‘Joan’ (not her real name) was living in a care home and privately paying substantial monthly fees for her care.
Her family made an application NHS Continuing Healthcare funding (CHC) but it failed, and Joan was found ineligible for free funded care. She was therefore forced to use up her savings to pay for her own ongoing care at the care home.
Her family approached Farley Dwek Solicitors to see if we could assist with Joan’s appeal to get NHS CHC funding for her care home fees.
After collating and analysing copious care home and medical records, we lodged Joan’s appeal with her local Clinical Commissioning Group (CCG).
Some months later the matter was dealt with on appeal by the CCG’s Local Resolution Meeting (LRM). Our nurse advocate in attendance found “many irregularities where due process and the NHS National Framework were not followed robustly.”
The LRM then took an inordinate time to consider eligibility, and despite much frequent chasing, no outcome decision was in sight. Our nurse advocate reported, “I am concerned the family are still awaiting an outcome of the LRM as this is usually completed on the day not 6 weeks later and still waiting….This has been extremely distressing for the family and unacceptable to not have an outcome and I believe NHSE would agree there have been major breaks within the CHC, LRM process.”
Given the delays in finalising the LRM appeal process and notifying the family of the outcome decision on eligibility, Farley Dwek lodged a formal complaint with the CCG.
In the meantime, whilst waiting for the outcome of the appeal, Joan was running out of funds and her family contacted us to say they were now having to consider selling her house in order to pay for her ongoing care. The matter was becoming even more urgent!
The LRM’s draft Decision Support Tool was eventually received some months later and it recommended Joan was indeed eligible for CHC funding. However, the LRM’s recommendation still had to be approved by the CCG, who had the final decision as to funding. Once accepted, it would result in the CCG taking over payment of Joan’s ongoing care home fees and relieve her of this huge financial burden.
Another two months on, and there was still no confirmation that the CCG had approved the LRM’s recommendations for CHC funding – despite more chasing, much frustration and anxiety, and Joan still paying care expensive daily care fees!
This triggered yet another formal complaint which eventually prompted the CCG’s agreement to CHC funding and accepting responsibility to take over funding Joan’s care home fees. Joan’s family calculate that this successful outcome has saved her over £231,000 future care during her placement in the care home. In addition, the CCG also made a backdated, retrospective payment of almost £120,000 – reimbursing Joan’s care fees wrongly paid during assessed period of eligibility for CHC funding.
The CCG’s conduct and significant delays in processing this appeal for a living patient who was running out of hard-earned funds, was simply shocking – even though the CCG were repeatedly made aware of the urgency of the situation.
The family recognise that without Farley Dwek’s intervention and perseverance to bring this matter to a successful conclusion, Joan may have continued paying for her care quite needlessly, and probably would have ended up selling her home.