East Lancashire CCG

6. Mr I complains about the time it took the CCG to assess his mother, Mrs I’s, eligibility for continuing healthcare (CHC, this is a package of funding provided to some people based on their health need) and pay the redress owed to her estate. He says this has caused unnecessary distress for him and the family.

7. He also complains about the CCG’s redress amount. Specifically, its decision to deduct the amount his mother received in AA, from its final payment. Mr I says his mother’s estate has been financially disadvantaged.

8. Additionally, Mr I complains about the CCG’s complaint handling. Specifically, he says:

· it did not address his complaint within its timescales, adding to his distress

· it did not provide an appropriate remedy for his complaint, which he feels is an ex-gratia payment, in line with the redress guidance.

9. Mr I wants a financial remedy in recognition of the distress caused to him and his family. He also wants the CCG to provide reimbursement for all his mother’s care costs. Finally, Mr I wants service improvements to the redress process to prevent this from happening again to another family.

10. In August 2012 Mrs I’s representative asked for a review of her needs. At this time CCGs were overwhelmed with requests for assessments due to a Department of Health imposed deadline.

11. The CSU (a department the CCG uses to help with its CHC assessments) completed a decision support tool (DST, a document used at the beginning of the CHC assessment to gather information about an individual’s needs) in November 2015. Sadly, by this time Mrs I had died.

12. The assessment found Mrs I was not eligible for CHC funding during the period under review (April 2004 and 28 November).

13. Mr I disputed the decision. The CCG held a local resolution meeting (LRM, this is a meeting to hear the appeal) in October 2016. The CCG upheld its original decision. It shared this outcome in January 2017.

14. The National Framework (the guidance that sets out how the CHC eligibility should be considered) says an individual can ask NHS England’s independent review panel (IRP, a independent panel who consider if the CCG reached the correct eligibility decision) to consider any concerns about the CCG’s procedure and its CHC eligibility decision at an IRP hearing.

15. In February 2017 Mr I asked for an IRP hearing. The IRP met in August 2018.

16. The IRP addressed Mr I’s concerns about the CCG’s procedure by making recommendations about how the CCG should act in the future. The IRP also addressed his concerns about the impact of the procedural problems on the outcome of the CHC assessment, by completing its own independent review of the eligibility decision.

17. The IRP found Mrs I was eligible for funding. It recommended the CCG provide appropriate redress.

Delay in finding Mrs I eligible

21. Mr I complains about the delays in the CCG’s assessment of his mother’s eligibility for CHC funding. He says he made the claim in 2012 and he still does not consider it resolved.

22. In its July 2019 complaint response, the CCG says NHS England considered Mr I’s concerns at the IRP and it made recommendations for improvements. These were accepted by the CCG and CSU.

23. Mr I’s does not dispute the findings of the IRP and he has not raised a complaint about its recommendations or the CCG’s compliance with them. His concerns about the CCG’s consideration of his mother’s eligibility have already been considered in full by the IRP. It is not proportionate for us to investigate these concerns too.

Delay in administering redress payment

24. Mr I complains that following the IRP’s decision the CCG took too long to make the recommended redress payment. He says in a letter dated February 2019 he was told the payment would be made in six weeks, but it was not. The CCG made the payment in May 2019.

25. The redress guidance does not specify a timeframe, but it says CCGs should promptly pay any redress sums owed. Our Principles of Good Administration also say organisations should do what they say they will.

26. The CCG said it would make this payment within six weeks. It did not meet this timescale. The CCG has not acted in line with the guidance. There is an indication of a failing.

27. Mr I says this additional delay was even more distressing given the delays he has experienced throughout the process. The records show the assessment process took over six years. We can understand why Mr I found an additional delay at the end distressing.

28. Our Principles of Good Complaint Handling say where an organisation cannot meet a timescale it should explain why and apologise. Our Principles for Remedy also say organisations should aim to return individuals back to the position they were in before the maladministration took place. Maladministration is when an organisation has done something wrong in its administration process and it caused an impact, such as a delay causing distress.

29. In its complaint response the CCG apologised for its delay, and it explained the reasons. This is line with our Principles.

30. As the CCG did not make the payment when it said it would, Mrs I’s estate did not benefit from interest that accrued whilst the delay was happening. The CCG has recognised this and included an interest payment for this period in its final payment. This is also in line with our Principles.

31. Overall, we are satisfied that although there were delays, the CCG has taken steps to remedy them in line with our guidance. There is nothing further we could add if we were to investigate this part of Mr I’s complaint.

Deductions from redress payment

32. Mr I complains the CCG deducted AA from its redress payment. He says this is not in line with the PHSO’s recommendations in its March 2007 report.

33. In its complaint response the CCG says at the time of writing it recognised a similar case was being challenged in the High Court. It told Mr I it would be in touch following the court’s decision.

34. When we began considering Mr I’s complaint the CCG had not made any further contact with him. We contacted the CCG for an update. The CCG told us following the court’s decision it has revised its position on deductions.

35. The CCG it has set out further work it wants to do to remedy Mr I’s complaint. It has told us it wants to make a payment in line with amount Mr I was asking for. We have decided we should allow the CCG the opportunity to update its process and discuss a further redress payment with Mr I.

36. If Mr I is still unhappy after he receives the further offer of redress, he should initially raise any concerns with the CCG directly. If these cannot be resolved, he can approach us again. Should that happen, we will reconsider if the complaint is ready for us to take a view.

Complaint handling: delays

37. Mr I says the CCG did not consider his complaint in line with its published guidelines.

38. The CCG’s complaints policy says it should acknowledge a complaint within three working days of receipt. It says a response period should be agreed with the complainant. This period should not longer than 40 days from receipt of consent unless agreed with the complainant.

39. Mr I complained by email on 7 May, the CCG acknowledged his complaint the following day. It told Mr I it would complete its investigation within 40 working days.

40. On 5 June the CCG sent Mr I an update. It said the investigation was underway.

41. On 5 July the CCG sent Mr I a further update. It apologised for the delay and explained the investigation was taking longer than expected. On 24 July the CCG sent its final response. The investigation took 55 working days.

42. On 4 September Mr I responded to the CCG’s complaint findings with further concerns. The CCG acknowledged the complaint on 15 October, 30 days later. It told Mr I it would complete its investigation within 40 working days. It provided its response on 1 November.

43. Initially, the CCG acknowledged Mr I’s concerns in line with the three days set out in its policy. It also explained it intended to provide a full response within 40 days. This was also in line with the policy.

44. On 5 June, two days later than the response was due, the CCG provided an update on the complaint. It did not meet the response time set out in its policy or agree a longer time frame before this time had passed. There is an indication of a failing.

45. On 4 September Mr I raised further concerns. His complaint was not acknowledged until 15 October. This acknowledgement was 27 days late. There is an indication of a failing.

46. In its acknowledgment the CCG set out its intention to address Mr I’s complaint fully within 40 days. It provided its final response 11 working days after its acknowledgement. It provided its response in line with its policy.

47. Mr I says the additional delays were frustrating and caused further distress. This is understandable. Mr I says he is looking for a financial remedy.

48. Our Principles for Remedy say in many cases an apology and explanation may be a sufficient and appropriate response. It also says in some cases compensation may be appropriate.

49. To decide if compensation is appropriate, we look at our guidance on financial remedy. This says where there is a minor administrative failure causing a short period of inconvenience, worry and annoyance, a financial remedy is not appropriate.

50. In this case the CCG’s delayed communication meant Mr I was unsure what was happening with his complaint on two occasions. There were a total of 29 days where he was waiting longer than he should have been for an update or an acknowledgement.

51. We appreciate the additional delays were frustrating. We have not seen any signs that this was more than the usual frustration we would associate with any minor delay.

52. An apology and explanation are in line with our guidance and with recommendations on other similar cases we have gone on to investigate. We think the CCG has done enough to put right the mistakes in its complaint handling.

Complaint handling: remedy

53. Mr I says the CCG has not given adequate consideration to an ex-gratia payment as a method to remedy his complaint. He says the CCG should award this in recognition of the delays in its complaint handling, the delays in its assessment process and its poor communication.

54. In its complaint response the CCG says it is genuinely sorry for the delays in its processes. It also apologised for the prolonging distress and inconvenience. It says it considered Mr I’s request for an ex-gratia payment, but it only makes these payments in exceptional circumstances. It says this is in line with its own standing financial instructions. It says it did not find grounds to make a payment in this case.

55. The redress guidance allows CCGs discretion to make additional ex-gratia payments as part of their redress offer. We cannot question discretionary decisions, unless we find a fault in the way the organisation reached its decision.

56. Our Principles of Good Administration say public bodies should balance evidence when making decisions and give reasons for their conclusions.

57. The CCG has shown it considered Mr I’s request for a discretionary payment and it has explained its rationale. We can see it has thought about the current redress guidance and its own standing financial instructions. This is line with the guidance.

58. We have considered the redress guidance and the CCG’s standing financial instructions. We have not seen anything in these documents that suggests CCG’s rationale for its decision is flawed. We have seen no indication of failings in the CCG’s consideration of an ex-gratia payment. This means there are no grounds for us to investigate this part of Mr I’s complaint.

59. We appreciate this was not entirely the decision Mr I was hoping for. We hope we have clearly explained our reasons for this.

1. We have carefully considered Mr I’s complaint about the CCG. We thank Mr I for providing us with the information we needed to reach a decision.

2. We have decided we are not going to consider this complaint any further. This is partly because Mr I’s complaint about the CCG’s delays in assessing his mother have already been addressed by another organisation. It would not be proportionate for us to look at the same issues again.

3. It is also partly because following a recent court case, the CCG has changed its position on the deductions from its redress payment (a payment made when an eligibility decision is backdated). It told us it is offering Mr I a further redress payment. This means Mr I’s complaint about the deduction of attendance allowance (AA, a benefit paid to people to help with their personal care costs) is not ready for us to take a view.

4. We did see delays in the CCG’s administration of the redress process. There were also delays in its complaint handling. The CCG has apologised for both these delays. We are satisfied this remedy is in line with our guidance. There is nothing we could add by looking at this part of Mr I’s complaint.

5. Finally, we decided not to look any further at Mr I’s concerns about the remedy offered by the CCG when it considered Mr I’s complaint. This is because we saw no indication of failings in its decision not to offer an ex-gratia payment1. We have carefully considered Mr I’s complaint about the CCG. We thank Mr I for providing us with the information we needed to reach a decision.

2. We have decided we are not going to consider this complaint any further. This is partly because Mr I’s complaint about the CCG’s delays in assessing his mother have already been addressed by another organisation. It would not be proportionate for us to look at the same issues again.

3. It is also partly because following a recent court case, the CCG has changed its position on the deductions from its redress payment (a payment made when an eligibility decision is backdated). It told us it is offering Mr I a further redress payment. This means Mr I’s complaint about the deduction of attendance allowance (AA, a benefit paid to people to help with their personal care costs) is not ready for us to take a view.

4. We did see delays in the CCG’s administration of the redress process. There were also delays in its complaint handling. The CCG has apologised for both these delays. We are satisfied this remedy is in line with our guidance. There is nothing we could add by looking at this part of Mr I’s complaint.

5. Finally, we decided not to look any further at Mr I’s concerns about the remedy offered by the CCG when it considered Mr I’s complaint. This is because we saw no indication of failings in its decision not to offer an ex-gratia payment1. We have carefully considered Mr I’s complaint about the CCG. We thank Mr I for providing us with the information we needed to reach a decision.

2. We have decided we are not going to consider this complaint any further. This is partly because Mr I’s complaint about the CCG’s delays in assessing his mother have already been addressed by another organisation. It would not be proportionate for us to look at the same issues again.

3. It is also partly because following a recent court case, the CCG has changed its position on the deductions from its redress payment (a payment made when an eligibility decision is backdated). It told us it is offering Mr I a further redress payment. This means Mr I’s complaint about the deduction of attendance allowance (AA, a benefit paid to people to help with their personal care costs) is not ready for us to take a view.

4. We did see delays in the CCG’s administration of the redress process. There were also delays in its complaint handling. The CCG has apologised for both these delays. We are satisfied this remedy is in line with our guidance. There is nothing we could add by looking at this part of Mr I’s complaint.

5. Finally, we decided not to look any further at Mr I’s concerns about the remedy offered by the CCG when it considered Mr I’s complaint. This is because we saw no indication of failings in its decision not to offer an ex-gratia payment1. We have carefully considered Mr I’s complaint about the CCG. We thank Mr I for providing us with the information we needed to reach a decision.

2. We have decided we are not going to consider this complaint any further. This is partly because Mr I’s complaint about the CCG’s delays in assessing his mother have already been addressed by another organisation. It would not be proportionate for us to look at the same issues again.

3. It is also partly because following a recent court case, the CCG has changed its position on the deductions from its redress payment (a payment made when an eligibility decision is backdated). It told us it is offering Mr I a further redress payment. This means Mr I’s complaint about the deduction of attendance allowance (AA, a benefit paid to people to help with their personal care costs) is not ready for us to take a view.

4. We did see delays in the CCG’s administration of the redress process. There were also delays in its complaint handling. The CCG has apologised for both these delays. We are satisfied this remedy is in line with our guidance. There is nothing we could add by looking at this part of Mr I’s complaint.

5. Finally, we decided not to look any further at Mr I’s concerns about the remedy offered by the CCG when it considered Mr I’s complaint. This is because we saw no indication of failings in its decision not to offer an ex-gratia payment1. We have carefully considered Mr I’s complaint about the CCG. We thank Mr I for providing us with the information we needed to reach a decision.

2. We have decided we are not going to consider this complaint any further. This is partly because Mr I’s complaint about the CCG’s delays in assessing his mother have already been addressed by another organisation. It would not be proportionate for us to look at the same issues again.

3. It is also partly because following a recent court case, the CCG has changed its position on the deductions from its redress payment (a payment made when an eligibility decision is backdated). It told us it is offering Mr I a further redress payment. This means Mr I’s complaint about the deduction of attendance allowance (AA, a benefit paid to people to help with their personal care costs) is not ready for us to take a view.

4. We did see delays in the CCG’s administration of the redress process. There were also delays in its complaint handling. The CCG has apologised for both these delays. We are satisfied this remedy is in line with our guidance. There is nothing we could add by looking at this part of Mr I’s complaint.

5. Finally, we decided not to look any further at Mr I’s concerns about the remedy offered by the CCG when it considered Mr I’s complaint. This is because we saw no indication of failings in its decision not to offer an ex-gratia payment