Arden and Greater East Midlands Commissioning Support Unit

5. Ms O is represented by a professional representative in the Bury area (the representative). They applied for a retrospective review for her father, Mr U, for the period 3 January 2009 to 22 September 2010. This request is to ask the CSU to look back at a period to consider eligibility for NHS Continuing Healthcare (CHC) funding. CHC is care provided over an extended period of time, to meet physical or mental health needs that have arisen as a result of disability, accident or illness.

6. The representative complains the CSU sent the outcome of the review to Ms O and not to themselves, despite previously sending the CSU authority to act. They say because of this, they were not able to appeal the CSU’s decision within the stated timeframe. They complain the CSU then declined their appeal as it was out of time.

7. The representative says Ms O has been denied the right to appeal and progress with local resolution.

8. Ms O would like the CSU to reconsider its decision and allow the local resolution process to go ahead.

9. In September 2012 the representative sent the CSU a ‘Client Authority’ form.

10. In September 2016 the CSU held a panel meeting to discuss Mr U’s eligibility.

11. The representative chased the outcome of the meeting in February 2017. A few days later, they were told by the CSU that the outcome letter should be sent within six weeks.

12. In March 2017 the CSU sent the outcome letter direct to Ms O.

13. In February 2018 the representative contacted the CSU for an update on the outcome letter being issued. On 5 March the CSU advised it needed the representative to send a new form of authority as evidence of Ms O’s updated consent for it to act on her behalf.

14. A copy of the outcome letter was sent to the representative in August 2018.

17. We are sorry to hear this complaint was not resolved when we returned the case to the CSU in March 2019. It is important that we give the organisation concerned the opportunity to look at a complaint first, as often it is in the best position to resolve things. However, we are now able to look at this complaint as the CSU has confirmed it has nothing more to add.

18. The National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care, November 2012 (Revised) says in paragraph 146 (regarding challenging decisions):‘Whether or not it is considered that the person has a primary health need, the CCG should give clear reasons for its decision. These should set out the basis on which the decision was made and explain the arrangements and timescales for dealing with a review of the eligibility decision in the event that the individual or someone acting on their behalf disagrees with it’.

19. This guidance means that where a decision is reached about an individual’s eligibility for CHC, the organisation should explain its decision and say if there is a way to dispute it, and if there is a timescale to do this.

20. We can see from the background section that the representative sent the CSU authority to act in September 2012, and then the events that followed this.

21. We have seen a copy of the CSU’s outcome letter. It explains Mr U did not meet the criteria for CHC funding. It says if Ms O disagrees with the decision, to contact the service ‘within 30 days of receipt of this letter’ to start the local dispute process. The address for the service is given in the letter header, and referred to at the end of the letter. Our view is this letter is in line with the guidance in the National Framework. It clearly explains the decision and what the next steps are.

22. We know the representative feels the letter should have been sent to them. We spoke to Ms O who explained that when she received the letter, she only read it partly. This is because she saw the outcome as a ‘flat no’ and thought her representative would be following this up. We understand Ms O’s thought process and are not saying she should have done more. As she was being represented, it is reasonable that she thought they would deal with this.

23. But, we can see that the representative had been told by the CSU, in February 2017, that the outcome letter should be sent within six weeks. It was sent in March but the representative did not chase this up with the CSU until February 2018. This is 11 months. There is also no indication that the representative contacted Ms O within this period. This is a significant amount of time.

It is reasonable to expect the representative to have contacted both CSU and Ms O sooner.

24. While the CSU did not send the letter to the representative, it did communicate its decision to Ms O. It is not unreasonable for the CSU to have expected Ms O to discuss this with her representative and instruct them to dispute the decision, if this is what she wanted to do. As we have said, we are not saying Ms O is to blame. We are looking at what it would have been reasonable for the CSU to think. We appreciate Ms O found this very upsetting and had asked to be represented for this reason.

25. We realise the representative says the CSU had not asked for new authority when they had contacted it before. While the representative sent signed authority in 2012, the CSU would have needed more current evidence of consent and authority. The Parliamentary and Health Service Ombudsman takes a similar approach, as we require fresh authority each time a representative brings a complaint to us, regardless of whether we have received this in the past. Our view is the CSU did need new authority, but we think there were missed opportunities for the CSU to tell the representative what it needed. It could have asked for this when it gave the representative updates before sending the outcome letter.

26. However, we do not think this is a failing. This is because the CSU still shared its decision by sending it to Ms O, in line with the National Framework. By telling the representative the letter should be sent within six weeks, it gave them enough information to follow this up. If this happened, they would have found out the outcome letter had been sent and allowed time to dispute this within 30 days. As we have discussed, the representative did not follow this up until 11 months later.

27. The contact the CSU had with the representative was to give updates. This is not confidential information that the CSU would have needed authority to share.

28. In March 2018 the CSU told the representative that it needed a new form of authority and updated consent, to show it was still representing Ms O. From what we have seen, the CSU continued to tell the representative what it needed, but this was not provided.

29. The representative sent its dispute to the CSU’s decision in September 2018, after it had received a copy of the outcome letter in August. They say this should be accepted as it was sent within 30 days of when they received the letter. The CSU declined this and said it was too late to raise a dispute.

30. We do not think the CSU should accept this late request. The letter does say to contact the service within 30 days of receipt of this letter. We do not think it is acceptable to extend this timeframe to when it was received by the representative. This is because, by saying ‘receipt’, it means following the date the letter was sent. The letter was sent in March 2017 and received by Ms O soon after this. The 30 days would apply from this date onward.

31. For these reasons we do not think the CSU did anything seriously wrong and we do not think it should have allowed a late appeal to continue through the local process.

1. We have carefully considered Ms O’s complaint about the Commissioning Support Unit (CSU) sending the outcome to the retrospective review request directly to her, rather than her professional representative (the representative).

2. We also looked at the CSU’s decision not to accept the appeal made by the representative, and its reasons for doing this.

3. We do not think the CSU did anything seriously wrong by not sending the outcome letter directly to the representative. We have not seen indications of failings in the CSU’s decision to not accept the appeal.

4. We will explain how we have reached our decisions below. We are sorry to hear about how difficult Ms O found the process and how this affected her. We thank her for sharing her concerns with us and giving us the opportunity to review them.