Case Study: Family Wins Appeal Against Withdrawal of Healthcare Funding

Summary

How Martin Searle Solicitors helped secure ongoing NHS healthcare funding after a patient’s primary care trust (PCT) ruled the individual was no longer eligible.

The situation

In 2008, the Foster family was delighted when the PCT approved fully funded NHS Continuing Healthcare for their mother, Sheila. The PCT also agreed to backdate the award to 2007 – the time when the Foster family had first applied for funding.

It therefore came as a shock when, in 2010, the Fosters learnt that Sheila’s funding was to be withdrawn. The PCT panel had determined that Sheila no longer met the eligibility criteria. The Fosters immediately requested a copy of the assessment, as Sheila’s needs were unchanged and they could see no reason for the removal of funding.

The family was clear there been no improvement in Sheila’s condition. In fact, her needs had increased in the three years since she was first awarded continuing healthcare funding. With a long-standing diagnosis of Alzheimer’s disease, Sheila presented with many healthcare needs including challenging behaviours, communication difficulties and mobility problems (she was totally immobile and reliant upon carers and hoists for all transfers).

Sheila’s husband, who had an Enduring Power of Attorney to act for his wife, wrote to the PCT with notice of the family’s intention to appeal. The Fosters then contacted Martin Searle Solicitors’ Brighton office for advice.

What Martin Searle Solicitors did

Specialist care funding solicitor Cate Searle first advised the Fosters to obtain copies of Sheila’s initial NHS assessments. Cate could then review the initial assessment against the latest one, noting how the PCT had scored Sheila and identifying any differences between the assessments.

As well as discovering significant flaws in the new assessment, Cate also found the PCT had under scored some of the healthcare domains in the initial assessment. Cate drew up a comprehensive table of advice. This addressed each of the healthcare domains, explaining what score the family should argue for, giving clear reasons, examples and evidence.

With this advice, the Fosters were in a strong position to fight the appeal on their own or to instruct Cate on their behalf. Impressed with the depth of Cate’s advice, the family decided they wanted her to run the appeal.

Cate immediately wrote to the PCT, drawing attention to procedural errors in the new assessment. In particular, she noted that a multi-disciplinary team (MDT) had recommended Sheila was still eligible for NHS fully funded care. The panel had ignored the MDT’s recommendation. Cate questioned this rationale, pointing out that a panel can only reject an MDT’s recommendation in ‘exceptional circumstances’.

Cate also requested that the PCT continued to fully fund Sheila whilst the matter was under dispute, which it agreed to do. Cate discovered this same PCT had withdrawn funding from another resident at Sheila’s care home in similar circumstances.

While waiting for answers from the PCT, Cate helped the Fosters obtain copies of Sheila’s care home records to support their arguments and strengthen their appeal. There was good evidence in the records to support what the family was saying. However, the daily carers’ notes were brief and did not go into useful detail about Sheila’s challenging behaviours. This is a common problem as carers can get so used to a person’s challenging behaviour they do not write down everything that happens, particularly when pressed for time.

Cate helped the Fosters convey to the care home manager the importance of writing down key incidents relating to behaviour, to build an accurate and detailed picture of how complex and unpredictable Sheila’s needs were. The Fosters discovered from the care home records that Sheila had experienced a number of seizures. This was vital evidence because it further demonstrated how flawed the latest assessment was – despite looking at the records, the PCT was also unaware Sheila suffered from seizures.

Before going to the appeals panel, the PCT asked to discuss matters with the family at a local resolution meeting. Using evidence from the nursing home records, Cate compiled a tips and tactics document to help the Fosters focus on the main arguments and get their points across succinctly.

As a result of the points the family raised at the meeting, the PCT agreed to start afresh and undertake another continuing healthcare assessment. This time it took into account the evidence the family had put forward. The panel agreed that Sheila did in fact have a primary health need and subsequently agreed to continue fully funding her care.

The result

By contacting Martin Searle Solicitors as soon as they received notification that Sheila’s funding would end, the Foster family saved themselves from becoming embroiled in the appeals process.

Using Cate’s advice, the family went on to secure ongoing fully funded care for their mother relatively swiftly. Furthermore, the PCT agreed to fully fund Sheila’s care whilst the matter was under dispute, ensuring there was never a gap in the funding.

To find out if you have a case to reclaim care home fees, call our expert Community Care Law solicitors’ on 01273 609911, or email info@ms-solicitors.co.uk.