessment for NHS Continuing Healthcare Funding.
Farley Dwek arranged for one of our Specialist Nurses to meet John and his family in advance to understand his care needs, and then attended the Full Assessment as advocate for John and his family.
The Full Assessment was carried out by a Multi-Disciplinary Team (MDT) on 24/01/2017 and comprised of the Clinical Commissioning Group’s Continuing Healthcare Operational Lead and a Social Worker. The MDT considered whether there was any evidence of John’s primary healthcare needs which would indicate whether he was eligible to qualify for CHC Funding. The CCG’s assessors reviewed John’s various healthcare needs across the 12 Care Domains as set out in the Decision Support Tool, and considered them in conjunction with the 4 characteristics/key indicators (Nature, Intensity, Complexity and Unpredictability) that may, in combination or alone, demonstrate a primary health need. Our Nurse Specialist assisted the CCG’s assessors and presented arguments in support of John’s healthcare needs. The outcome was that the MDT Assessors found that there was sufficient evidence of a primary healthcare need and recommended funding be backdated to the date of the initial Checklist (05/09/2016). This great result meant that not only would John receive reimbursement of some care home fees already paid for his care (in excess of £20,000) but would also have all his ongoing care needs and accommodation paid for in full by the CCG. The outcome would save John more than £4,000 per month in care fees.
However, that was not the end of the matter. We were not satisfied with just obtaining a partial repayment for John’s past care dating back to the initial Checklist assessment. We felt it was appropriate to investigate whether CHC Funding should in fact have been granted retrospectively at a much earlier stage (from 14/07/2014 to 04/09/2016).
We reviewed John’s healthcare needs prior to the screening Checklist being completed. The Nature, Intensity, Complexity and Unpredictability of his needs had remained consistent throughout the whole period of care. Farley Dwek therefore set about obtaining all his relevant care home notes and records and GP records to see whether he was entitled to an additional repayment for the earlier retrospective period prior to the initial Checklist assessment.
A formal claim was presented to the Clinical Commissioning Group in July 2018. The Clinical Commissioning Group completed their initial review of John’s healthcare needs using the Needs Portrayal Document (NPD). Farley Dwek carefully considered the CCG’s 70 page NPD in conjunction with the all the care home and medical records received, and after consulting with the family, sent the CCG our detailed Written Submissions in reply.
This retrospective claim was then reviewed by the CCG at a Multi-Disciplinary Team Meeting, who found that John was eligible for fully-funded NHS Continuing Healthcare Funding for this earlier period as well. They agreed that the Nature, Intensity, Complexity and Unpredictability of his needs indicated that he had a primary healthcare need, and therefore he was eligible for CHC Funding.
Our client recovered an additional refund of care home fees paid for a period in excess of two years amounting to over £105,000 when interest was added.
Many families don’t realise that their relative can seek an assessment for NHS Continuing Healthcare Funding both in respect of their ongoing care needs as well as retrospectively for past care fees that have already been paid.
Pursuing an assessment for NHS Continuing Healthcare Funding is something that individuals can do for themselves without involving lawyers. Our Free Guide outlines the assessment process and what is involved. However, many families who do embark upon this process without professional input, tell us how daunting and overwhelming it can be. They soon get caught up with the emotions of dealing with their relative’s assessment, compounded by the added frustrations of battling alone against the NHS, and the lengthy delays that inevitably occur. We know from experience that many families who try to pursue CHC Funding themselves can easily get bogged down in the assessment or appeal’s process, or have the ‘wool pulled over their eyes’ by CCG assessors.
Farley Dwek are renown experts in the field of NHS Continuing Healthcare Funding and offer a ‘one-stop shop’ service to assist individuals with any stage of the CHC assessments or appeal’s process, and with retrospective reclaims.
We take the stress of dealing with the NHS on our shoulders, so you don’t have to worry. You don’t have to fight this battle alone!
Call us now, on 0800 011 4136 for a free consultation.
Posted In: Case Studies