A medical practice in the Lancashire area

7. Mr O also complains about how the Practice handled his complaint.

8. Mr O says it caused him distress, frustration, and anguish when he was asking for help. He says he was caring for his father at a time when he was nearing the end of his life and needed support. Mr O says his father may have been able to go into a care home sooner than he did.

9. Mr O would like the Practice to provide an apology, acknowledgement of failings, service improvements, and a financial remedy.

10. Mr R was over 90 years old and living at home. His son, Mr O, cared for him for around eight years.

11. In January 2020, Mr O felt his father was deteriorating and his needs were becoming more complex. His father had late-stage vascular dementia, which is a type of dementia caused by reduced blood flow to the brain.

12. Mr O telephoned the Practice on 14 January 2020, to ask about continuing healthcare (CHC) funding for his father. CHC is a package of care for adults which is arranged and funded by the NHS. The Practice said it thought the process was started via social services and advised Mr O it would contact him.

13. The Practice spoke with Mr O on 24 January 2020. It advised him he would need to contact social services. The Practice said it had never had to complete anything to do with CHC.

14. Mr O then contacted social services. On 26 February 2020, Mr O called the Practice again to explain he was having difficulty with social services. He asked for clarity on the continuing healthcare process. The Practice advised Mr O this was to be arranged by social services.

15. There was then a national lockdown. Mr O cared for his father at home during this time.

16. On 1 June 2020, Mr O telephoned the Practice to say he thought his father was in the final stages of dementia. He explained social services declined to carry out a CHC assessment. The Practice offered Mr O social services’ number and explained they needed to do an assessment. Mr O asked to speak with a GP about CHC funding.

17. Mr O telephoned the Practice again on 2 June and asked to speak to someone urgently regarding a Fast Track funding application. Fast Track funding is where an appropriate care and support package can be put in place quickly if someone is nearing the end of their life.

18. Mr O telephoned the Practice on 3 June and asked to speak to a doctor about his father’s situation. He said there was a lack of understanding from the GP about CHC and that he would email information to the Practice.

19. The Practice agreed to send a Fast Track application to the relevant Clinical Commissioning Group (the CCG). The form was not completed correctly, and the CCG advised Mr R would need to have an assessment as part of the Fast Track process.

20. On 4 June, the Practice sent a task to the district nursing team to arrange a Fast Track assessment. The district nursing team said they were not involved with the patient.

21. Mr O contacted the Practice on 4 June, and said the Practice were able to complete the Fast Track form without an assessment from the district nursing team.

22. A GP reviewed Mr O that day and determined he was end of life and suitable for Fast Track funding. The Practice submitted the application to the CCG on 5 June.

23. The CCG accepted the application and granted Fast Track funding. Mr R was admitted to a care home on 7 June 2020.

January and February 2020

27. Mr O complains he contacted the Practice for help with a continuing healthcare assessment for his father in January and February 2020. He says they did not help him or advise him properly.

28. The Practice says the normal process involves social services and district nurses. It says it has always followed the normal protocol and has never actively got involved with the CHC process.

29. The records show Mr O first contacted the Practice for advice regarding CHC funding on 14 January 2020. The evidence shows Mr O wanted to know how to get CHC funding for his father. The Practice felt this request was for social services, but noted the website stated a GP could do this. The Practice arranged for the practice manager to inform Mr O how to action his request.

30. On 24 January, the Practice manager contacted Mr O to discuss CHC funding. The Practice manager advised Mr O he would need to speak to social services about this. They explained the Practice had never had to complete anything to do with CHC funding. Mr O proceeded to contact social services.

31. Mr O contacted the Practice again on 26 February. The records show he explained he was having problems with social services regarding CHC. He said the CHC funding would need triggering by the GP, and he would like clarity on CHC. The Practice confirmed to Mr O this would need to be arranged by social services.

32. We have first considered what happened in January and February. We have taken into account the phone records taken at the time, Mr O’s account, and the Practice’s response. The evidence does not suggest Mr O was specifically enquiring about Fast Track funding at that time. The records refer to the general CHC process. The records from 26 February show Mr O wanted clarity on the continuing healthcare process.

33. Later in the year, Mr O went to seek advice from Beacon (an advocacy service) and the CCG. It appears this is when he was approaching the Practice for advice specifically on the Fast Track process. We will address this later in the report.

34. The standard CHC and Fast Track funding processes are different. From the evidence provided, we cannot see a specific reference to Fast Track funding from January and February. There is no reference to Mr R rapidly deteriorating at the time. Reference to Fast Track funding specifically appears to be first mentioned in the records in June. On balance, it appears Mr O was asking for support in January/February with the standard CHC process.

35. Based on this, we have gone on to consider if what happened in January/February was in line with the National Framework and standard CHC process.

36. The Framework sets out who can begin the CHC process. It says: ‘92. The Checklist can be completed by a variety of health and social care practitioners, who have been trained in its use. This could include, for example: registered nurses employed by the NHS, GPs, other clinicians or local authority staff such as social workers, care managers or social care assistants (refer to Practice Guidance note 13).

93. It is for each CCG and local authority to identify and agree who can complete the tool, but it is expected that it should, as far as possible, include staff involved in assessing or reviewing individuals’ needs as part of their day-to-day work’.

37. In line with the Framework, a GP can start the CHC process via a checklist, if appropriate. A checklist is a screening tool used to identify individuals who may need a referral for a full assessment. Our adviser says, based on the advice the Practice gave at the time, it appears staff at the Practice may not have been trained in how to use the checklist. The guidance is specific that a checklist should be carried out by someone trained in its use.

38. Based on this, the advice and signposting the Practice gave to Mr O in January and February to contact social services, or district nursing, for assistance with CHC was appropriate advice and in line with the Framework. We have seen no failings here.

39. Our adviser noted that when Mr O contacted the Practice in February to explain he was having difficulties with social services and navigating the CHC process, the Practice could have offered support in contacting social services on his behalf.

40. Our Principles of Good Administration say public bodies should deal with people helpfully, promptly, and sensitively, bearing in mind their individual circumstances. They say public bodies should communicate effectively using clear language people can understand and is appropriate to the circumstances. We recognise the Practice’s signposting was in line with the National Framework, but there was an opportunity to provide Mr O with help in line with our Principles, which is a shortcoming.

41. We can see from the evidence that the Practice made a comment to Mr O in January and February stating it does not get involved with the CHC process. This does not align with the National Framework. We therefore will explore this further later in the report as part of how the Practice dealt with Mr O’s complaint.

June 2020

42. Mr O complains he contacted the Practice again in June 2020 to ask for support in making a Fast Track application for his father, so his father could go into a care home. He says the Practice did not help or support him when his father was at the end of his life.

43. The Practice said in its response that GP surgeries do not get involved with funding, however, because Mr O said he had lost faith in social services it tried to get involved.

44. The records show Mr O contacted the Practice on 1 June 2020. He explained his father had become very frail, with a dramatic cognitive decline. He told the Practice he felt his father was in the final stages of dementia. He asked to discuss continuing healthcare, as social services had rejected an application for his father.

45. The Practice offered Mr O a number for social services, saying they do the assessment. The records show Mr O asked to speak to a GP and the Practice sent a message to the GP.

46. A consultation on 1 June with the GP shows Mr O’s father had a dramatic cognitive decline. The GP recorded Mr O’s father, ‘poss qualifies for continued care at present’. The GP arranged for the Practice manager to look into this and call Mr O back.

47. On 2 June Mr O called the Practice again to say he would like to speak to someone urgently regarding a Fast Track referral. He telephoned the Practice on 3 June asking to speak with a GP, as he felt the Practice was not understanding the process.

48. On 3 June the Practice sent a Fast Track form to the CCG. The CCG rejected it because the Practice had not followed the process. The CCG explained Mr O’s father needed to have had an assessment as part of the process. The Practice said Mr O’s father would need to be referred to district nurses or social services for this assessment.

49. Mr O telephoned the Practice on 4 June to explain he had spoken to the CCG and Beacon. They advised him the GP could fill in the form without social services or a district nursing assessment. He explained the GP could carry out this assessment in line with the Fast Track Pathway.

50. The Practice reviewed Mr O’s father on 4 June. It determined he was very frail and agreed he was end of life. The Practice agreed he met the Fast Track criteria. The Practice sent the Fast Track application to the CCG on 5 June.

51. We have considered if this was in line with what should have happened under the Fast Track Pathway and National Framework.

52. The Fast Track process differs to the standard CHC process referred to above. The Fast Track pathway should be used when an individual has a rapidly deteriorating condition and may be entering a terminal phase. It can be used in any setting and is designed to replace the need for a checklist or decision support tool (a national tool used to support decision making on CHC eligibility).

53. The pathway is intended to identify individuals who need access to CHC quickly and with minimum delay. The purpose of the pathway is to enable the individual’s needs to be urgently met.

54. The Fast Track pathway sets out that an ‘appropriate clinician’ determines if an individual has a primary health need. It says:

‘6. An ‘appropriate clinician’ is defined as a person who is: a) responsible for the diagnosis, treatment or care of the individual under the 2006 Act in respect of whom a Fast Track Pathway Tool is being completed; and b) a registered nurse or a registered medical practitioner

7. The ‘appropriate clinician’ should be knowledgeable about the individual’s health needs, diagnosis, treatment or care and be able to provide an assessment of why the individual meets the Fast Track Pathway Tool criteria’.

55. A GP can be an appropriate clinician under the guidance. A GP can initiate a Fast Track pathway if it is indicated at the time.

56. The National Framework outlines that CHC can only be effectively delivered with a partnership between bodies at all levels. Practice Guidance 48 says: ‘48.1 NHS Continuing Healthcare can only be delivered successfully through a partnership approach at both organisational and practitioner levels between NHS England, CCGs, LAs, local NHS bodies, and provider organisations. Local protocols covering the areas where agreement is needed on policy and processes relevant to NHS Continuing Healthcare may be helpful in ensuring consistency and developing relationships. Annex G contains guidelines on what could be included in such protocols. Trust between organisations is developed by actions that are trustworthy and transparent, and by an approach that is based on everyone seeking to accurately apply the eligibility criteria rather than seeking to move responsibility to another organisation’.

57. The Fast Track Pathway sets out the tool should only be used in circumstances where an individual has a ‘rapidly deteriorating condition’ and may be entering a terminal phase. It is the responsibility of the appropriate clinician to decide if the individual’s needs meet the Fast Track criteria.

58. The Fast Track Pathway does not provide a timeframe specifically outlining how long a GP should take to complete it. However, our adviser says the records show from 1 June, the Practice was aware of Mr O’s father’s dramatic cognitive decline. The Practice had the information that Mr O was end of life at this time. The Practice therefore should have started the process from 1 June, in line with the guidance.

59. The district nursing team can also complete a Fast Track pathway. If the GP was not aware of the CHC process, or that it could have completed the application, it should have made an urgent referral request to the district nursing team to request it carry out a Fast Track assessment on 1 June.

60. The Practice did not appear to have an awareness of the process without the involvement of the district nursing team. The Practice should have had an awareness of the local process and that it could complete a Fast Track pathway.

61. The delays caused between 1 and 5 June were because the Practice did not have an awareness of the Fast Track process. In its complaint response, the Practice said GP surgeries do not get involved with Fast Track funding or the CHC process. This is not in line with the Fast Track Pathway or National Framework. There is a failing here.

62. We have gone on to consider the impact of this failing. Mr O says it was distressing and frustrating when he was trying to get help with his father’s Fast Track application. He says this caused him a lot of anguish at a time when he was already trying to care for his unwell father. He says this added to the difficulty of his father approaching the end of his life.

63. Mr O feels the process of getting his father into a care home was hindered, and he may have had more adequate care sooner.

64. Mr O has told us that the way he was treated when he was trying to get help for his father was distressing. He felt the Practice tried to set back his efforts to help his father at the end of his life. He says there was hostility, and this was distressing. Mr O explained the whole situation was very upsetting because of how he was treated.

65. We can see from the evidence, when the CCG received the Fast Track pathway on 5 June it accepted it. It actioned the request and placed Mr O into a care home by 7 June.

66. Our adviser says if the application had been completed on 1 June, when it was evidenced Mr O’s father was end of life, Mr O could have been moved into a care home a few days sooner than he was.

67. Section 238 of the National Framework sets out a CCG should take action urgently to agree and commission a care package. It says CCGs should have processes in place to enable such care packages to be commissioned quickly. Given the nature of the needs, the time period should not usually exceed 48 hours from the receipt of the completed Fast Track Pathway Tool.

68. The National Framework says it is not appropriate for individuals to experience delay in the delivery of their care package while concerns over the use of the Fast Track Tool are resolved. The evidence shows the CCG did go on to commission the care package within 48 hours, in line with the guidance. On balance, it is therefore reasonable to conclude if the pathway had been completed on 1 June, Mr O’s father would have been able to move to a care home by 3 June.

69. Mr O has highlighted that when the CCG received the completed Fast Track application it accepted it within two hours of receipt. We can never know if the CCG would have accepted the application within two hours on a different day, or in different circumstances. This is because the pathway does give a 48-hour timeframe. However, it is useful for reference and context to recognise the CCG accepted the application promptly in the circumstances.

70. We acknowledge that the Practice did complete the Fast Track application. We also recognise this would only be four days earlier than when Mr O’s father went into a care home. However, we must also take into account that four days is a considerable period of time at the end of a person’s life.

71. It is understandable that Mr O was distressed caring for his father at home during this time. He felt his father did not have the proper support he needed at the end of his life. Our view is the delay caused Mr O unnecessary distress. It is clear this caused him uncertainty and worry at an already difficult time.

72. We have looked at the steps the Practice has taken to put things right and considered if these actions go far enough. The Practice’s position is that it did not get anything wrong. It says GP surgeries do not get involved with Fast Track funding. We do not consider the Practice has taken steps to acknowledge where it got things wrong. Therefore, we uphold this part of the complaint. We have set out recommendations below to put this right.

Complaints handling and advice

73. Mr O complains about how the Practice dealt with his complaint and the advice it gave in response to his complaint. He says it was unhelpful and he felt his main points were ignored.

74. We have considered the Practice’s complaint response to Mr O. The Practice says in its response, it cannot reiterate enough that the normal referral protocol for CHC involves district nurses and social services. It also says GP surgeries do not get involved with CHC.

75. The Practice went on to say in its response the relationship had broken down between all parties.

76. As set out above, Practice Guidance 48 of the National Framework states CHC can only be delivered successfully through a partnership approach at organisational and practitioner levels. It highlights the importance of local protocols across all levels. It explains the need to apply the eligibility criteria, rather than seeking to move responsibility to another organisation. It also sets out what good partnership working involves and examples of good partnership working.

77. We acknowledge the Practice may not have dealt with a situation like this before. The Framework and pathway set out what should happen in these situations. As set out earlier in our report, the National Framework and Fast Track pathway outline a GP can be involved in the CHC process. Therefore, the information the Practice has provided in its complaint response is contradictory with the National Framework.

78. Our Principles of Good Complaint Handling ‘Putting Things Right’ say that public bodies should provide an ‘apology, explanation and acknowledgement of responsibility’. In addition, ‘remedial action which may include reviewing or changing a decision on the service given; revising published material; revising procedures, policies or guidance to prevent the same thing happening again; training or supervising staff; or a combination of these’.

79. We have not seen any evidence the Practice has acknowledged the incorrect advice it gave to Mr O or its communication about the CHC process. We consider the Practice failed to provide an adequate response to Mr O and there is a failing here.

80. We have considered the impact of this failing on Mr O. Mr O says the complaint handling compounded what he was going through at the time, and the stress he experienced trying to get his father into a care home. He says he did not feel supported.

81. We accept the information given to Mr O caused frustration and upset.

82. We uphold this part of the complaint. We have set out recommendations to address this below.

1. We have investigated Mr O’s complaint about a medical practice in the Lancashire area (the Practice). We acknowledge this has been a difficult time for him and appreciate that his complaint is important to him.

2. We have found the Practice acted in line with the National Framework when Mr O first contacted it for support with continuing healthcare funding in January and February 2020.

3. We have also found the Practice delayed making Mr O’s father’s (Mr R) Fast Track funding application when he approached it in June 2020. This caused a delay in his father going into a care home and caused him distress and worry at what was already a difficult time. We do not think the Practice has done enough to put this right, so we recommend it takes action to address this. We therefore uphold this part of the complaint.

4. We have recommended the Practice write to Mr O to acknowledge its mistakes, apologise for their impact, and pay Mr O £300. We have also recommended systemic learning and improvement in the form of an action plan.

5. We have found the Practice gave Mr O incorrect advice when handling his complaint. This caused Mr O stress and frustration. We do not think the Practice has done enough to put this right, so we have recommended it takes action to address this. We therefore uphold this part of the complaint. We recommend the Practice write to Mr O to acknowledge its mistake and apologise for its impact.