Derby and Derbyshire Integrated Care Board

4. Mr A complains the ICB did not follow the National Framework as it did not carry out a review after three months of the DST in June 2019. The ICB also did not carry out a review of the DST until October 2020 when it should have been done in June 2020.

5. Mr A states as a result this has denied the estate of a robust assessment of needs and possibility of recovering previously paid care fees.

6. Mr A is seeking a retrospective review of 1 June 2019 to 17 January 2023.

7. Mr A has sought the assistance of solicitors to help him with this complaint.

8. On 18 February 2019, a Fast-Track assessment concluded Mrs Y was eligible for Fast-Track CHC funding.

9. Continuing healthcare (CHC) funding is NHS funding provided to cover the health and social care needs of people with complex health needs. A checklist is used to determine a patient’s needs. A positive checklist indicates a patient has high needs and so is to be discussed at a meeting attended by different clinicians (MDT). A decision support tool (DST) is a national tool for CHC funding. The tool brings together information from the assessment of a patient needs (checklist) to facilitate evidence-based recommendations and decision-making regarding eligibility for NHS Continuing Healthcare (CHC) during the MDT. An IRP is an independent review panel used to review the MDT decision regarding CHC funding.

10. Individuals with a rapidly deteriorating condition who may be entering a terminal phase may require ‘fast -tracking’ for immediate provision of NHS continuing healthcare. The intention of the fast-track pathway is that it should identify individuals who need to access NHS continuing healthcare quickly.

11. On 26 June 2019 a DST was carried out and concluded Mrs Y was no longer eligible for CHC, and was awarded funded nursing care (FNC).

12. Funded Nursing Care is NHS funding to cover nursing care only.

13. On 5 October 2020 a CHC review was carried out and concluded no change in Mrs Y’s needs. FNC was awarded.

14. On 4 August 2021 a CHC review was carried out which concluded no change in Mrs Y’s needs and continued to award FNC. At this review, it was concluded that Mrs Y no longer had capacity (ability to make her own decisions).

15. A subject access request (SAR) was sent by Mr A’s solicitor to the commissioning support unit (CSU) on 5 December 2022, requesting Mrs Y’s personal data held by the ICB.

16. On 4 January 2023 Mrs Y’s personal data held by the ICB was provided to the solicitor but it considered some information was still outstanding.

17. On 21 January 2023 a CHC review was carried out and found no change in Mrs Y’s needs and she was still eligible for FNC.

18. A second SAR was submitted in late March and the information was supplied to the solicitor in full on 17 May 2023.

19. On 14 August 2023 the solicitor wrote to the ICB requesting a retrospective review from June 2019 to January 2023. On 2 October 2023, the ICB confirmed it would not carry out a retrospective review as there were no unassessed periods of care.

20. On 15 November 2023 the solicitor made a complaint to the ICB and the CSU. On 23 January 2024 the ICB responded to the complaint.

21. The solicitor made further contact with the ICB and asked for the complaint to be reopened on 7 March 2024. The ICB issued its final response on 2 May 2024.

22. On 8 May 2024 the complaint was made to us.

23. We reached a decision on the 19 February 2025 which Mr A requested the decision is reviewed. We identified that we did not appropriately consider all relevant guidance when reaching a decision on the timeliness of the reviews and therefore this issue has been reconsidered.

Timeliness of reviews

27. Mr A complains the ICB did not follow the National Framework as it did not carry out a review after three months of the DST in June 2019. The ICB did not carry out a review of the DST until October 2020 when it should have been done in June 2020.

28. A fast-track decision concluded Mrs Y was eligible for funding in February 2019. A DST was carried out in June 2019, which concluded she was no longer eligible for funding. Mr A states this decision should have been reviewed in September 2019, and a full consideration of Mrs Y’s needs should have been carried out in June 2020. No review of Mrs Y’s needs was carried out until October 2020.

Our consideration

29. We previously considered this complaint issue and reached a decision on the 19 February 2025. We concluded the ICB acted in line with the National Framework and therefore found no indications of failings in how frequently the ICB completed the fast-track reviews.

30. Following this, Mr A requested our decision is reviewed and submitted that all relevant guidance had not been considered. Further to considering his submissions we have reconsidered the complaint.

31. To robustly consider this we have obtained clinical advice from our adviser.

32. Having done so, we agree with Mr A that the ICB failed to robustly complete the reviews in a timely manner. When considering the complaint we have considered both the National Framework and the Practice guidance.

33. The National Framework states ‘Where an individual has been found eligible for NHS Continuing Healthcare, a review should be undertaken within three months of the eligibility decision being made. After this, further reviews should be undertaken on at least an annual basis, although some individuals will require more frequent review in line with clinical judgement and changing needs.’

34. The Practice guidance says in section ‘3 and 12 month Reviews of NHS-funded Nursing Care’ in paragraph 87:

‘Where an individual has been found eligible for NHS-funded Nursing Care, a review should be undertaken within 3 months of the eligibility decision being made. After this, further reviews should normally be undertaken on at least an annual basis’.

18 February 2019 Fast track- CHC funding awarded 26 June 2019 Decision Support Tool- no longer eligible for CHC- awarded funded nursing care (FNC) 5 October 2020 CHC review- no change, still eligible for FNC 4 August 2021 CHC review- no change, still eligible for FNC 21 January 2023 CHC review- no change, still eligible for FNC

35. We consider there to be indications of failings as following the award of FNC funding in June 2019 the next review took place in October 2020. This is not in line with the stipulated three month review as detailed in the Practice guidance.

36. Mr A tells us that a result this has denied the estate of a robust assessment of needs and possibility of recovering previously paid care fees. Having carefully considered this, we cannot link this claimed impact to the failings as we can see when the reviews were completed eligibility remained the same.

37. However, we consider the failure to complete the reviews in a timely manner caused Mr A and the family distress. We think the complaint can be resolved at this stage and accordingly we have had discussions with the ICB.

38. As highlighted, we have found no indications to suggest that the failure to complete timely reviews affected eligibility, but caused the family distress. We have discussed this with the ICB who is in agreement to provide an apology to the family with an acknowledgment of the failings. It will also provide an action plan detailing how it will ensure the same does not happen again.  We consider these actions to be in line with our Principles of Remedy and are satisfied this would resolve the complaint and the distress caused.

39. We have asked the ICB to complete this within one month of our decision.

40.  Based on this we consider the ICB have completed actions to remedy the distress caused to Mr A, specifically following the failure to complete timely reviews. We consider the complaint to be remedied and do not propose any further actions.

41. We recognise this has been a difficult process and we were sorry to hear about his concerns. We thank Mr A for bringing this complaint to our attention and for the feedback he provided following our initial consideration of the complaint. This has allowed us to robustly consider the complaint.

1. We have carefully considered Mr A’s complaint about Derby and Derbyshire Integrated Care Board (the ICB).

2. We have found indications of failings in the timeliness of the fast-track reviews that the ICB completed when considering Mrs A’s continuing healthcare (CHC) funding eligibility. The ICB has proposed to complete further actions which we consider remedies the distress this has caused to Mr A. We consider this resolves the complaint.

3. We understand the CHC process can be frustrating and take a long time. We recognise this has been a difficult experience for the family and we understand this has been a long process.