Disputing a CHC funding decision

Disputing a CHC funding decision

​You may have had an NHS continuing healthcare assessment and the decision may not have been favourable – what do you do then? Do you just leave it? Should you challenge it?

The first stage in disputing a funding decision is to request a local review process at Clinical Commissioning Group (CCG) level and if still no change you can then make a request to the NHS Commissioning Board (the Board) which may then refer the matter to an independent review panel (IRP).

When requesting a review by the CCG review panel you must state that the person (if it is not you) has a primary health need that fits the criteria for NHS continuing healthcare.

There should be a local review process in place which includes timescales and this should be made publicly available by CCG’s. A copy should be automatically sent to you when you request a review of the decision. The local review process may include a referral of the case to another CCG for consideration or advice so that there is greater patient confidence in the impartiality of the decision making.

If you or your representative remains dissatisfied with the review by the CCG you or your representative should write to the CCG to inform them of this and asking for an independent review of the case. In the letter you must explain the reasons for disagreeing with the CCG’s initial decision.

Once you have exhausted the local procedures you can request that the case is referred to the Board’s IRP which will then consider the case and make a recommendation to the CCG.

When requesting the review you must state that the criteria has been wrongly applied for NHS continuing healthcare (or NHS funded nursing care); or that there is a dispute about the process used by the CCG to reach its eligibility decision and recommendation to the Board about its findings.

The eligibility decision that has been made remains in place until the independent review has been held.

Following the IRP or if it was not agreed by the CCG for the case to be heard by an IRP you can make a complaint to the Parliamentary and Health Services Ombudsman (PHSO). They can investigate maladministration where there has been poor administration or the wrong application of rules and clinical judgment where an inappropriate action or decision has been made by a member of staff.

The complaint must be made no later than 12 months from the date when the local resolution process ended although the PHSO does have discretion to extend this time limit if considered reasonable.

If you do not think that you would be able to manage some or any of this process then I can help you with it. Please contact me to discuss

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