One Devon Integrated Care Board

4. Mr O complains the ICB upheld its decision his father was not eligible for CHC on 20 June 2018. Mr R died in November 2018.

5. Mr O also complains the ICB refused to assess his father’s CHC eligibility as a period of previously unassessed care between 1 August 2016 and 19 June 2018.

6. Mr O says the ICB’s actions have caused him distress. His father’s estate has also been financially disadvantaged as he had to pay for his own care.

7. Mr O wants the ICB to reconsider its decision for the assessment it carried out on 20 June 2018. He also wants it to assess his father’s care needs between 1 August 2016 and 19 June 2018.

8. On 3 August 2016, the ICB used the checklist screening tool to establish if Mr O’s father should have a full CHC assessment. It found he should have this assessment. The ICB arranged for this assessment to go ahead, with an external provider, on 20 June 2018.

9. The external provider arranged a multi-disciplinary team (MDT) to assess Mr O’s father. The MDT found he was not eligible for CHC on 20 June 2018.

10. Mr O appealed this decision and the ICB considered the reasons for his appeal in a meeting on 4 February 2019. It upheld the original decision. The ICB also agreed to send Mr O the relevant paperwork so he could apply assessment for his father’s CHC eligibility for the time between his father’s checklist assessment on 3 August 2016 and the MDT’s meeting on 20 June 2018.

11. On 12 July 2019, the ICB wrote to Mr O and told him it would not be considering this period of previously unassessed care unless NHS England overturns the eligibility decision it made on 20 June 2018. It also told Mr O he would need to prove his father’s needs were significantly greater than when he was assessed.

14. Before we decide if we should investigate a complaint, we look at whether there are signs the organisation concerned has got something wrong. We do this by comparing what should have happened, with what did happen. If what happened fell short of what should have happened, we call this a failing. When we see an indication of a failing, we next look at whether that failing had a negative impact on the person involved. If we think it did, we will go on to consider what, if anything, the organisation has done to try to put things right.

The ICB’s eligibility decision on 20 June 2018

15. Mr O complained the ICB did not find his father eligible for CHC after an assessment of his care needs on 20 June 2018. Mr O told us this caused him distress and contributed to his father’s estate being disadvantaged. Mr O asked the ICB to reconsider its decision and find his father eligible for CHC.

16. The ICB has considered his father’s eligibility for CHC and has carried out a review of its own decision, in line with paragraphs 194 and 195 of the National Framework. Following this review, paragraph 196 of the National Framework says Mr O can apply to NHS England for an independent review if he still is not happy with the decision. Mr O did not do this because he did not know this was the next step in the process.

17. Paragraphs 192 and 193 of the National Framework says it is the responsibility of the ICB to inform Mr O he can ask NHS England for an independent review if he was not happy with its decision. We cannot see the ICB did this, instead it signposted Mr O to us.

18. We think Mr O needs to complete the independent review process with NHS England. We cannot consider a CHC funding decision until it has completed the appeals process. In line with the National Framework, an individual has six months from when they get the outcome of the local appeal to appeal further to NHS England. We have discussed this with the ICB and it has agreed to reissue its appeals decision and signpost Mr O to NHS England so he can request an independent review. This will reset the six month timeframe for him.

19. The ICB have confirmed it will reissue its original decision and has confirmed it has been sent. It has also confirmed it will change the wording in its standard letters to prevent this from happening again in the future.

The ICB’s decision not to consider the previously unassessed period of care

20. Mr O complained the ICB would not allow him to apply for it to consider if his father was eligible for CHC between 1 August 2016 and 19 June 2018. Mr O says this caused him distress and contributed to his father’s estate being financially disadvantaged. Mr O wants the ICB to assess this period of care.

21. We have considered all the information Mr O sent us, including copied of the correspondence he received from the ICB. This contains the report from the appeals meeting he attended with the ICB. This meeting was held to hear Mr O’s appeal against the ICB’s decision his father was not eligible for CHC on 20 June 2018.

22. The report also documents Mr O asking for the previously unassessed period of care to be assessed for CHC. The ICB confirmed it would send Mr O details on how to make this application. When Mr O made the application, the ICB responded to him and explained it would not assess this period of care unless he proved his father’s needs were significantly greater than they were when he was assessed on 20 May 2018. It also said it would not consider this period of care unless NHS England overturned its original eligibility decision.

23. We think the ICB should have considered Mr O’s application to have this period of care assessed. The position the ICB took is not supported by the National Framework’s guidance. It is not the responsibility of the claimant to prove what the person’s needs were. If they think the person may have been eligible, they have a right to ask for a retrospective review. The ICB should then have considered this in line with the National Framework, firstly by doing a checklist to see if the person’s needs met the threshold for a full CHC assessment.

24. We have discussed this with the ICB and it has agreed to send the appropriate paperwork to Mr O so he can apply for the period of care to be assessed.

25. We think the ICB will be acting in line with our Principles of Remedy by sending this paperwork to Mr O. Our Principle says a public body should return a complainant back to the position they would have been in if the poor service had not occurred. By the ICB doing this, it is giving Mr O the opportunity to make this application he wanted to make originally.

26. We are satisfied the actions we have asked the ICB to take, and it has agreed to take, are enough to put right Mr O’s complaint, in line with our Principles. We have discussed this with Mr O and are pleased to hear this resolves his complaint for him.

1. We have carefully considered Mr O’s complaint about how One Devon Integrated Care Board (the ICB) looked at the NHS funded continuing healthcare (CHC) claim for his father, Mr R. We do not think the ICB acted in line with the National Framework when it did not clearly signpost Mr O to NHS England, after it heard his appeal on 4 February 2019. We also think the ICB should have considered Mr O’s application for his father’s needs to be assessed for CHC between 1 August 2016 and 19 June 2018.

2. The ICB has now agreed to signpost Mr O correctly to NHS England and has agreed to consider a retrospective CHC claim for his father, between 1 August 2016 and 19 June 2018.

3. We are sorry to hear Mr O found this process distressing and we appreciate his father’s estate has been financially disadvantaged. We understand Mr O has dedicated a lot of time to this complaint. We think this action taken by the ICB to put things right is in line with our Principles of Remedy, and we are pleased to hear Mr O is satisfied with this outcome.