Recent success stories

Complex needs

Mr S’s late mother had previously been found eligible for CHC. However, the evidence clearly indicated this should have been for a much earlier period. Unfortunately it’s quite common for local health authorities to make a ‘compromise’ offer in the hope the applicant will accept it, thus enabling a considerable saving against their CHC budget. A retrospective application was made together with comprehensive written and verbal submissions that his mother’s needs were complex and intense, as she had been suffering not only from dementia but chronic pain from a degenerative spine and sadly developed a stage 4 pressure ulcer to her sacrum which in itself was indicative of poor care from her provider. Even though the DST scores did not illustrate a primary healthcare need, it was still possible to demonstrate eligibility in any one or more of the four key questions and in this case, it was clear that his mother did have complex and intense needs around pain management, nutrition and skin. The local health authority therefore agreed to backdate eligibility for an additional 12 months of nursing home fees.

UPDATE: The family decided to act on my view that their mother received poor care which lead to the development of a stage 4 pressure ulcer. Legal proceedings were issued against the provider who recently offered to settle out of court. Research shows that 95% of pressure ulcers are caused by failures in care and providers would be well advised to do all they can to prevent these occuring or risk legal action for neglect.

Full reimbursement of 16 months nursing home fees.

Limited care records

Mrs F’s mother moved into a nursing home due to cognitive decline associated with likely undiagnosed dementia. Sadly, this affected her psychological and emotional state of health, resulting in her refusal to eat or drink very much which led to more than 10kg of weight loss over two months and social isolation. The care provider did not consider making an application for CHC. Based on review of limited care records, I completed a draft ‘Checklist’ and advised Mrs F that an application can and should be made in light of potential eligibility and helped prepare for the DST assessment. The multi-disciplinary team agreed that Mrs F’s mother not only qualified for CHC but she would be fast tracked for it as well.

Qualified on the first application and fast tracked for CHC.

Dementia behavioural challenges

Mrs C’s father was sectioned under the Mental Health Act due to his unpredictable aggressive behaviour and then, after a short period of care at his daughter’s purpose-built annex, had to go into a nursing home where he required 24-hour care and supervision until he passed away eight months later. However, he continued to display challenging behaviour and was assessed for CHC but found ineligible. His daughter made a local appeal which was unsuccessful and then asked for my help to prepare an appeal to the Independent Review Panel (IRP). On review of the care records and CCG paperwork, I submitted the CHC assessment had been flawed from the outset. The IRP remitted the case back to the CCG for another review and I made further written representation on behalf of his daughter. The CCG admitted that Mrs C’s father should have been eligible for CHC for the entire duration of his nursing home placement and further agreed to review his needs for an earlier period.

Update: Following another assessment of Mr C's needs for the earlier period of about 12 months, the ICB (the new name for CCG's) agreed that he should have been funded for the entire period. This demonstrates the ICB selected an arbitrary date from when Mr C was first found eligible but given his needs were the same for the earlier period, they couldn't claim otherwise.

IRP remitted case back for another review and then found eligible for CHC.

Another retrospective assessment found eligible for an earlier period of 12 months.

Dementia 1:1 care

Mr J complained to his mother’s CCG about their decision to deny eligibility. He received a letter from a director of the CCG advising him their decision stood because the “law was the law.” Mr J noted with some irony the director had listed her qualifications which included a degree in law. On appeal I was able to demonstrate the directors learned opinion was wrong because his mother required extensive periods of 1:1 care to manage extreme anxiety and that sedation (via Lorazepam) was not always successful because she would often refuse to take it. Medication had to be given covertly, adding complexity to an already intensive level of care.

CCG applied the law incorrectly. On review, eligible for CHC.

Unmet psychological and emotional needs

Mr R was admitted to a nursing home after neighbours were no longer able to support him, nor did he have any family living locally. He had a history of OCD and generalised anxiety disorder but was never properly assessed by mental health and support put in place for him. He required constant attention albeit for no apparent reason, as he himself often admitted, but if staff didn’t respond he would engage in continual shouting and make unfounded allegations of staff assault and abuse resulting in the care home having to ensure 2 staff at all times for their own protection. However, was not physical aggressive. He was frequently non-compliant with care interventions resulting in the development of stage 4 pressure damage to his heel. The MDT decided Mr R was not eligible for CHC. On behalf of family, I appealed and that decision was overturned on the basis there was sufficient evidence that DST scores had been downgraded and there was intensity, complexity and unpredictably in his needs, contrary to what the MDT had claimed.

MDT downplayed needs. On local appeal, eligible for CHC and backdated 10 months.

Review of existing Fast Track

Mrs A was eligible for CHC under Fast Track as the clinical indicators suggested she was entering the terminal phase of her life. On behalf of my client, I attended the MDT meeting when it reviewed her case and noted that whilst she had rallied and was no longer nearing the end of her life, she still had sufficiently intense needs to justify on-going CHC funding. The MDT agreed and recommended funding continue. However, that recommendation was rejected by the ICB and they duly gave my client 28 days’ notice that funding would stop and thereafter she would be paying for her care. I asked the ICB to prove that exceptional circumstances justified overturning the MDT recommendation and I made a number of subject access requests. These disclosed damning evidence that senior ICB managers had meddled in the process by quietly changing some of the text in the recommendation and pressured the social worker (who was part of the MDT) to change her mind. Thankfully she stood her ground. When I challenged the ICB about this, Mrs A’s funding was re-instated and has remained in place despite a brief review 12 months later.

Dishonest and disreputable ICB management.