Continuing Health Care - Preparing to fight PCT's decision

Racoulter200752

For the IRP and the SHA appeals it is most important that you are armed with all the medical facts. You need copies of care home notes and hospital notes. Highlight any medical interventions. Futhermore, send letters to say why you disagree with past decisions to PCT, CEO of local Health Authority, PALS and panels. It is a long hard fight, but winnable if you study the National Framework and the Coughlan case. Never write to just one person. Kick up as much fuss as possible. This is how I won a payback of £17000 last year, five months after my father's death

milliemonster

Racoulter200752 wrote: »

Oramorph is not a controlled drug. It is not given as an injection but as a medicine by mouth. It is used for severe pain.

Sorry but you are incorrect, Oramorph is a controlled drug, it is morphine in liquid form

realshannon

Havent been on this link for a while as unfortunately my MIL passed away. Hugh James (Solicitors) are trying to assist via legal expenses cover on the house insurance that was in force at the time of her going into care. They are trying to finalise our CHC as I ran out of steam basically. Anyway, I diversed - I just wanted to add that after many many months of CHC assessments and alot of errors - I think it safe to say I was stressed! no one else in our small family could cope so it was just me. Somewhere I read that Altzheimers Uk or Society could provide support, so I contacted them as they linked me with a wonderful lady who knew EVERYTHING about the subject, it was a real relief to speak to someone who knew what I was going through. she gave me real support, motivation, confidence and knowledge - she was based in Manchester and I am Devon but we spoke on the phone and emailed alot. just thought for those that maybe are in a difficult place, this was a real boost - it is very complex subject when you already dont need anything else to deal with - but hope it helps
ps will post what happens with Hugh James when we hear from the insurance company but so far they have also been very helpful and knowledgeable

Katykat

Condolances RS. I'm glad you had some support. I too had a wonderful mentor, a volunteer from the CHC group. Without her I doubt I would have won. However, its shameful that we have to rely on others who have already been through the mill to help us. We shouldn,t have to put up such a fight to get what is fundamentally a basic human right- the right to healthcare when you need it most.

malid

Short update as it's a difficult time.

Attended MDT to be part of DST completion with a friend a few weeks ago. The DST went well and scoring came out at 1 Priority, 6 severe, 2 high, 1 moderate, 1 low and 1 no needs. Recommendation FOR CHC funding - no brainer really - or so we thought given her FIL's condition.

I have just found out that the LHB has turned it down!! Trying to get to the bottom of it. Will post on thread as soon as I can but gobsmacked as Welsh Assembly Government Circular states:



Establishinga Primary Health Need

31. At the end of theDST, there is a summary sheet to provide an overview of the levels chosen and asummary of the person’s needs, along with the MDT’s recommendation abouteligibility or ineligibility. A clear recommendation of eligibility forcontinuing NHS healthcare would be expected in each of the following cases:

• Alevel of priority needs in any one of the three domains that carry this

level.

• Atotal of two or more incidences of identified severe needs across allcare domains.

If there is:

• Onedomain recorded as severe, together with needs in a number of other domains.

Errata

This has got me thinking. Eligibility means only that, the person is eligible, but there also has to be a clear instrument enabling provision to all those who are eligible.
This may seem a bit odd, but I'm thinking about cancer cases for instance, where the patient is eligible for and needs a certain treatment but there is nothing to make their local health provider provide it. HTH

malid

Errata wrote: »

This has got me thinking. Eligibility means only that, the person is eligible, but there also has to be a clear instrument enabling provision to all those who are eligible.
This may seem a bit odd, but I'm thinking about cancer cases for instance, where the patient is eligible for and needs a certain treatment but there is nothing to make their local health provider provide it. HTH

I am totally perplexed. I thought the whole point of the framework and use of DST was to ensure consistency and transparency. If domains were scored according to specific criteria and a primary health need identified, CHC should be approved. At this point in time, we have insufficient information as to why th eLHB has found against the MDT recommendation. This is a huge concern as the scoring conclusions were not marginal as you can see. I will update when I have further information

monkeyspanner

This is a real problem with the DST and framework as neither specifies the criteria for a CHC award. The result is that each PCT can set their own barrier or even make a judgement on a case by case basis.

There is a document published in 2007 from the Association of Directors of Adult Social Services (link here http://www.buckscc.gov.uk/moderngov/Published/C00000124/M00002459/AI00002867/$ContinuingCareGuidanceAppendix3.doc.pdf ) which suggests criteria.
• The correct use of the DST is essential to ensuring a consistent approach
to assessing eligibility. However inconsistency may continue if LAs or
PCTs adopt different views on the combination of high/moderate (etc.)
needs that would normally indicate a PHN. As one guideline it is
suggested that anyone found to have the following combination of needs:
• two or more high needs (or need above high), AND at the same
time
• three or more moderate needs (or needs above moderate)
should normally be considered to be beyond the scope of LA provision
(see para. 5 h) below).

Obviously the needs outlined by Malid are way beyond this standard but I believe this opinion has been largely ignored by PCT's. In Malids case the priority need should have indicated a need for CHC funding as outlined in the National framework document 2009 section 77.

77.
As is described in the Decision Support Tool, the multidisciplinary team should use it to set out the evidence and enable them to consider not just the overall needs, but also the interaction between the needs, and evidence from relevant risk assessments.Although the tool supports the process of determining eligibility, and ensures consistent and comprehensive consideration of an individual’s needs, it cannot directly determine eligibility. Indicative guidelines as to threshold are set out in the tool (for example, if one area of need is at Priority level, then this demonstrates a primary health need), but these are not to be viewed prescriptively. Professional judgement should be exercised in all cases to ensure that the individual’s overall level of need is correctly determined. The tool is to aid decision making in terms of whether the nature, complexity, intensity or unpredictability of a person’s needs are such that the individual has a primary health need.

There has previously been mention on this thread of the National Framework stating that the recommendations of the assessment team should not be ignored by any PCT panel.
The relevant section in the National Framework 2009 is section 80 as below:

80.
Many PCTs use a panel to ensure consistency and quality of decision making. However, a panel should not fulfil a gate-keeping function, and nor should it be used as a financial monitor. Only in exceptional circumstances, and for clearly articulated reasons, should the multidisciplinary team’s recommendation not be followed. A decision not to accept the recommendation should never be made by one person acting unilaterally.

The National Framework for Wales 2010 ( link here http://wales.gov.uk/docs/dhss/publications/100614chcframeworken.pdf ) has a similar section 5.40

5.40 Some LHBs have a panel to confirm the conclusions of the MDT to ensure, at least, the consistency and quality of decision-making. Only in exceptional circumstances and for clearly articulated reasons should the LHB not accept the
multidisciplinary team’s recommendations. A decision not to accept the
recommendation should not be made by one person acting unilaterally.

Good luck Malid

claudiac_2

I have spent all day, on and off, reading this thread. Can I just ask if the rules apply in Scotland?
My FIL has been taken in as an emergency admittance for assessment, will be there for 6-8 weeks, is in a locked ward due to a violent episode at home last weekend. He has Parkinsons, dementia as well as other health problems, and it is highly unlikely he will be back home.
Can anyone point me in the direction of some advice on what I should be doing.
Thanks

monkeyspanner

claudiac wrote: »

I have spent all day, on and off, reading this thread. Can I just ask if the rules apply in Scotland?
My FIL has been taken in as an emergency admittance for assessment, will be there for 6-8 weeks, is in a locked ward due to a violent episode at home last weekend. He has Parkinsons, dementia as well as other health problems, and it is highly unlikely he will be back home.
Can anyone point me in the direction of some advice on what I should be doing.
Thanks

The care system in Scotland differs from England and Wales. You can find a basic guide to the system here:
http://www.counselandcare.org.uk/category/advice/pdf/care-home-fees---paying-them-in-scotland-guide-52
Arrangements for CHC funding are briefly discussed on page 40 of this guide. Scotland has not yet adopted the DST (decision support tool) systems used in England and Wales.

More detail can be found here.
http://www.sehd.scot.nhs.uk/mels/cel2008_06.pdf

As your FIL is in a locked ward I assume he is subject short term mental health detention. A short summary of these provisions can be found here. http://en.wikipedia.org/wiki/Mental_Health_%28Care_and_Treatment%29_%28Scotland%29_Act_2003
Whilst detained the NHS will be responsible for his care costs.
A full text of the act can be found here.
http://www.legislation.gov.uk/asp/2003/13

I would advise that you or another family member request to be involved in any discussion of what provision is to be made so that your FIL and carers can have an advocate.

Hope this helps.