NHS Continuing Healthcare Funding: “How one family was left £50,000 out of pocket because of a seven-year care funding backlog”

NHS Continuing Healthcare Funding

Sunday 10th November 2019

The Sunday Telegraph wrote an excellent article dealing with the failings of NHS Clinical Commissioning Groups, and inordinate delays encountered as more people are forced to appeal poor or wrong decisions when rejected for NHS Continuing Healthcare Funding. Statistics produced show an increasing numbers of cases decisions being overturned.

The NHS are clearly under pressure to make £855m savings by 2021. It therefore seems more than coincidental that the number of people being rejected for NHS Continuing Healthcare Funding, or else having it withdrawn once granted, is increasing despite our ageing population.

The Daily Telegraph’s article indicates that in 2015/16 there were around 160,000 people receiving CHC funding at a cost of £3.6bn, and this is forecast to rise to £5,2bn by 2021.

The article quotes Andrew Farley, Solicitor and Director of Farley Dwek Solicitors:

“Andrew Farley of Farley Dwek, a law firm that specialises in CHC reviews, said: “We are finding that there has been an increase in cases where someone has been granted funding and has later been told it will be taken away.”

“It is because the NHS wants to save money. There are situations where it is correct that funding has been removed, but we are getting more and more people who don’t understand why the money has been withdrawn.”

“You know that when they come along and say they want to review your case, sure as eggs is eggs they are looking to pull the funding.”

Mr Farley said: “There should be some kind of independent body that regulates or oversees this process because at the moment the NHS is judge, jury and gatekeeper.”

“Mr Farley cited a recent case of an 80-year-old who was left needing care following a stroke. She first received CHC funding in 2012 but was reassessed in 2017, resulting in the cash being withdrawn. She was left with a £1,000 weekly bill for her care. She appealed against the decision in late 2017 and, while waiting for her case to be heard, she was reassessed in 2018, when funding was reinstated. The appeal eventually took place in March and determined that funding should not have been removed. Mr Farley said his firm was now recovering more than £50,000 that she should have received.”

You can read the full article here: https://www.telegraph.co.uk/money/consumer-affairs/one-family-left-50000-pocket-seven-year-care-funding-backlog/?WT.mc_id=tmgliveapp_iosshare_AtXnZ994SfZD

Case study Overview:

‘Mrs X’ (to preserve her anonymity) has the following health needs:

She suffered a stroke in 2012 which resulted in her being quadriplegic and fed by PEG tube • has a risk of skin breakdown and needs to be regularly repositioned every 2-3 hours • needs management for double incontinence and urinary tract infections • suffers with Oedema in her legs which resulted in her being on fluid restriction as she is on the highest dose of diuretic medication • has a contracture to her right hand • requires management of her medication via PEG including monitoring of pain which she experiences on movement • has heart failure • chest infections  • and fluid on lungs. 

Chronology:

08/08/2012 – Mrs X was assessed as eligible for full NHS Continuing Healthcare Funding (CHC).

17/08/2016 – A review took place and Mrs X was still eligible.

14/09/2017 At the Annual review the Clinical Commissioning Group’s assessor felt there had been changes to Mrs X’s needs and a Full Assessment (with a DST) was arranged.

09/10/2017- The Full Assessment found that Mrs X was no longer eligible for CHC funding and Farley Dwek Solicitors were then instructed to represent her.

After a detailed and thorough analysis of the relevant care home on medical records, Farley Dwek felt that there had been no significant change to Mrs X’s needs throughout this period and no justification for removing the CHC funding.

Farley Dwek appealed this withdrawal of CHC funding and a Local Resolution Meeting (LRM) – a first stage appeal conducted by the same Clinical Commissioning Group – which took place on 10/05/2018.  Although the CCG increased some of the Care Domain scores at the appeal, they did not change the overall decision and confirmed that Mrs X was no longer eligible for fully funded CHC care.

Farley Dwek launched an appeal to an Independent Review Panel (IRP) – the final appeal stage conducted by NHS England in relation to the 09/10/2017 decision.

Whilst waiting for this appeal to be arranged, Farley Dwek supported Mrs X through a new assessment that took place on 06/11/2018. The outcome found she was once again eligible for funding!

The IRP appeal before NHS England took place on 12/03/2019 to consider the earlier period from 09/10/2017 to 06/11/2018.  The Panel confirmed that CHC funding should have remained in place as there had been no change to Mrs X’s needs to justify the withdrawal of CHC!

The result has saved Mrs X around £1,000 per week in care fees.

Farley Dwek are now in the process of recouping around £50,000 of care fees which should not have been spent on care at all during this period.

Summary

Whilst many families try to obtain CHC funding for their relative and attend a Full Assessment or appeal themselves, they can often become bamboozled and overwhelmed by the Clinical Commissioning Group’s assessors and the whole process. Many quickly realise that they don’t have the right ‘tools’, ‘know how’ or stamina to fight the NHS on level terms. In Mrs X’s case, her CHC funding was wrongly withdrawn after 5 years on arbitrary grounds which proved to be fundamentally flawed and incorrect. She and her family undoubtedly suffered while seeking to reinstate critical funding.

Farley Dwek offer a FREE guide to help families through the assessment and appeals process. However, if you need professional legal help, please call is on 0161 272 5222 or 0800 011 4136

/by

“More older people dying from injuries caused by falls”

This headline came from The Telegraph on 2nd May 2019, where it stated that “More than 5,000 older people died due to a fall in 2017, marking a 70% increase on the numbers in 2010.”

That is a staggering statistic.  Deaths from falls in a care home environment should be entirely avoidable with adequate monitoring, risk assessment, supervision and care.

In addition to those elderly residents who tragically pass away, inevitably there will also be many thousands of elderly people who have fallen, but have been left with significantly debilitating or even permanent injuries; or else injuries from their fall which could trigger or aggravate other complex and serious secondary medical conditions.

A contributor to the article from Age UK, said that, “Falls are the leading cause of hospital admissions for older people” and went on to say, “The sad fact is that older people who live in poorer areas often have more complex health needs and poor access to health, care and also community services that can help people remain active and help resilience”.

Residents in care homes can be at high risk of falling due to lack of supervision and understaffing.  Some residents with intense nursing needs may require 24/7 monitoring and assistance by full-time carers.  But many care homes simply don’t have the funds or staff resources available to cope with such demands or needy patients, who by nature of their mental or physical conditions require closer attention.

Whilst staff/nursing attention is being diverted to one resident, it can mean other residents are being left on their own, unsupervised, for long periods of time.  This places vulnerable residents who need assistance with mobility, or who struggle to mobilise independently, at a higher risk of falling.  Some residents with dementia or other cognitive impairments, or behavioural, psychological or emotional needs, may be left to wander freely (sometimes outside on the street), unwatched, placing themselves and others at risk of harm, whilst staff are distracted (or simply not available).

This, too, can result in residents falling, sometimes out of bed or even down stairs – sustaining significant injuries (typically a head injury, fractured arm, wrist or leg) leading to emergency hospital admission.  Many falls tend to go ‘unsupervised’.

Tip:  It’s worth checking the care plans regularly to ensure that they accurately record your relative’s mobility needs, and any ongoing changes or measures required to assist them (eg hoisting, 2 carers for mobilisation etc).

If your relative is known to be at high risk of falling, then ensure there is a good risk assessment in place and that they are being properly monitored and supervised at all times.

A serious fall for an elderly person can have a dramatic effect and be a life-changing event for them, often leading to a loss of independence, and a rapid deterioration in their overall health.  Elderly or frail people with thin bones (and thin skin) who fall badly, don’t generally have a good prognosis.  Often it is too difficult or risky to operate on a fracture, whether due to their age, frailty or risk of anaesthetic, and they can be left in immense pain indefinitely with reduced mobility.  Bruises or open wounds can become infected and can take many months to heal. Worst still, if they cannot communicate the level of pain to you or their carers due to cognitive impairment.

Action:  If you feel your relative is not being adequately monitored and supervised, then act immediately and raise your concerns with the care home manager and ensure that a full written record is made on file.

Negligence? If your relative has fallen at a care home, or out of a hospital bed, then you need to enquire how and why this happened and whether it could reasonably have been prevented. Your relative may be able to claim compensation for their injuries. Visit our website for more information.

Call Farley Dwek on 0800 011 4136 or 0161 272 5222 for a FREE telephone consultation to see whether or not your relative may have a separate claim for negligence.

Read more on our Hospital Falls page

/by