Continuing Health Care - Preparing to fight PCT's decision

monkeyspanner

In my MIL's case a social worker was not present at either DST assessment and in fact as soon as she was discharged from hospital to a care home she did not have an active social worker as she had been "signed off". As far as the social services department was concerned she was self-funding had active representation by relatives and did not need their help and as none of their funds were involved (apart from 4 weeks of a possible 12 week disregard period) they were decidedly disinterested.

I am not sure if it is a requisite that a social worker attend as much of the documentation regarding NHS CHC assessment and funding is framed as "guidance" i.e. social services can ignore the documents and work in their own way.

I would guess that if it was a choice between Social Services providing financial support or the PCT providing funding, a social worker may be more likely to take an interest in the assessment process.

frogfez

Hi, I am a new member of the forum, dont really know what I'm doing but I read your thread with interest and I wondered if you could help me please? My problems are not quite the same as yours but you may be able to give me some practical advise??

My friend and work colleague is having sleepless nights over her MIL who is in residential care. The MIL's house was sold and the proceeds used to pay for this care until it dwindled to £23,500 and then social services helped pay part of the care bills. My friend knows there is a lower threshold when social services will take over the full payment of her care but does not know what this threshold is (she thinks it may be £9,000).

Then the dilema starts - a social worker (I think) came to my colleagues house last week to meet with her and her husband. The social worker got the husband to sign something which she then took away with her. My colleague did not read the document (because her husband is power of attorney for his mother) but is now concerned that they have agreed to sell THEIR house to pay for the MIL's care - because this is all the social worker was talking about... she couldn't (or wouldn't) tell my friend any details about anything social services will help with, not even the lower theshold amount. Her husband also did not read the document fully (stupid I know) and normally leaves his wife, my friend, to cope with everything because he finds it too stressful.

My friend is really worried and at 65 is still working because they dont have loads of savings. The husband is 71 and not worked for years due to heart problems. Can you tell me are social services allowed to try to sell their house to pay for the MIL's needs - surely they should be paying for the MIL's care once they have taken all her money?? Is there anyone my friend, or I, can talk to for advise, like age concern or citizens advise, who would know best... I dont know who to go to to help her. I'm sorry if some of the information seems rather vague but my colleague does not explain things very clearly when she is worried.

I would be most grateful for any help!!!!

monkeyspanner

frogfez wrote: »

Hi, I am a new member of the forum, dont really know what I'm doing but I read your thread with interest and I wondered if you could help me please? My problems are not quite the same as yours but you may be able to give me some practical advise??

My friend and work colleague is having sleepless nights over her MIL who is in residential care. The MIL's house was sold and the proceeds used to pay for this care until it dwindled to £23,500 and then social services helped pay part of the care bills. My friend knows there is a lower threshold when social services will take over the full payment of her care but does not know what this threshold is (she thinks it may be £9,000).

Then the dilema starts - a social worker (I think) came to my colleagues house last week to meet with her and her husband. The social worker got the husband to sign something which she then took away with her. My colleague did not read the document (because her husband is power of attorney for his mother) but is now concerned that they have agreed to sell THEIR house to pay for the MIL's care - because this is all the social worker was talking about... she couldn't (or wouldn't) tell my friend any details about anything social services will help with, not even the lower theshold amount. Her husband also did not read the document fully (stupid I know) and normally leaves his wife, my friend, to cope with everything because he finds it too stressful.

My friend is really worried and at 65 is still working because they dont have loads of savings. The husband is 71 and not worked for years due to heart problems. Can you tell me are social services allowed to try to sell their house to pay for the MIL's needs - surely they should be paying for the MIL's care once they have taken all her money?? Is there anyone my friend, or I, can talk to for advise, like age concern or citizens advise, who would know best... I dont know who to go to to help her. I'm sorry if some of the information seems rather vague but my colleague does not explain things very clearly when she is worried.

I would be most grateful for any help!!!!

Now that your friends MIL's savings have reached the upper savings threshold the social services have to assist with the care home fees. This works broadly as follows. All of MIL's income including state pension plus any benefits apart from a weekly allowance of £21.90 will be taken towards the cost of the care home and the balance up to a standard level will be paid for by the social services. There is no level of savings at which the SS will take over the full cost of the care but between the lower and upper savings (£14000 to £23000) limit the capital is assessed as having a notional "tariff income" of £1 per £250 in savings per week between those limits and this is added to the income assessed. i.e. a maximum of £36 per week.

For a very good fact sheet on funding care home fees please goto this site www.counselandcare.org.uk . Here is a more precise link for a fact sheet http://www.counselandcare.org.uk/assets/library/documents/16_Care_home_fees_paying_them_in_England_2009.pdf
The equivalent age concern factsheet is here
http://www.ageconcern.org.uk/AgeConcern/Documents/FS10Paying_for_permanent_residential_care.pdf

But there are two possible twists here.
1. Often a self-funding resident will be paying a higher rate to the care home than a SS assisted resident. As the resident transitions between self funding and SS assisted the care home sometimes insists that the same rate continues. Thus there can be a shortfall between the rate the SS are prepared to make the fees up to and the rate the care home wishes to charge.
2. The SS if they are assisting with the fees make an assessment of MIL's care needs and will assist up to the level of one of 4 different fee levels plus the possibility of a nursing supplement. Again this can create a shortfall.

For instance the standard rates for our area from April 2009:
Level 1 Standard Dependancy £295
Level 2 Medium Dependancy £309
Level 3 Mental Frailty & High dependancy £330
Level 4 Very High dependancy £391
As an example my MIL was a self-funded and paid £416/week but during an initial period at the home whilst the house was sold was SS assisted at level 3 which at that time was £315/week. This was for the same level of care so as a self-funder she was subsidising the SS assisted residents to the tune of £101 per week from the proceeds of the sale of her house. If she had reached the upper savings limit there would have been a shortfall of £101/week.

In the case of a shortfall the SS will ask MIL's family to make a third party top-up towards the weekly fees. As no-one can be forced to contribute towards the care home fees the SS need an agreement. I don't want to worry your friend but it could well be that they have agreed to a third party top-up. So it is essential that if this document was not explained in a clear way by the Social worker that your friend and husband find out what was signed and complain if it was not properly explained.

If your friend cannot fund the top-up then the council may decide to move MIL to a care home that will take the standard SS level of fees. If they cannot find an alternative care home then they cannot force your friend to make the top-up and the SS have to make up the shortfall. In any event the SS cannot force the sale of your friend house or fiorce them to make a 3rd party top-up especially if their circumstances do not allow it. The council need to spell out what they want and why they want it and also to prove there is an alternative care home that will take the level of fees they are prepared to assist up to and has an available space. Incidentally SS cannot use MIL's savings under £23000 for topping up the fees it has to come from a third party.

There are obviously a number of other issues arising from this situation not least the possibility that MIL may have to move from a care home where presumeably she is settled.

Les_Booth

Have now received official response from NHS - see below

10th November 2009
Dear Mrs **********
A full consideration of your husband, Mr Patrick ********’s healthcare needs took place on the 5th November 2009 for the purpose of determining his eligibility for NHS Continuing Healthcare funding under the arrangements for the National Framework for NHS Continuing Healthcare and NHS-funded Health Care. A comprehensive assessment of your husband’s needs was considered by Worcestershire Primary Care Trust and at this time it was determined that he does not meet the eligibility criteria.
You should be aware that you have the right to request a review of the procedure where you should clearly highlight where you believe that the Primary Care Trust have not followed due process. Please write to Continuing Healthcare Manager .......... stating your reasons for review. A copy of the Decision Support Tool is available on request.
If you require any further clarification about the Continuing Care process or the arrangements of care for your husband please do not hesitate to contact a member of the team on the above number.

Senior Practitioner for Continuing Healthcare

It appears they are only offering a review if I think due process has not been followed.
I am still unsure about whether due process has been followed, but I am sure we can question some of the 'scores' on the DST.
I would be interested to hear what you think the next step/s should be please.
Thanks
Les

CHCscandal

Les, Sorry to hear you are still striggling to understand that the process has not been followed in your BiL's case so far.

Below is a copy of post 345 see & refer ALSO posts 310/314/316/320/ 324/ 331 / 340, 343
also copied below your post 351 with answers again in red

RE your latest post 365 , the letter confirming ineligibility, the letter is not compliant with the current mandatory framework, where it clearly
advises that a full, comprehensive rationale must be given in writing when informing you that NHS CHC us not applicable,
as to why a health need either doesn't exist or is not primary if it does exist!!



Of course if any health need does exists,& they have advised you that it does because they very kindly have awarded your BiL the funded nursing contribution, whilst not carryiing out this process correctly either.

When the full CHC assessment is carrried out and duly found ineligible for NHS FF CHC, a SEPARATE funded nursing contribution assessment MUST be carried out. the CHC asssessment does not assess for funded nursing contribution, this is an input related assessment, although they actually don't need to do this now as there is only one band, whereas previosu to 1/10/07 there were three, which band depended on the INUT, from a registered nurse, i.e.
WHICH IS NOT NHS FFCHC, THIS IS DEPENDENT ON HEALTH NEED, NOT NURSING INPUTS, MANY MANY PEOPLE WHO HAVE CHC
DO NOT HAVE NURSING NEEDS OR IF THEY DO THEY ARE NOT EXCESSIVE.

The con trick is to call the documentation NHS Funded Nursing and the office that control it the NHS Funded Nursing Team, a deliberate attempt to put the phrase into the general publics perception
that only funded nursing contribution is applicable, when in fact this is a secondary, CHC is the only MANDATORY assessment and primary reason that
every case is assessed as a duty of care, not claimed, not a benefit, not a poor relation to fudned nursing contribution.

CHC is not about nursing need what so ever, they make that quite clear, it is about a HEALTH NEED only, not a NEED for Health CARE.

Your PCT, has not followed procedure yet again in both respects, recently a PCT had to pay £100k back to the family of Mrs Rowe, I think it is your PCT? link enclosed, here:-
[URL="mhtml:{648DC2E2-4F05-4994-9C5D-0F22C5857FA6}mid://00001341/!x-usc:http://www.dailymail.co.uk/news/article-1207384/Council-ordered-pay-100-000-family-Alzheimers-sufferer-refusing-pay-care-home-fees.html"]http://www.dailymail.co.uk/news/article-1207384/Council-ordered-pay-100-000-family-Alzheimers-sufferer-refusing-pay-care-home-fees.html[/URL]
.

POST 345

If a health need exists then that is the primary reason someone has health need/s, due to this fact the dientified health needs take primary position over anything else
because social care needs are a direct consequence of a health need, and social care is provided free of charge within healthcare,
all clearly acknowledged in the framework documentation, which it is a lot to take in, digest and understand when in this very stressful situation.

The fact is the social services and the NHS did not carry out their duty of care to assess your biL when in hospital, it is mandatory,
following this, the process used to date seems to be their own 'take' on the mandatory directions and repsonsibiltiies.

Within your case, both the process and the application fo the process have not been followed.

When appealing after a CHC assessment has supposedly been carried out and the PCT have held their first level panel. There is generally no going back after this point, that is why it is essential that the CHC MDT/MDA is carried out correctly and comprehensively right first time.

The appeal process is the only hope and it's remit is to merely check

1. has the process been followed,
2. has the 'criteria' been applied in accordance with the directions.

When a PCT IRP panel or the SHA IRP panel is the next stage after CHC assessment, it is imperitive that either or both of these points are applicable, the panel will not deliberate on the actual eligibility decision, that is made quite clear within the framework.
Appeal panels have two functions, they merely scrutinise the PCT for the process and application of the process, that is amde clear within the framework.

It is clear that in your case Les, the process has not been followed and the application, resulting in the weakest rationale I have every seen, from both the assessor and the PCT panel is another area for appeal.

These are definite grounds for appeal to the relevant to the IRP panel, the IRP panel must return the case back to the PCT to complete properly, if they are doing their job correctly.
This is the basis of the appeal submission, firstly the process has not bee followed, secondly the application/rationale is not robust.

The rationale for ineligibility must be comprehensive, and state why a health need doesn't exist, from both the assessor and the panel ratification of the assessors findings,
the sentences in your case are not acceptable.
The Ombudsman can always be consulted at any time to verify any informaiton, prior to 1/4/09 the Health Care Commission was the first step prior to the Ombudsman for Current Cases,
they could 'clarify' whether or not the process had been followed.

A current case, is any case where the predominant relevant period which may be CHC is after 1/4/04, this includes periods prior to 1/4/04 as long as' most of the period' is after 1/4/04.

If anyone was in 'care' or thought to be eligible within 'a care regime at home' prior to 1/4/04 as time moves on each year the period prior to 1/4/04 comes within the 'current' classification not a restitution classification.

Although cases for resitution have been advised as closed off, anyone can bring any cases to the attention of the PCT at any time, if their case is current.

If anyone discovers that their case may be relevant to CHC they can legitimately request a review, the relevant date that the PCT cannot go beyond is April 1996.



Your POST 351

Dear Mr Booth



I reply in response to your email.



Social Services carried out an Adult Care Assessment, dated 7/10/09. The social worker identified that Mr ***** required a Continuing Healthcare (CHC) Screening.
The screening is carried out when someone becomes a permanent resident in a Nursing Home (this is not true, it should ahve beenc arried out as discharge when it became obvious that
care home palcement was required)
and looks to see if the client is eligible for CHC funding..
There is a further screening after 3 months and thereafter, a routine annual review unless there is a change in health needs. (this is not true at this stage, this statement is only true if the screening, ie checklist shows that the perosn is not eligible for full chc assessment.




The NHS Funded Care Advisors (FCA) assess eligibilty for NHS continuing healthcare based on assessed health needs.
The first part of the screening is completion of a checklist.
This was carried out by Simon **** (FCA) at the review visit on 20/10/09 at ****Nursing Home (NH). The result of the screening was that Mr ***** had a positive checklist, therefore, Simon completed the Decision Support Tool (DST).
This took into account supporting evidence from Nursing Home documentation and NH staff. (this statement is non compliant, the assessment should have taken account of ALL records, notes from the beginning especially as the mandatory assessment at discharge was NOT carried out)
I understand that you were present at the review meeting with Mrs ***** and that Simon spoke with both of you.
( You & Patrick's wife, & anyone else you may have required at this meeting, should have to hand ALL details, records, etc that the PCT have access to, when attending in order to 'dialogue' with the ASSESSORS/ not a single person from the PCT, and scrutinse their INTERPRETATION, which is all that the assessment is merely interpretation)


Following completion of the DST a recommendation is made based on the assessment of health needs. (which should have been conveyed to you clearly at the end of this meeting, also signed and agreed or disagreed by yourselves)

The DST is then considered by the Continuing Healthcare Senior practitioner (this is not normal practice, the framework clearly states, that a singel person unilaterally cannot make a decision, it also states that most PCT's use a panel, which is generally a gatekeeping function, this panel/person are really the funding/budget/finance person, they in principle have to RATIFY, the DST decisiion not form their own decision, condsidering! it is not an option!!!)

who signs it off and a letter is sent to the appropriate relative/next of kin.

This letter will give you the information which you require should you wish to appeal.
The Senior CHC practitioner signed off Mr *****’s DST on 5/11/09.
The CHC Team is based in Worcester. (they appear to use their own interpretation of the national framework, fettering discretion is the usual phrase to describe this practice)



As you sent the Power of Attorney documentation to the office (via email) we were able to let you have a copy of the DST, which you collected in person from the Funded Care office.
You should also receive a letter from the CHC Senior Practitioner explaining the outcome of the review – which was that Mr ****** is not eligible for continuing healthcare funding at this time. He will be due a review in 3 months.
(This requires a full clear rationale the letter you posted does not comply with directions)



As Mr ****** is now a permanent resident at ***** NH, he receives a ‘Funded Nursing Care’ payment from the NHS of £106.30 per week (paid directly to the NH on a monthly basis) to pay for the registered nursing element of his care.
(Which is WHAT?)


At the date he became a permanent resident there would have been a retrospective payment made for the period of respite care – paid to ***** NH.



In brief the CHC checklist was completed on 20/10/09 and Mr ***** has had a full NHS Continuing Healthcare Assessment. End of post


finally:-

As advised earlier, this case started prior to 1/10/09, therefore the previous framework rules apply, the PCT's know this but try to impose the post 1/10/09 revision on all decisions from 1/10/09, and knew well before the public did about the CONTENTS & changes of the revision 1/10/09.

The main change being that for all NEW patients from 1/10/09 7 not cases under revieww which were in the system prior to 1/10/09, when an eligibility decison is reached that decison is upheld/remains whilst in appeal,
WHEREAS PRIOR TO 1/10/09, IF FOUND INELIGIBLE, THE NHS MUST PAY FOR CARE UNTIL ALL APPEAL PROCESS HAS BEEN EXAUSTED, THE SS HAS NO PART TO PLAY AT ALL UNTIL THE FULL APPEAL PROCESS HAS BEEN EXHAUSTED, INCLUDING OMBUDSMAN.

In view of the fact that the NHS were negligent in never assessing in your case and many mnay others, as is their statutory duty at discharge, you may wish to stop payment and refer the care home to the NHS.

The SS and / or NHS together manoeuvred Patrick into a care home for respite, when he was in there, they neglected their statutory, mandatory duties of care to assess for CHC FIRST until your sister requested it!, the care home are complicit too and may I say complacent in this area too, as they presumptiously took the funded nursing contribution very kindly off the fees, even though an assessment had not even been convened, as a matter of course, whilst they waited for it to be confirmed??!!!, You advise this is the current situation.

Every report, media article etc for years even NHS choices, confirms that the process is complex, when people, especually vulnerbale people, family in particualr are faced with these types of situations, they are not told of their absolute rights regarding this matter which is statutory, mandatory and part of both NHS and SS's duty of care.
Maladministration causing injustice has cocurred, when the assessment is not carried out at the outset, first and foremost before anything else, this is the ombudsman's findings and is applicable to every case where the process is not followed.

As advised also, an appeal panel, will not look at the DST, they will only scrutinise that the PCT have followed the process, in order to make sure that they are covered, the appeal panel works for the PCT,

If you appeal, you have to tell them where they have not complied, if they discover that you may have a case that the ombudman may agree with, they will then have to refer the whole case back to the PCT to start again, totally,

The appeal panel will not voluntarily carry out this function, in fact an IRP chair, unilaterally makes the decision, (Annex E) if they do not believe that the 'evidence' shows that the process has been breached, then they won't hold an appeal panel, they MUST refer the case back to the PCT.

Les_Booth

Hi CHC
I really do appreciate the time and effort you are taking in helping with this. As we speak I'm rather busy- but will print out your response and take it with me when I visit Patrick this afternoon so I can have a quiet read then.
Sorry if I appear to be obtuse - will try to do better in future :-)
Many thanks
Les

Savvy_Sue

Les, you are NOT obtuse! It really is that complicated ... and I fear we're going to be facing this in the not too distant future.

monkeyspanner

Thanks CHC for the comprehensive reply.

Could I pick up on one point? In the 2 PCT IRP's (spring and summer of 2008) that were held in my MIL's case the emphasis was almost entirely reviewing the medical evidence and decision based on the DST. The lay chair was very reluctant to discuss adherence to process by the PCT even though we wanted to raise several points of non-adherence at that time.

Although not relevant now as we obtained retrospetive NHS CHC funding, I assume from what you have written that the PCT's IRP process we experienced was also not adhering to the National framework.

CHCscandal

monkeyspanner wrote: »

Thanks CHC for the comprehensive reply.

Could I pick up on one point? In the 2 PCT IRP's (spring and summer of 2008) that were held in my MIL's case the emphasis was almost entirely reviewing the medical evidence and decision based on the DST. The lay chair was very reluctant to discuss adherence to process by the PCT even though we wanted to raise several points of non-adherence at that time.

Although not relevant now as we obtained retrospetive NHS CHC funding, I assume from what you have written that the PCT's IRP process we experienced was also not adhering to the National framework.

Yes moneyspanner, this is an area where the rules are again interpreted.

The appeal panel, apparently doesnot have the authority to change a dst marking, but can advise if they think it is wrong (application).
If they find this, they should then refer the case back to the PCT to re-address.
Framework directions seem tosupport this?


The whole CHC scenario is open to interpretation only, how each SHA area interpret their role within it, seems to differ.

In the recent media case of Mrs Eyton Jones, link here:- [URL="mhtml:{648DC2E2-4F05-4994-9C5D-0F22C5857FA6}mid://00001352/!x-usc:http://news.bbc.co.uk/1/hi/wales/north_west/8198159.stm"]http://news.bbc.co.uk/1/hi/wales/north_west/8198159.stm[/URL]

Mr Line, her son in law, confirmed that, as in your case, the SHA IRP after using the new DST on this case for a period which was not within that timeframe, moved some domains up to severe and sent the details back to the PCT to 'ratify' the SHA Irp was North West..

In our case, we have been told by the SHA that the IRP cannot act as a MDT/MDA as they only have one professional health representative on the panel.

The chair is merely a lay person and the social services rep cannot assess a health need, but that their duty and function is to scrutinise the process used firstly then the application of the process to determine if it may have not been applied appropriately, if they decide it has not their duty is to return the case to the PCT to re-address?

The SHA is North West in our case.

In your case, are you advising that theSHA IRP appeal panel, changed the interpretation / markings/dst of your PCT/assessor in that meeting which meant that eligibility was then applicable?, did they then send their findings back to the PCT to 'ratify'?

Les. the government and every other commentator on CHC agrees that this is a complicated and complex area, which is being made as difficult to interpret as possible in order to justify the registered nursing contribution as the only NHS responsibility in continuing healthcare, and as sue says, it will not get any better in the future.

Pam coughlans case clearly defined the social services lawful responsibility in this area, the benchmark was then set.
Maureen Grogan case in 2006, defined another legal area where the SHa/PCt's had to rush to check, because the judge suggested that there was a 'GAP' in provision which is not lawful and not allowed.

When the social services responsibility stops, then the NHs fully funded continuing care responsibility starts, that is the law, the Govt have introduced the 'gap' filler, RNCC/funded nursing care now renamed just 'continuing care, which is all that is promoted, whereas Fully funded continuing Healthcare is the primary acknowledged service to be assessed first with the RNCC merely supposedly representing a very small area of health need, measured by inputs of nursing involvement.

To challenge a professionals' opinion/interpretation is very daunting.

I apologise if my use of the word 'struggling' was interpretted wrongly, I use it only in the context that it does mirror what everyone finds when faced at very stressful times, with the daunting task of challenging the authorities for not carrying out their duty of care, whilst trying to come to terms with the immediate care needs of family, friends etc that are possibly not being met and not being put through the mandatory processess.

Les_Booth

CHC
No need to apologise at all - struggling was very apt. Thought I'd have a quiet half hour in the home before they brought him to his room - but they brought him down within 5 minutes - so spent the next hour (until sister arrived) just chatting to him and desperately trying to understand what he was talking about - at least there were a number of smiles - made it all seem quite worth while. Will get down to your reply in detail as soon as I get a couple of hours free.