The NHS Continuing Healthcare Funding (CHC Funding) decision-making process can be complex and you might not get the outcome you or your relative were hoping for. If you’ve been refused CHC Funding, you may be able to appeal the decision.
This is a difficult area to navigate, however, as your approach will depend on the circumstances of the assessment you are appealing and the Integrated Care Board (ICB) - previously known as Clinical Commissioning Groups - responsible for your appeal.
The National Framework for Continuing Healthcare provides broad guidelines to the ICBs as to how they should address appeals against NHS Continuing Healthcare Funding decisions. These guidelines highlight the importance of offering a meeting with the appellate to discuss any concerns regarding the assessment.
However, ICBs will often have their own local policy in place to achieve consistency in dealing with appeals.
We offer an extensive service that provides complete clarity on how to go about the appeals process. For a discussion with no obligation, get in touch with our Care Home Fees Solicitors.
How to Appeal an NHS Continuing Healthcare Funding Decision
The Continuing Healthcare Funding appeal process will depend largely on which stage you are at in your application.
If you or your loved one has been turned down for NHS Continuing Healthcare Funding, you should receive a decision outcome letter which will explain the reasons for the decision and provide details of your associated right of appeal.
Initial Checklist Assessment
The Continuing Healthcare Checklist is the first stage in determining whether an individual is entitled to free care. You cannot appeal to the outcome of this stage, but you will have the right to access the NHS complaint procedure. This will consist of:
- A written letter of complaint sent to the ICB, with the reasons why you feel you’re entitled to a full assessment. Make sure you provide as much evidence as you can at this stage and specify the areas you disagree with.
- Once you have exhausted the NHS complaints process, you can seek out the assistance of the Parliamentary and Health Service Ombudsman.
Decision Support Tool
The Decision Support Tool is completed once an individual has passed through the Checklist stage and needs a full eligibility assessment.
The ICB should enclose with the decision letter a copy of the Decision Support Tool, so that you can see the basis for the assessment and the decision taken.
Unfortunately, in our experience, some ICBs will fail to provide this and should this be the case, you must contact the ICB immediately to request a copy as without this document you will not be in a position to articulate proper grounds for appeal.
We always recommend that you communicate your appeal in writing. Make sure your letter confirms that it is to serve as an appeal and states the date of the Decision Support Tool you are appealing.
You should always set out your reasons for making an appeal in as much detail as possible. If you can’t include everything, for example, because you are still waiting for more information, state this in your letter and confirm that you reserve your right to make further representations once you have received the relevant information or evidence.
You should give consideration to:
- why you are unhappy with the decision;
- whether you feel any of the needs in the Decision Support Tool have been assessed too low;
- whether you have any concerns over the way the assessment was handled. Were your views taken into account? Did the assessors look at all available evidence, such as care plans and daily care records?
Local Disputes Resolution
Before a Continuing Healthcare Funding appeal can be escalated further, the local dispute resolution process should be invoked to resolve the matter. ICBs operate differently depending on where you are geographically, so each one will have their own localised dispute resolution procedure.
We can represent you at this stage, helping you to evidence your claim in the best possible way.
Similarly, if your appeal has been unsuccessful with the ICB and you wish to make a final appeal to NHS England to ask for an Independent Review of the decision, it’s important that you reiterate any arguments to NHS England which have not been satisfactorily resolved.
NHS England will also want to hear about the process the ICB has followed and may ask you to provide a statement setting out your experiences of the process, as well as your views about the individual’s needs.
We can assist you with all aspects of NHS Continuing Healthcare appeals and will consider any evidence you have, both from the family and care provider in order to present your appeal in the best way.
Because we know the process, the law and relevant guidance we can advise you which arguments are best to focus on.
Is There a Time Limit on Appealing a CHC Funding Decision?
There are strict time limits to exercise your right to appeal a CHC funding decision. National guidance indicates that the time limit is six months from the date of the decision letter you receive from the ICB.
Some ICBs will seek to impose much shorter timeframes. Whilst this is improper and contrary to best practice, it is important that you address this with the ICB, and we recommend seeking professional advice as soon as possible.
For further advice that is tailored to your situation, get in touch with our Care Home Fees Solicitors today.
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