Complaints about continuing healthcare funding

What is Continuing Care?

'Continuing care’ means care which is given for a long period of time to someone who is over 18 years old, to meet their physical or mental health needs caused by disability, accident or illness. ‘NHS continuing healthcare’ refers to a package of continuing care arranged and funded solely by the NHS. It is provided to anyone who is assessed as having a ‘primary health need’ 1. These people will often be living in a nursing home, but they may be receiving care at home, perhaps from relatives.

How does it work?

Assessments for NHS continuing healthcare are often carried out routinely when people go to live in a nursing home, but anyone who believes that they might be eligible has the right to ask to be assessed. There are a number of stages in the process. Usually the NHS will go through a brief ‘checklist’ which determines whether a full assessment is needed. If a full assessment takes place, the NHS will then make a decision about eligibility. If their decision is negative, the claimant or their relatives can ask for an Independent Review.

What can you do if you’re not happy

Requests for an assessment can be made after the period of care concerned – for instance, on behalf of someone who has since died. However, last year the Department of Health announced final deadlines for any new claim in the period from April 2004 until 31 March 2012. The deadlines have now passed, and we know that the NHS received about 60,000 new claims when the deadlines were announced. We understand that the NHS is currently processing those claims, and it is likely that in many of these cases, claimants will be disappointed and may think about complaining to us.

How we can help

If, after the Independent Review, the claimant or their relatives still feel that they have not had a fair assessment they can come to us.

The NHS has nationally agreed criteria for making decisions about eligibility which should mean that they have been made consistently and fairly. When we investigate complaints about decisions over eligibility, our role is to decide whether or not the NHS has carried out the assessment and/or appeal processes properly and fairly. We cannot simply make our own decisions about a person’s eligibility.

So, if we agree to investigate your case, we will look to see that the NHS has followed the process properly. If we think it hasn’t, we usually ask the NHS body to take further action. For example, we might ask them for a better explanation or another review.

That does, however, depend on us finding something wrong with the way the decision was originally made. If you bring a case to us, you will need to point out specifically how the process was unreasonable or unfair in your case. We will not review a case unless there seems to be a good reason for doing so.

The kind of things we look for

  • Were the person’s needs assessed in enough detail by a multi-disciplinary team?
  • Was the assessment clinically-led?
  • Were all the right people involved (including family and clinical staff)?
  • Was all the relevant information considered, including clinical records?
  • Was the decision explained thoroughly?

These are examples of what we are looking for when we judge whether a complaint is justified or not.

Disputes about financial redress when eligibility has been agreed

When you have succeeded in being assessed as eligible for NHS funding, you may feel that the sum you have been offered for past care costs is not enough. If you complain to us about that, we will take account of the Department of Health’s March 2007 guidance on Continuing Care Redress which sets out how these calculations should be made.You can find this on the National Archives website.

Professional representation

We do our best to make sure that we are accessible to everyone, and we try to make sure that we understand people’s complaints fully by talking to them directly if we are not sure what their complaint is about.

We know that a large number of recent claims to the NHS have been put through professional representatives (such as solicitors and claims companies) who charge for their services. We rarely find that there has been a need for a complainant to pay someone to put their complaint to us, or to the NHS. Because of this, it is unusual for us to recommend that representatives’ fees should be repaid.

Time limits

In the guidance about deadlines for claims, which the NHS works to, there are also time limits for paid representatives to prove that they are authorised to act on behalf of a claimant. These time limits are usually reasonable, and it is only in exceptional cases that we will recommend that they should be waived because an NHS body has applied the time limit unreasonably.

Complaints about delays

Because the announcement of the final deadlines for claims has led to such a large number of requests for assessments, we know that the NHS will take a while to process them. We would expect the NHS to prioritise current cases (where the claimant is still alive and needs on-going care) over past cases where there is no longer a need for financial help with care needs.

However, we would also expect NHS bodies to keep claimants informed about progress. And, of course, if your claim is approved, the guidance on redress requires interest to be paid for all of the time since the period of care concerned.

Making a complaint to us

If you feel that the way the NHS processed your continuing care claim was unreasonable or unfair, you can complain to us.

1This means that they are assessed as needing mainly health care rather than social care..