Appeals

Appeals

If an assessment has been unsuccessful, then it may be worthwhile appealing.  There are 2 reasons for appeal, one is that the process has not been correctly followed and the other reason is that you disagree with the clinical decision.

The decision is made by scoring the 11 named domains and domain 12 (if used).  If the score is 1 priority, then funding should be granted.  This usually means that the person would be in hospital or a secure unit; it would be unusual for them to be in the community or in a mainstream care home.  If they score 2 severes, then funding again should be granted.  I have come across lots of people who have scored severe in respect of their cognition, but it is not very common at all to score the second severe.  Again therefore there are not many people who qualify in this automatic funding.

The other way that funding is granted is “with a number of highs and moderates”.  Then the CCG will look at the nature, complexity, intensity and unpredictability.  This is the route that the vast majority of people who obtain funding that I’ve been involved with get it.  The problem with this route is that it is very much up to interpretation.  Although the aim of the Department of Health is to have a nationally consistent decision making process, each CCG area does make slightly different decisions and therefore some CCG areas are granting funding to a proportionally larger group.

I generally don’t advise appealing a decision solely on the basis of a problem with the process, as if the clinical decision was denied, then once the process issue is resolved, the clinical decision will still stand and funding won’t be granted.  A complaint and an apology can work well to resolve these issues.

If there is a disagreement regarding the clinical decision, then the matter is worth appealing.  The first level of appeal is local resolution within the CCG.  This should be decision making, but not always, sometimes it is just a matter of explanation of the process, so before I go, I ask to make sure that it is decision making, I don’t want to sit there whilst someone explains NHS Continuing Care Funding to me!!.

The next step after local resolution is a CCG Panel meeting, so an entirely new group of people from the CCG should sit with the family & advocate and discuss the case, the needs of the person and what the differences of opinions are in the scoring.  The Panel meeting can be intimidating.  There is a Chair of the Panel, a representative of Social Services (hopefully) and someone from the CCG.  These 3 are the decision makers.  Therefore walking into a room with this many people when you are about to talk about a loved family member when they are unwell can be intimidating.  It is also an opportunity to talk about what has happened since the assessment meeting, which might shed more light on the situation, such as a situation at that time that was considered temporary at that time, may be permanent.

Once the matter has been finalised within the CCG the next level of appeal is to the Strategic Health Authority.  They also invoke a Panel process, as well as the chair, representative from a different CCG and representative from a different region by social services, there is usually someone taking minutes and a clinical advisor.  The process is slightly adversarial,  in that the CCG go through their process and often defend their decision and position, whilst the family are still trying to argue that their loved one should be eligible, giving clear reasons why they disagree.

If the decision is still unfavourable, then there is appeal to the Healthservice Ombudsman.  The Ombudsman will not make their own clinical decision and substitute it for the SHA or CCG’s decision.  They will look at the process and if they consider that the process has been reasonably followed, they will accept that the decision is reasonable, unless it is so clearly wrong that it would be considered unreasonable.  The Ombudsman is therefore a good place to tackle administrative issues along the way, but I have not found that route very helpful to tackle clinical decisions that I disagree with.