Continuing Healthcare and Funded Nursing CareLocal ReviewPolicy
1.1This is the NHS SheffieldLocal Review Policy. It is created in accordance with paragraph 151 of the National Frameworkfor Continuing Healthcare (CHC) as revised in November 2012. It is designed to set out a clear pathway as to how individuals, or their representatives, may challenge a decision regarding eligibility for an episode ofCHC.
1.2The Health and Social Care Act established new structures and a framework for the NHS, with effect from 1 April 2013. Regulations issued under the Act set out the Standing Rules to be followed when determining eligibility for CHC.
1.3The Regulations are supported by the National Framework for Continuing Healthcare, which was revised in 2012. The Framework and the associated Practice Guidance assist with the application of the Standing Rules.
1.4The Standing Rules use the term ‘review’ when referring to a challenge made by an individualor their representatives, following an assessment of eligibility for an episode of CHC. This policy uses the term ‘appeal’ to describe such circumstances.
1.5This policy only applies where an individual has been assessed for eligibility for an episode of CHC and is seeking a review of the outcome of that assessment, or their representative is seeking a review on the individual’s behalf. It does not apply where an individual, or their representative, believes they should have been eligible for CHC for an unassessed period of care.
1.6This policy applies to all assessments for eligibility for an episode of CHC where Sheffield Clinical Commissioning Group (the CCG) is the Responsible Commissioner.
1.7The policy aims to:
- provide transparency on the appeals process.
- ensure alignment with the National Framework and Department of Health guidelines and timescales.
- ensure alignment with theprocesses regarding Independent Review Panels.
1.8The policy applies to all patients who have been assessed for Continuing Healthcareand wish to appeal within 6 months of an eligibility outcome.
1.9This policy has beenconsulted on with partner agenciesthrough the CHC Operational Group. It has been and disseminated through partner agencies.
2.0 Requests for Appeal
2.1This policy applies to appeals made afterApril 2012 in line with national guidance, which can be found on the Department of Health website at:
Appeals that were made before April 2012 will continue in line with the previous appeals policy.
2.2A request for an appeal must be madeno later than 6 months from the date stated on the letter of the original eligibility decision and may be made in the following circumstances:
- where an individual or a relevant party is dissatisfied with the decision regarding eligibility for NHS CHC; or
- where there has been a failure to follow Sheffield CCG’s procedure in reaching its decision as to a person’s eligibility for NHSCHC.
2.3 This policy is not for use where disputes arise between public bodies as to funding responsibilities.Sheffield CCG and Sheffield City Council have agreed a separate Disputes Policy for use in such cases. Disputes between Sheffield CCG and other bodies are settled with reference to the Department of Healthguidance such as the National Framework for Continuing Healthcare and the Responsible Commissioner guidelines.
2.4A request for anappeal can only be made once aneligibility decision is ratified. This initial eligibility decision will continue to apply until the review has been completed. If the appealresults in a different eligibility decision being made, Sheffield Clinical Commissioning Group will usually treat this decision as if it had been made on the date of the initial eligibility decision. However, where the different eligibility decision arises from a change in need which occurred after the former assessment the new decision would only be back dated to that change.Where appropriate, i.e. where, throughthis review process, aninitial decision is overturned then,the CCG will consider whether to refund the reasonable direct costs of care incurred by the patient. Decisions regarding refunds will be made in line with the Department of Health’s Refunds Guidance and any associated guidance produced by the CCG.
2.5This policydoes not apply to requests that the CCG review its decisions regarding packages of care. Where a patient or their representative does not wish to accept an offer of care made to them, they may challenge this decision using the CCG’scomplaints process.
2.6This policyis not for use where patients / representatives wish to challenge the content of the eligibility criteria or the National Framework. Queries about the National Framework and associated policy should be directed to the Department of Health.
2.7An assessments for eligibility for an episode of CHC will only take place where a patient has screened in, following the completion of a Checklist. Where a health and social care practitioner has been asked to complete a Checklist for a patient, but has declined to do so, the patient or their representative may challenge this decision. The patientor their representative should raise this with the practitioner direct in the first instance. However, where the practitioner continues to decline to complete a Checklist, the patient or their representative may address this request direct to the CCG. The CCG will then consider whether it would be appropriate for a Checklist to be completed, in line with the National Framework.
2.8In cases where the individual does not have the mental capacity to manage their own affairs a representative may request an appeal of an eligibility decision on their behalf if they hold one of the following documents:
•A Lasting Power of Attorney which has been registered with the Office of the Public Guardian. This can be either a Health and Welfare Lasting Power of Attorney or a Property and Financial Affairs lasting Power of Attorney;
•An Enduring Power of Attorney which has been registered with the Office of the Public Guardian.
•An order of the Court of Protection appointing them as Deputy and the order enables them to decide to request a review of an eligibility decision.
•An order from the Court of Protection, deciding that a review of eligibility should take place.
2.9Where no person holds any of the documents listed in paragraph 2.8, Sheffield CCG will consider each case on an individual basis taking into account what would be in the best interest of the individual.
2.10There are limitations as to when the CCG may share information when the patient is deceased. The Department for Health has issued guidance on sharing such information Sheffield CCG will apply this guidance to sharing information in respect of appeals. This guidance is therefore incorporated into this policy as appendix one.
2.11An illustrative process chart is attached at appendix two.
3.0 Stage One Review– Departmental Process
3.1 An initial request for an appeal againstan eligibility decisioncan be made where:
- the patient has been screened out for assessment for an episode of continuing healthcare. The screening will be recorded on a Checklist; or
- the patient has been assessed for eligibility for an episode of continuing healthcare and disagrees with that decision. This assessment will be recorded on a Decision Support Tool (DST)
3.2The appeal must be received by Sheffield CCGwithin 6 months of thedate of the letter sent to the patient, notifying them of the outcome of their assessment. .
3.3Where a dispute has been raised under the Disputes Policy referred to in paragraph 2.3, the final eligibility decision will not have been made until the dispute has been resolved. Therefore the 6 month deadline for lodging an appeal will not commence until the date of the letter to the service-user telling them the outcome of the dispute.
3.4 If an individual has screened out for full consideration following the use of a Checklist and an individual / representative wishes to the appeal this decision NHS Sheffield will give full consideration, taking into account all information available including any additional evidence provided by the individual / representative. The decision as to whether to assess a patient in these circumstances will be made by the Lead Nurse for NHS Continuing Healthcare at NHSS. The criteria that she will use to make this decision are set out in a separate guidance document, called “Completing a Checklist to Screen a Patient for Assessment for NHS Continuing Healthcare”
3.5Where a patient screens in for assessment for a period of CHC, an assessment will take place, by a multidisciplinary team. The multidisciplinary team will be coordinated by a Nurse Assessor appointed by Sheffield CCG. The multidisciplinaryteam will make a recommendation to the CCG, regarding the patient’s eligibility for CHC. Once a recommendationhas been ratified,an outcome letter is sent to the patient, informing them of the decision. This letter containsdetails of the person to contact if the individual or their representative wishes to request a review ofthe eligibility decision.
3.6Arequest for an appealshould usually be made in writing. If a challenge is made orally, the individual or representative must be encouraged, or where necessary, assisted, to put their appeal in writing, including email.TheCHC team will take details of an oral request for a reviewwhere a person is unable to put their request in writing due to illness, disabilityor unfamiliarity with written English.
3.7The appeal letter should be acknowledged in writing within 5 working days of receipt.
3.8Where possible, a member of the CHCTeam will meet with an individual / representative to discuss their concerns and reasons for appealing, to explain the process and to make every effort to ensure that they have a clear understanding of both NHSCHC eligibility criteria and how it may be applied to them.
3.9 Where an individual or their representative wishes to continue anappealfollowing the discussion referred to in paragraph 3.8 a second assessment of eligibilitywill be arranged. A different Nurse Assessor from will be allocated to co-ordinate this second assessment of eligibility as part of a multidisciplinary team, and the patient and their representative is encouraged to participate in the assessment. As stated in the National Framework, neither the patient nor their representative is a member of the multidisciplinary team. The recommendation of multidisciplinary teams may be different to the recommendation that the patient or their representative believes they should make.
3.10The multidisciplinary team will make a recommendation to the CCG regarding the patient’s eligibility for CHC. Once a recommendation has been ratified, an outcome letter is sent to the patient, informing them of the decisionwithin 14 working days of the date that the decision was made. Assessments that are completed as a result of a request for anappealwill be considered at Sheffield CCG’s CHC Eligibility Panel.
3.11The timescale from 3.6 to 3.10should be 3 months. Where this does not occur the reasons for this will be documentedand explained to the patient or their representative.
3.12If the individual / representative remain dissatisfied with the outcome then they can write to the Sheffield CCG Continuing Healthcare Appeals Team, these contact details are included in the outcome letter and the appeal then becomes a Stage Two Reviewand is part of the Local Review Policy.
4.0Stage Two Review.
4.1Wherean appeal of an eligibility decision continues the initial eligibility decision will continue to apply. Where a patient is in receipt of other NHS funded care (ie a joint package of care or Funded Nursing Care)they will continue to have regular reviews, which will consider their on-going eligibility for CHC and the suitability of their package of care.
4.2 A request for a second stage review should usually be made in writing. If a challenge is made orally, the individual or representative must be encouraged, or where required assisted, to put their challenge in writing. The CHC team will take details of an oral request for a review where a person is unable to put their request in writing due to illness, disability or unfamiliarity with written English.
4.3 The request for a second stage reviewshould be acknowledged in writing within5working days of receipt. This will include aquestionnaire requesting details of the reasons for appeal and specific dates of appeal period (Appendix three).
4.4 Where possible, the Appeals Team will meet with an individual / representative to explain the process and timescales, gather any relevant background information and discuss those aspects of the assessment with whichthe patient or their representative disagrees.
4.5All relevanthealth and social records for the appeal period are requested. However, there may be circumstances where records are no longer available.
4.6 ANHSSheffield clinician will collate and review all available information;where applicable this will be demonstrated on a Decision Support Tool (DST).For all reviews of decisions made after April 2012. Where the request for a review concerns an eligibility decision made before April 2012, alternative documentation may be used, as set out in the appeals process applicable to that time.
4.7This DST is sent to the person requesting the reviewand where appropriates the CHCTeam meet with individual / representative to discuss the recommendation. The individual / representative will be given the opportunity to comment on the information gathered. This will be recorded in the minutes taken during the meeting.
4.8The DST is thenconsidered bySheffield CCG’s Local Review Panel. The Local Review Panel’s terms of reference set out how it will operate.
4.9An outcome letter will be sent to the patient or the representative after the panel has met. The letter will contain a detailed rationale for the eligibility decision and signed panel minutes. Where possible this letter will be sent within 14 working days.
4.10If the individual / representative are dissatisfied with the outcome then they can request that NHS England convenes an Independent Review Panel. This request must be made no later than 6 months following the date of outcome letter.
5.0Previously Unassessed Periods of Care
5.1 Requests for reviews of previously un-assessed periods do not come under this policy. Guidelines from the Department of Health were announced on 15th March 2012 with regard to these, further information about this can be found on the Department of Health website at the link below:
6.1 The CSU will consider whether there are exceptional circumstances and if a request for an assessment should be considered outside of the deadlines. Each case will be considered on its individual merits.
6.2The CSU will make a recommendation to Sheffield CCG, as to whether a request for an appeal after the deadline should be accepted.
6.3In order to determine whether exceptional circumstances exist, the CSU will consider all relevant factors, including:
6.3.1 if the individual lacked the capacity to understand the meaning of the deadline referred to in paragraph 3.2 and the steps they needed to take to request an appeal:-
•did they have anyone appointed to manage their affairs (e.g. an Attorney registered with the Office of the Public Guardian or a Court of Protection appointed Deputy)?
•If so, were there circumstances that meant such an Attorney or Deputy could not reasonably have been expected to know about the deadline (e.g. they were out of the country for the entire period or they were themselves incapacitated)?
•Was there any other individual who could reasonably have been expected to know about the deadline and its consequences for the individual?
•Would it be in the best interests of the individual to apply for an assessment?
6.3.2if the individual had the capacity to understand the meaning of the deadline referred to in paragraph 3.2and the steps they needed to take to request an assessment:-
•were there circumstances that meant the individual could not reasonably have been expected to know about the deadline (eg they were out of the country for the entire period or they were otherwise incapacitated)?
6.3.3was there an error on the part of any NHS body in processing a request for an appeal, which was received prior to the relevant deadline?
6.3.4at the time when of the assessment is there evidence that was known, or should reasonably have been known to the relevant PCT or CCG, that the individual did have a primary health need?
6.5Examples of issues that are not exceptional include where a patient or their representative:
- believes they were unaware of the deadline for appealing despite a letter having been sent to the patient stating that the deadline existed;
- was unaware that care provided by the Local Authority is means-tested;
- was unaware of a decision taken by the patient or an alternative; and representative not to pursue an appeal and disagrees with that decision;
The above list is illustrative and is not intended to be exhaustive.
7.1In March 2013 the Department of Health issued a Guidance Note, which concerned sharing patient information, regarding continuing healthcare. NHS Sheffield will follow the advice in this Guidance Note when applying this appeals policy. A copy of this Guidance Note is attached at Appendix four.
8.1This guidance is owned by Sheffield’s Clinical Commissioning Group. It has been developed in consultation with stakeholders through the CHC Operational Group.
8.2This guidance will be reviewed during May2014. Responsibility for the review will lie with the Head of Clinical Services at Sheffield Clinical Commissioning Group.
8.3The CCG may delegate some of its functions under this policy to a Commissioning Support Unit.
8.4This policy will take effect once authorised by the CCG’s Chief Nurse.
Document ControlVersion / Date / Author / Status / Comment
0.1 / H Snowdon / Draft / For internal consultation
0.2 / Feb 2013 / H Snowdon /E Harrigan / Draft / For consultation at Operational Group
0.3 / May 2013 / H Snowdon /E Harrigan / Draft / After consultation at Operational Group
0.4 / May 2013 / H Snowdon /E Harrigan / Final / Incorporating Chief Nurses Comments