Continuing Health Care - Preparing to fight PCT's decision

CHCscandal

Monkeyspanner, as a newbie to mse and finding this thread which exactly reflects out situation at the moment I too as most others on here are in awe of you.

I note on early posts quote
It seems as usual in the Continuing healthcare assessment process you have not been kept fully informed. Your experience to date is fairly typical. I am not sure if our experience will give you any comfort, but it took us 12months, 2 appeal panels, 3 assessments and a lot of effort to get a successful retrospective and ongoing CHc award for my MIL.
unquote

that you finally gained chc.

Currently we are two years in, 3 assessments and 2 IRP panels so far, we have had after a stiff fight, gained two periods, first and last, but the 'bit in the middle' has so far been deemed as ineligible.

What seems to be the crux is that the needs identified as being complex/unstable etc in the first period are no longer present when removed from a res home to a 24 hr care home.
Of course we have been through the mill, with no assessments as discharge etc etc. I know all the new framework inside out, inclduing the managed needs still being needs but they are totally ignoring that and insisting that MiL just had social needs until she started to deteriorate in a number of areas, which in totality meant that she did fit the eligibility criteria as the needs in totality became intense.

What actually is a healthcare need, and a primary one, anyone have a definition?

Monkeyspanner, in your situation, what was the rationale for eligibility?
How did you 'win' from all the refusals? what changed ?

Can anyone help? we know we have to take it forward ourselves, we are at 2nd stage local independent appeal panel, but sinking fast at the end of our tether.

Thank you:mad:

monkeyspanner

Essentially I think it was a combination of persistence:-

We went to the last panel with a rebutal of their assessment about an inch thick and made it clear we were prepared to go though it page by page, point by point if necessary.

The fact that the hospital trust and PCT had not followed the correct process:-

Too numerous to mention everything but typical was that the the first IRP had not been provided with the latest DST and it was still not available for them at the second IRP despite them requesting a copy. We also heard that the lay chairman of the IRPs told the CHC manager in the PCT that if we took the matter to the SHA for a process review (as we were threatening at the time) the PCT would be heavily criticised for their handling of the assessment process.

and a certain amount of luck:-

We caught them on the hop because we ended up knowing the framework and DST better than the people administering the system in the early days of the new DST.

We too were awarded for periods leaving gaps were the IRP thought there was "insufficient evidence" of a primary medical need. Essentially this was because my MIL had a relatively staple period in the early part of here care home residency. The CHC manager took it on himself to award for this period (under the threat of SHA review). Also our success was acheived in a very different economic situation. As you so rightly point out there is a new DST but seemingly no rules as to how to interpret the DST scores, at least none that we have been able to find. This of course leaves a lot of scope for different PCTs to make different decisions.

I believe the next steps available to you are an SHA review this can only take place when the PCT process is exhausted I think. After that I think the next step would be a judicial review. I hope this helps.

greenflamingo_2

Thanks all for useful tips after my recent posting. We are now booked in for 2pm on the 19th May for the IRP. I am going to spend next week compiling a report under each of the DST domains - but as said we are basically fighting the Continence and Drugs/Pain caterogies where my FIL was scored as no needs despite being doubly incontinent and on steroids + 5 other meds.

Am I right in thinking the meeting is attended by an independent chairman, member of the Local Authority PCT and a relative's representative? Or are other persons present as well? Do we get to know immediately after the meeting i.e. whilst there, what the decision is or do we get told later when ? I am sure the lady administrating the meeting said something about having to wait outside the meeting room during part of the meeting so we wouldnt be present for the whole meeting?

If someone can give me their experiences at the IRP and what to expect that would be great?

monkeyspanner

Hi
My recollection of our 2 IRP meetings.
3 member panel
-Lay Chair (I say lay but he did seem to hold a lot of chairs of various panels in several PCT's)
-Retired Senior Social Worker
-Senior assessor from a different area within the samr PCT
Essentially they had been given files for consideration by the PCT, but we discovered the second DST was missing together with a number of other documents including the results of a retrospective review which had been carried out by a senior nurse assessor within the PCT.

Meeting opened with introductions and then we were given the opportunity to put our case we chose to do this by taking each DST section in turn and comparing our view with the scoring actually given. We also spent some time discusing proper process or lack of it. We then spent quite a bit of time arguing the nature and definition of a well managed need with the lay chair. My feeling was they were very open to hear our view of my MIL's condition and needs and gave us a reasonable amount of time.

We were then asked to withdraw whilst they considered our submissions and the evidence provided by the PCT. On this occasion the panel decided they wanted to make more enquiries of the PCT and the care home. We assumed (wrongly) they would get hold of the latest DST and decision for the next panel. All told I think this took about 2 hours.

Second panel (about 4 weeks later) same members. Similar ground covered but more attention paid to the initial period in the care home. Disappointingly the PCT had not come up with the second DST but strangely the panel decided to award from the date of the second DST(even though they had never seen it) but not for the initial period in the care home from hospital discharge. This was due to 'lack of evidence' for this period.
We had a protracted 'discussion' with just the lay chair at his request concentrating on our assertion that MIL's condition in the care home was stable but this was because her medical needs were well managed at the time. We came away thinking that he did not see well managed needs in the same way as us but it was clear he was less than impressed that the panel had not been given all the relevant information by the PCT. Subsequent to the panel the PCT's CHC manager reviewed the file and decided to award from hospital discharge (had he been pressured by the lay chair and SHA? - possibly)

So in your case I would suggest
-As your FIL is doubly incontinent if you can get care home records or a written assessment of how they need to manage his medical needs in this area it may help.
-If his meds need to be managed carefully by time point this out.
-I assume that if left on his own your FIL would not take his meds on time or in the right doses. If this is the case he is non-compliant with his meds. Does he ever object to taking his meds? If so make a point of saying he objects.
-Does he ever exhibit inappropriate or uninhibited behaviour? This seems to carry extra weighting as it implies additional management is required.
-Instability of Mental or physical condition seem to count in the patients favour.

Finally going back to the IRP members. This is supposed to be an independant review so I personally would not be happy if anyone from the area of the PCT involved in the previous decisions attended the meeting, as this compromises the panels independance. However, I have heard different PCT's approach the IRP's in substantrially different ways and some are still refusing to allow a patient's representative to attend. So our experience may not be what you find at your IRP.

I wish you the very best of luck.

greenflamingo_2

Thanks Monkeyspanner - so basically assume nothing and go through everything you have with a fine toothcomb. We also are hoping to reclaim what he has had to pay since entering the nursing home in April 2008 -the 12 weeks initial period. I was told by our ex-solicitor that you couldnt claim back legal fees so wondering if anyone has used a solicitor and done this.

Can you also claim back interest on the fees paid - or would this be going too far?

monkeyspanner

We did claim interest on the retrospective element and out of pocket expenses in atending the IRP's and correspondence. We did not use a solicitor so don't know if that can be claimed

chcfan24

greenflamingo there can be interaction between the domains. My father was doubly incontinent which added to the scoring in the Skin category which he scored a Severe due to having a high score on the Waterlow chart this chart can be downloaded.

My dad also scored a Severe in the Drugs domain due to the severity of his dementia he would flatly refuse to take the tablets most of the time, and the rest of the time needed a lot of persuasion. This left him very unpredictable in the behaviour domain.

I hope this helps.

chcfan24

p.s I received interest at the RPI rate which now wouldn't be very good, it wasn't brilliant when I claimed but I took into account that the full funding meant he had not paid anything from pensions during the two and half years.

nololly

I'm just at the beginning of the application for CHC for my uncle. he has had a severe stroke. this has left him immobile due to paralysis down his left side, unable to communicate. doubly incontinent, needing attention when swallowing, being on thickened fluids, and a soft diet, receptive and cognitive impairment, supervision for medication. his frustrations can occasionally result in aggressive outbursts and yet i am being told that he probably won't qualify. feel as though I am being fobbed off by the nursing staff and social workers. he is being discharged shortly to an EMI nursing home.

malid

nololly wrote: »

I'm just at the beginning of the application for CHC for my uncle. he has had a severe stroke. this has left him immobile due to paralysis down his left side, unable to communicate. doubly incontinent, needing attention when swallowing, being on thickened fluids, and a soft diet, receptive and cognitive impairment, supervision for medication. his frustrations can occasionally result in aggressive outbursts and yet i am being told that he probably won't qualify. feel as though I am being fobbed off by the nursing staff and social workers. he is being discharged shortly to an EMI nursing home.

So sorry to hear of your uncle's situation. You really need to read through this thread because it is a wealth of advice and information. I've posted several times sharing my experiences with my uncle. I still keep an eye on postings although sadly my uncle passed away on the morning of his assessment. Monkeyspanner's posts are invaluable.

My advice, refuse to have him discharged to the nursing home. Insist on a CHC assessment whilst he's in the hospital. Social services should be more helpful as CHC would mean the LA doesn't have to pay anything. Also, do not get into discussions about his ability to pay for the nursing home (or any declaration of income/assets etc.). His financial situation has nothing to do with CHC assessment although it appears that some families are being misled on this front.

Good luck.