Derby and Derbyshire Integrated Care Board

2. Mr R complains that the ICB did not do a retrospective review of his mother’s, Mrs R, eligibility for CHC for the period 1 April 2011 to 10 June 2012. He says the ICB completed a desktop review (not a full assessment) on 8 February 2021 it did not consider evidence from 1 April 2011.

3. Mr R says his mother should have had a full assessment because he thinks she would have been eligible for CHC funding at that time. He says his mother’s estate has been affected financially because she had to pay for her own care. He explains he has lost faith in the ICB.

4. Mr R wants the ICB to review its decision for this period and do a retrospective review.

5. Derbyshire County Primary Care Trust (PCT) was responsible for reviewing the care needs. In April 2013, PCTs became clinical commissioning groups, or CCGs. Then in July 2022, CCGs became ICBs. We will refer to the organisation as the ICB throughout our statement for consistency.

6. Mrs R moved to a care home in February 2010 because she was struggling to cope with daily activities. She was admitted to hospital under Section 2 of the Mental Health Act 1983 in May 2012. She was discharged to another care home and lived there until she died in July 2013.

7. The ICB completed a CHC checklist and nursing assessment on 11 June 2012. The checklist is a screening tool used to help identify if an individual may need a full CHC assessment. A person is eligible for CHC if they are found to have a ‘primary health need’. Their care is then fully funded by the NHS. The ICB decided Mrs R did not qualify for a full assessment and it sent its decision on 20 June 2012.

8. The family later asked the ICB to do a retrospective review of Mrs R’s eligibility. The ICB sent its decision on 8 February 2016. It did a full retrospective CHC assessment for 30 July 2012 to 13 July 2013 (period two) and decided she was not eligible. It declined to do a retrospective review for the period before this.

9. The family appealed the period two decision to NHS England. It decided the ICB’s decision was not sound and overturned it. In 2020, it accepted Mrs R had been eligible between 30 July 2012 and 13 July 2013 and reimbursed the care costs.

10. In September 2020, the family’s representatives asked again for a retrospective review for 1 April 2011 to 10 June 2012 (the first period). The ICB did a desktop review of the 11 June 2012 checklist to make sure it had been done correctly. It sent its final response on 8 February 2021. It was satisfied that the checklist had been completed properly.

13. Before we decide if we should do a detailed investigation of a complaint, we look at whether there are signs the organisation got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not seen any signs that the ICB got anything wrong.

14. Mr R says the ICB did not do a retrospective review for the period 1 April 2011 to 10 June 2012. He says the desktop review of the 11 June 2012 checklist did not consider evidence for the right period.

15. The ICB’s officer said its investigation found the decision to decline Mr R’s original request for a retrospective review to be appropriate. This was based on the checklist and nursing assessment completed on 11 June 2012. Mrs R did not meet the threshold for CHC funding.

16. The PUPoC guidance allows a person to ask an ICB to do a retrospective review as long as the period had not already been assessed. The guidance gives deadlines for requesting retrospective reviews. For claims between 1 April 2011 and 31 March 2012, the deadline was 31 March 2013. The Department of Health and Social Care (DHSC) set no deadline for retrospective reviews requests for periods after 1 April 2012.

17. The checklist and nursing assessment in June 2012 was a ‘current’ assessment. That means the ICB was looking at Mrs R’s needs at that time, rather than retrospectively. It sent an outcome letter on 20 June 2012. We know Mr R did not challenge the decision. He had 12 months to do this.

18. On 8 February 2016, the ICB told Mr R’s representatives that it would not do a retrospective review for the period before July 2012. It said there had been an assessment in 2012 (the checklist) so this period was already assessed. We cannot see that Mr R challenged that decision. He had 12 months to do that.

19. We know the earlier period was mentioned again during a local dispute resolution meeting (complaint meeting) on 24 July 2017. The meeting was to discuss the later period, period two. The family’s representative was advised to approach the ICB about the earlier period. We have not seen evidence that they did this.

20. The representative says NHS England’s decision to overturn the ICB’s decision about period two and the comments made during its review made the family wonder if Mrs R would have been eligible for CHC sooner. They say they made a complaint in 2020 and the ICB then did the desktop review of the June 2012 checklist. The way the ICB did the desktop review became the subject of the ongoing complaint. They say the ICB failed to request or consider any evidence from April 2011 to June 2012.

21. We can see that when the family asked for a retrospective review in 2020, the first year of the claim period (1 April 2011 and 31 March 2012) was significantly out of time. The family would have had to ask for a retrospective review by 31 March 2013 to meet the deadline. The ICB did not have to accept the request in line with the PUPoC guidance. This leaves only 1 April 2011 to 10 June 2012, a period of just over two months. When the registered mental health nurse did the checklist on 11 June 2012, they would have looked at evidence from the time leading up to the assessment. So we do not think the period 1 April to 10 June 2012 was unassessed. Mrs R’s needs from that time were taken into consideration as part of the checklist.

22. The family had the chance to challenge the June 2012 checklist at the time. They had the chance to challenge the ICB’s decision in 2016 not to do a retrospective review for the period 1 April 2011 to 10 June 2012. They did not do either of these things. The ICB did not have to do anything more when the family asked again in 2020 for a retrospective review.

23. Our Principles say that organisations should treat people with sensitivity, bearing in mind their individual needs, and respond flexibly to the circumstances of the case.

24. We can see the ICB did a desktop review of the June 2012 checklist after the representative’s complaint. This was to check there was nothing that might suggest it should look again at that decision. The ICB would only have considered putting the deadline to one side (to look at evidence from the period from 1 April 2011) if it found something. The ICB would have had to see exceptional reasons to do that.

25. We think the ICB was being helpful and thorough when it did the desktop review, so it acted in line with our Principles. But even if it had done nothing more, we could not have said it did anything wrong.

26. The desktop review assured the ICB that the checklist was done correctly, so there was no indication to revisit any earlier period.

27. We are satisfied the ICB did not do anything wrong. The ICB’s decisions and actions seem to have been in line with our Principles and the National Framework.

28. We understand why Mr R and his family have questions about when Mrs R should have started getting CHC funding. When we weigh up the evidence, we can see they had the chance to question the ICB’s decisions in 2012 and 2016. So we think it was right for the ICB to decline to do a retrospective review in 2020. We hope our explanations help the family understand why the ICB did not do anything wrong.

1. We have carefully considered Mr R’s complaint about Derby and Derbyshire Integrated Care Board’s (the ICB) decision not to complete a retrospective continuing healthcare (CHC) review for the period 1 April 2011 to 10 June 2012. CHC is an NHS-funded package of care for an adult with specific care needs. A retrospective review is when an ICB looks back at a period of time and decides if someone should have qualified for CHC. We do not think the ICB did anything wrong when it made its decision. We explain the reason for our decision below.