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How to appeal against a NHS Continuing Healthcare assessment

Service directory for older people

While we trust that the NHS will professionally and comprehensively assess our parent’s healthcare needs, when it comes to deciding whether they qualify for NHS Continuing Healthcare it may be that the decision doesn’t go in our favour.

If you’re concerned that your parent hasn’t been properly assessed or the review of their needs has meant that their NHS funding has been withdrawn we share the steps to take to contest the assessment decision.

How long does a NHS Continuing Healthcare assessment decision take?

After the assessment process has been completed your parent’s Clinical Commissioning Group (CCG) should tell them both verbally and in writing what decision has been reached. Typically this will be within two weeks of your parent’s referral. Whatever the outcome of the assessment the decision is not necessarily permanent and may alter as your parent’s condition changes and their needs are reassessed.

What if my parent loses their NHS Continuing Healthcare funding after their review?

After your parent has been in receipt of NHS Continuing Healthcare for 3 months their health needs will be reassessed and their eligibility reviewed. If their condition has improved it could be that their funding is withdrawn which could lead to you or your parent footing their care bill.

It’s important to remember that if your parent’s reassessment deems them ineligible to continue receiving NHS Continuing Healthcare and you embark on appealing their decision you shouldn’t have to start paying for your parent’s care again until your appeal has been heard and resolved by the relevant authority.

This is often a point of contention with the NHS as they will assume that the responsibility for funding your parent’s care now lies with you and your family. By law health and nursing care is free of charge in the UK and your parent’s entitled to it no matter what their age or condition. NHS care should only be refused if they can reliably show that your parent isn’t entitled.

How do I appeal my parent’s assessment outcome?

If your parent was deemed ineligible for NHS Continuing Healthcare after their checklist assessment, Decision Support Tool (DST) full assessment or 3 month review you can appeal, in the first instance, to your parent’s CCG to have your parent’s needs reassessed.

You, or your parent, may be unhappy that the CCG has not followed the correct procedure to reach the decision; alternatively both of you may feel that the evidence collected or the application of the DST has not been properly interpreted.

You can write to the Manager or Appeals Coordinator of your parent’s local NHS Continuing Care Team as well as getting in touch with the CCG directly to ask them to reconsider the decision. When you write to the Care Team or CCG they may ask you to fill in an appeals questionnaire in which you can state the reasons why you’re challenging their decision as well as present evidence to support your claim.

You will have 6 months from the date of the decision concerning your parent’s eligibility for NHS Continuing Healthcare to begin an appeal with your parent’s CCG or NHS Continuing Care Team.

What happens if my parent’s been reassessed but deemed ineligible?

If you’ve succeeded in your appeal and managed to arrange for your parent to be reassessed for NHS Continuing Healthcare but they’ve been deemed ineligible for the second time you’ll need to appeal the CCG’s decision differently.

You can ask your parent’s CCG to get in touch with the NHS National Commissioning Board or contact them yourself (which has since been renamed NHS England) to request an Independent Review. Contact the regional team nearest to your parent to ask for and arrange an Independent Review on your parent’s behalf.

If you’re successful in organising a review it should be carried about by an Independent Review Panel (IRP) which is a team of representatives from NHS England, a CCG and a local authority (uninvolved in your parent’s case) as well as a clinical advisor who look at the CCG’s decision on your parent’s primary health need as well as the procedure they followed in reaching an eligibility decision.

How can I escalate my appeal or complaint?

If you and your parent are unsatisfied by the results of your Independent Review you can submit a complaint to the Parliamentary and Health Service Ombudsman. It’s worth bearing in mind that the Ombudsman will only investigate your claims against the NHS Continuing Healthcare assessment process after they’ve reviewed the evidence you’ve submitted. They clearly state on their site that they “will not review a case unless there seems to be a good reason for doing so”.

What if my parent was wrongly assessed in the past?

The National Framework was only introduced in October 2007 and, prior to that, each health authority used a different set of criteria to assess the funding a patient was eligible for. It could be possible that your parent was denied NHS Continuing Healthcare in the past but could now qualify for healthcare support.

If you believe your parent was wrongly assessed it’s best to talk to their GP about organising a Continuing Healthcare review or a retrospective assessment. A retrospective assessment will only be carried out if your parent entered a nursing or care home after 1st April 2012. Backdated claims before this date are now time-barred.

If it’s decided that your parent was wrongly assessed, then they could reclaim care home fees, including accommodation costs as well as the cost of home carers etc. This applies even if your parent no longer resides in their care or nursing home or they have died.

For more information on how to appeal a NHS Continuing Healthcare decision or help with putting together your appeal visit Care To Be Different. You can also contact VoiceAbility’s NHS Complaints Advocacy Service as well as SEAP’s Independent Health Complaints Advocacy – both charities cover different parts of the country.

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