NHS Continuing Healthcare Tips: The local resolution process

For anyone who is living with a long-term condition, which is progressive in nature, has the potential burden of escalating care costs, NHS Continuing Healthcare can be a lifeline. It is a package of care that is fully paid for by the NHS, for adults with long-term and complex health needs.

For over two decades, tens of thousands of people with a range of conditions, including dementia, stroke, Parkinson’s Disease, have had their applications rejected. From our fifteen years of experience, we know thousands of individuals and their families are missing out due flawed assessments and a lack of understanding. If they are aware of the process, families struggle to navigate the system and feel discouraged and daunted by a complex process.

This series is to raise awareness of the funding and assist families so they are empowered to make the right decisions for their relatives.

The first step to challenge a NHS Continuing Healthcare assessment is the local resolution process.

What is a local resolution process?

When considering whether an individual is eligible for continuing healthcare, the relevant Clinical Commissioning Group (CCG) of Health Board (in Wales) will complete a Decision Support Tool (DST) assessment. If following the DST, the CCG concludes that the assessed individual is not eligible for NHS Continuing Healthcare Funding (CHC), this decision can be challenged by either the individual or their representative. The process involves an informal dispute resolution process.

An appeal of the DST can be made if you disagree with the eligibility decision; or the procedure followed by the CCG in making their decision.

In order to challenge a negative DST, the National Framework for NHS continuing healthcare outlines that you have six months from the date of the decision to submit a challenge. This deadline is strict and should be met. All challenges should be made in writing to the relevant CCG Appeals Team and should outline the reasons why the appellant believes the eligibility decision made by the CCG is incorrect, providing evidence to support their arguments. When a written submission is provided, the relevant CCG will then take steps to proceed through their local resolution process and will arrange a local resolution meeting (LRM).

What is a local resolution meeting?

The LRM is the first stage in the appeals process and provides an opportunity for both family members and a representative to submit their views and opinions of the patient’s needs. The LRM will focus largely on the written submission provided to the health authority, as well as the available medical evidence. However, a large emphasis will also be placed on anecdotal information provided by family members. Evidence of this kind can form a crucial part of the appeals process, and the outcome of claims often hinges on how this evidence is received by the health authority, particularly in cases where the medical evidence available is sparse.

Who will be in attendance at a LRM?

Attendees of a LRM can vary between differing health authorities. However, it can be expected that the following individuals will be in attendance in most cases:

• LRM chair (this individual will lead the LRM)
• continuing healthcare representative from the CCG
• local authority representative (this will usually be someone with previous CHC experience or a medical background)
• administrator / minute taker

How long will a LRM last?

The length of LRM’s can vary significantly, based on how many aspects of a claim are being disputed, as well as the size of the evidential period. However, it can be expected that the majority of LRM’s will last between 30 and 75 minutes.

Where do LRM’s take place?

A LRM will take place at the headquarters of the relevant CCG. Prior to the Covid-19 pandemic, representatives of the patient in question would attend the LRM in person and participate in a face-to-face discussion with the panel members. However, in light of Covid-19, LRM’s are presently being held virtually, via Microsoft Teams video conference. However, alternative ‘audio dial in’ arrangements are also available for those who do not wish or are unable to participate via Microsoft Teams.

Top tips before an LRM?

The prospect of participating in a LRM can often be overwhelming for representatives or family members. However, it is important to note that LRM’s are designed to be an informal process whereby the CCG listens to the thoughts and opinions of representatives, to gather all of the necessary information before making a final decision on whether the individual is eligible for NHS Continuing Healthcare. Prior to a LRM, it is important to be familiar with the Decision Support Tool (DST) document which formed the basis of the eligibility decision, as well as the written submission which was drafted in response to the DST.

How Hugh James can assist at a DST meeting

We know that families and friends of people who are going through the process are often doing so at an emotionally difficult time and the system itself can be onerous and emotionally difficult. Due to our experience and depth of knowledge, our clients inform us we remove this burden from you.

Some of our clients question how non-medically qualified professionals can challenge health decisions. Whilst the people making decisions regarding eligibility for continuing healthcare are health and social care professionals, their decisions are being challenged and it is our job to demonstrate they are unsound by analysing medical evidence and applying it to the criteria. Whilst the process is not legal, it is a dispute resolution process.

Due to our 15 years of experience and depth of knowledge, we are respected by health and social care professions and panel chairs for the work we do.

The skills developed by lawyers – analytical, evaluating, interpreting and advocacy is essential in being successful. We analyse the CCG decision together with the records, provide detailed submissions on why we challenge a decision. We will agree with the family the best arguments to raise before a meeting and will attend LRMs to assist the family in putting forward the best possible arguments for a successful conclusion.

What happens during an LRM?

A LRM usually begins with an informal introduction of all parties. Once this has been completed, the CCG will usually ask the family member or representative to provide a brief background / pen portrait of the patient in question, should they be comfortable in doing this. Once this has been completed, the attention of the LRM will turn to the DST.

When a DST is completed, an individual is assessed under 11 care domains:

• breathing
• nutrition
• continence
• skin
• mobility
• communication
• psychological and emotional needs
• cognition
• behaviour
• drug therapies and medication
• altered states of consciousness
• other significant care needs

When completing the DST, the CCG will have prescribed a level of need under each care domain, ranging from no needs to a priority level of need. The LRM will discuss each domain in turn, but a particular focus will be placed upon the areas of dispute. Family members/representatives/solicitors will be given the opportunity to address each domain and provide their opinions on the levels of need awarded.

Once a discussion of the care domains has been completed, the LRM will then turn its attention to the primary health needs approach. The primary health needs approach considers the four key indicators of nature, intensity, complexity, unpredictability and applies this test to the patient in question. To be eligible for CHC, an individual will need to evidence that one of the four key indicators has been met.

Once the discussion of the four key indicators is complete, the LRM will conclude and the participants will exit the meeting.

How long will it take to receive the outcome of the LRM?

Following a LRM, the length of time taken to receive the outcome can vary between health authorities. However, it can be expected that an outcome would be received within four to six weeks.

What happens following a LRM decision?

Once the CCG has considered the available evidence, in conjunction with the LRM discussion, an outcome letter will be sent either to the patient’s family or the legal representative. The outcome letter will detail whether the CCG has:

• overturned the initial negative decision and found the patient to be eligible for CHC
• upheld the initial decision and found the patient to be not eligible for CHC

If the CCG has found the patient to be eligible for CHC, the representatives will need to provide proof of payment information detailing all care fees paid during the period of eligibility. Once this information has been received, the CCG will process the reimbursement of fees in full.

Alternatively, should the CCG find the patient to be not eligible, it is arguable that the local resolution procedure has now been exhausted. However, a further avenue of appeal is available should the individual remain dissatisfied. To challenge a negative decision following a LRM, individuals should write to NHS England within six months of receiving the outcome letter, detailing why they remain in conflict with the decision made by the CCG and request that an Independent Review Panel be convened to consider an appeal. Again, this deadline is strictly applied and should be met or the individual may lose their opportunity to challenge the decision.