NHS South West London Integrated Care Board

3. Ms E complains about the ICB. She specifically complains in August 2024 the ICB: • did not inform the family the meeting was an MDT (Multidisciplinary Team) • did not appropriately constitute a correct MDT panel • reduced her care hours from 12 to four.

4. She also complains following the ICB’s decision in August 2024 the ICB: • provided a carer(s) who were not tier three as outlined in her care plan • ignored a request for an urgent ICB review as well as a joint review meeting.

5. Ms E says as a result of the reduction in hours, she has no carer from 3.30pm to 9pm. Ms E says she had to go to A&E three times in the three months after the ICB actually reduced her care hours from 12 to four in December 2024.

6. Ms E says this decision has caused a huge amount of stress and she had a suspected heart attack due to the stress. She says due to the lack of care hours and properly trained complex carers, she has experienced knee injuries due to the mistakes of domestic carers that are not trained as complex carers. Her knee injuries and pressure sores made her bed-bound for three weeks. Her knee injuries means she cannot stand or use a frame to do her physio exercises as she cannot put weight on her knees and set back her hard work in trying to improve.

7. Ms E is seeking the ICB to review its decision and an apology

8. In April 2020 Ms E had 12 hours of care provided on a temporary basis following a discharge from hospital. On 25 November an assessment took place.

9. On 9 December 2020 Ms E was informed her needs did not meet the eligibility level for NHS Continuing Healthcare. She was informed in the same letter she was eligible for NHS FNC (NHS funded nursing care).

5 August 2024

13. Ms E complains the ICB did not inform her family the meeting on 15 August 2024 was an MDT meeting. She also complains the ICB did not appropriately constitute a correct MDT panel.

14. The ICB’s response dated 21 November 2024 did not directly address Ms E’ complaint. The ICB explained it completed Ms E’s annual review on 15 August 2024.

15. We have reviewed the records.

16. On 12 November 2020 the ICB informed Ms E it would be completing a DST (decision support tool) to review Ms E’ care needs. This would be carried out on 26 November 2020.

17. The National Framework 2018 explains the Decision Support Tool (DST) has been developed to aid consistent decision making. The purpose of the DST is to help identify eligibility for NHS Continuing Healthcare. An assessment of eligibility process must be undertaken by a multidisciplinary team (MDT).

18. On 9 December 2020 Ms E was informed her needs did not meet the eligibility level for NHS Continuing Healthcare. She was informed in the same letter she was eligible for NHS FNC (NHS Funded Nursing Care).

19. The National Framework 2018 explains reviews are to occur every year. We can see in the records an FNC review took place on 15 June 2021. No change in need had been identified. This was communicated to Ms E on 26 August 2021. A FNC review took place on 5 July 2023. No change in need had been identified. This was communicated to Ms E on 17 July 2023.

20. The National Framework 2018 says:

‘When reviewing the need for NHS-funded Nursing Care, potential eligibility for NHS Continuing Healthcare must always be considered. This will normally be achieved by completing a Checklist and where necessary a full assessment for NHS Continuing Healthcare using the DST.

However, where: • a Checklist and/or DST has previously been completed (with the result that the individual was not found eligible for NHS Continuing Healthcare), and • it is clear that there has been no material change in need then it will not be necessary to repeat the Checklist and/or DST and this should be recorded.

The individual should be informed of this outcome and the reasons for it.

Where a new Checklist is completed and indicates that a full assessment of eligibility for NHS Continuing Healthcare is required, then an MDT should complete a DST and follow the normal decision-making process.’

21. At this stage the National Framework had been updated. The National Framework 2022 explains when reviewing the need for NHS-funded Nursing Care, eligibility for NHS Continuing Healthcare will normally be considered by a full assessment using the DST. However, where a DST had previously been completed and there is no clear material change then it is not necessary. As the ICB had identified no change during Ms E’ review on 17 July 2023, an MDT was not required to complete a DST.

22. We will now consider the specific review Ms E complains about. On 15 August 2024 an annual FNC review took place. In line with the National Framework 2022 and as explained above, the ICB had identified no change during its previous review therefore the review on 15 August 2024 was not an MDT.

23. Ms E also complains this meeting was not properly constituted.

24. We have considered NHS-funded Nursing Care Practice Guidance Supporting the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care July 2022. It says:

‘An assessment by a registered nurse is required to inform eligibility for NHS-funded Nursing Care, irrespective of the setting in which the individual is currently placed. Consideration of NHS-funded Nursing Care must be undertaken by a registered nurse, following a decision that the individual is not eligible for NHS Continuing Healthcare.’

25. We have reviewed the annual review. We can see Ms E was in attendance along with her mother. It is noted Ms E had capacity. The review was completed by the CHC nurse assessor. We consider this to be in line with the practice guidance.

26. We acknowledge the CHC process is complex. We are sorry to hear Ms E feels her family was not informed the meeting was an MDT meeting and it was not constituted properly. We consider the meeting on 15 August 2024 was not an MDT and was a FNC annual review. The meeting held by the ICB was appropriate and in line with the National Framework 2022. The meeting was also properly constituted in line with practice guidance. We have not seen evidence the ICB said the meeting on 15 August 2024 was an MDT. We see no indication of a failing here.

Care hours

27. Ms E complains the ICB reduced her care hours from 12 to two.

28. The ICB said in April 2020 the ICB commissioned a 12 hour interim package of care support to enable Ms E to be discharged from hospital during the COVID-19 pandemic. An NHS CHC assessment in December 2020 determined Ms E was not eligible for NHS CHC funding. The ICB awarded a package of two hours.

29. The ICB acknowledged the plan to reduce the interim care support from 12 hours to two hours was not done in a timely way. As a result, the reduction of care had not taken place at the time of the ICB’s response. From the records, it is indicated the reduction of hours commenced on 6 December 2024.

30. We will now review the records.

31. On 24 May 2020 the ICB sent Ms E a letter. It explained in accordance with NHS COVID-19 Hospital Discharge Service Requirement Continuing Health Care assessments are currently suspended. Ms E will be provided with a package of care covered by the ICB. The ICB said it will be in contact to arrange a review of her needs.

32. On 12 November 2020 the ICB wrote to Ms E. The ICB informed Ms E a DST to review her care needs would take place on 26 November 2020. The DST was completed on 26 November.

33. The ICB informed Ms E on 9 December 2020 her needs did not meet the eligibility criteria for CHC funding. The ICB informed Ms E she would be eligible for joint funding with the local authority. The ICB informed Ms E she would be eligible for two funded hours of care each per day. It explained it would reduce Ms E’ package of care from 12 to two by 4 January 2021. The ICB explained if she did not agree with its decision, she had six months to appeal.

34. We have considered National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care October 2018. It says:

‘Once the eligibility decision is made by the ICB, the individual should be informed in writing as soon as possible (although this could be preceded by verbal confirmation where appropriate). This written confirmation should include: • the decision on primary health need, and therefore whether or not the individual is eligible for NHS Continuing Healthcare; • the reasons for the decision; • a copy of the completed DST; • details of who to contact if they wish to seek further clarification; and • how to request a review of the eligibility decision.

Where an individual is not eligible for NHS Continuing Healthcare, the outcome letter may also include, where applicable and appropriate, information regarding NHS funded Nursing Care or a joint package of care.’

35. In line with guidance Ms E was informed of the ICB’s decision, its reasoning and how to appeal the decision. Ms E was also considered for a joint package of care which was awarded. We have not seen Ms E made a formal appeal to this decision. We cannot say the ICB got anything wrong here.

36. As Ms E did not appeal this decision, we would not be able to comment on the DST as it would be out of time for our consideration. We have continued to review the records to understand the ICB’s actions leading up to the point where Ms E hours were reduced.

37. A joint review took place on 15 June 2021. The ICB sent a letter on 26 August confirming the FNC Review identified no changes in Ms E’s required needs.

38. We have seen after the review in June 2021, on 1 December 2022 Ms E sent an email to the ICB. She wanted to complain about the ICB. She informed the ICB it had knowingly created more stress and distress by reducing hours without any medical input. We consider at this point Ms E was aware the ICB intended to reduce her care hours in line with the DST completed in December 2020.

39. We have not seen at this point the ICB took any further steps to reduce Ms E’ care hours.

40. On 5 July 2023 a second review joint review took place. The ICB sent a letter on 17 July 2023 to Ms E confirming a recent joint funding review identified no changes from the assessment in December 2020.

41. At this stage the National Framework had been updated. The July 2022 National Framework says:

‘NHS Continuing Healthcare Reviews These reviews should primarily focus on whether the care plan or arrangements remain appropriate to meet the individual’s needs. It is expected that in the majority of cases there will be no need to reassess for eligibility.

It is expected that the most recently completed Decision Support Tool (DST) will normally be available at the review and should be used as a point of reference to identify any potential change in needs. Where there is clear evidence of a change in needs to such an extent that it may impact on the individual’s eligibility for NHS Continuing Healthcare, then the ICB should arrange a full reassessment of eligibility for NHS Continuing Healthcare.

Outcomes of an NHS Continuing Healthcare review The outcome of an NHS Continuing Healthcare review will determine whether: (a) the individual’s needs are being met appropriately, and (b) whether eligibility should be reconsidered through reassessment for NHS Continuing Healthcare.’

42. In line with the National Framework 2022 Ms E was reviewed against the DST which took place in December 2020. As no clear change was identified the decision Ms E was eligible for two hours of care remined. We have not seen the ICB got anything wrong here.

43. On 15 August 2024 a joint funding review took place. The review found no significant changes since the DST in December 2020. Following this review the ICB began to reduce Ms E’s care in December 2024. We have considered this review further.

44. Ms E and her mother were in attendance during this review. The review acknowledges and refers to the DST dated December 2020. The reviews considered each of the 12 domains. We have not been provided with a specific dispute over any domains. No changes were noted in comparison to the DST in December 2020.

45. We have seen the four key indicators were also discussed. We have not been provided with a specific dispute over any key indicators. No changes were noted in comparison to the DST in December 2020.

46. Point 203 of the National Framework 2022 says the review should focus the care plan or arrangements remain appropriate to meet the individual’s needs. We consider all 12 domains, and four key indicators were discussed. This is in line with the National Framework 2022. We have not seen the ICB got anything wrong here.

47. We have continued to review the correspondence between the ICB and Ms E.

48. We have seen in the records Ms E raised a challenge to the ICB’s decision to reduce her hours of care. We do not have a specific date as this appears to have been done over the phone.

49. The National Framework 2022 says:

‘Local resolution Where an individual or their representative asks the ICB to review the eligibility decision, this should be addressed through the local resolution procedure, which is normally expected to resolve the matter. ICBs should deal with requests for review in a timely manner. For guidance on this issue please refer to NHS England website.’

50. We have reviewed the records to see if this has been done.

51. On 7 October 2024 the ICB wrote to Ms E. The ICB explained Ms E was informed in December 2020 she was not eligible for CHC funding. She was awarded two hours of funded care. The ICB acknowledged the interim care of 12 hours provided during the COVID-19 pandemic was not reduced in a timely way. Ms E at this point remained in receipt of 12 hours of funded care. This was due to be reduced to two.

52. Following a letter from Ms E’s local MP, the ICB responded to the MP on 21 November 2024. The ICB explained the DST in December 2020 found Ms E was only eligible for two hours of care. The ICB explained the three reviews since have found no significant changes.

53. Ms E’s mother sent two emails to the ICB on 25 and 27 November. She was seeking to challenge the decision to reduce her daughters care hours from 12 hours per day.

54. While local resolution was ongoing, on 20 January 2025 a joint review took place. The review found no further DST was required and no significant changes found since Ms E’s DST in December 2020.

55. A final response letter was sent on 5 April 2025. The ICB explained the plan to reduce Ms E’s care had always remined following the DST in December 2020. It found no failings in its decision to uphold this decision.

56. We consider the ICB has followed the National Framework 2018 and 2022 and has tried to address Ms E concerns through the local resolution procedure.

57. We acknowledge the stress and anxiety this complaint has caused Ms E. We understand she feels two hours of care is not enough for her needs. We are sorry to hear of her experience. The decision to reduce Ms E care hours was made in December 2020. The ICB have acknowledged it look longer than it should have to implement this change. No formal appeal was made to the ICB’s decision in December 2020.

58. We consider the ICB has acted in line with the National Framework 2018 and 2022 since this decision. We consider it has supported its decision through annual reviews as set out in both of the National Framework. We cannot say it got anything wrong here.

Tier three

59. Ms E complains the ICB’s did not provide tier three carers as outlined in her care plan. In an email 20 July 2025 Ms E mother explained Simplified Staffing, the agency providing care at the time, are not complex tier three carers.

60. The ICB did not directly respond to Ms E about this complaint. The ICB responded to us and advised Simplified Staffing assured the ICB carers were appropriately trained to meet Ms E’s needs.

61. We consider the complaint is regarding the care provided by Simplified Staffing.

62. Firstly, we have considered if Mrs E’s plan indicated the need for tier three carers.

63. As noted above on 15 August 2024 a joint funding review took place. It states Ms E is receiving joint funding from the ICB and local authority (LA). She is receiving tier three package of care. We have reviewed the joint funding review which took place on 20 January 2025. The review says Ms E’s care was provided by a tier three carer.

64. We consider tier three carers should be provided.

65. We will now consider the ICB’s actions in relation to commissioning Simplified Staffing. The records show Simplified Staffing started providing care on 15 November 2024. We have reviewed the care and support plan for complex care.

66. We have seen the service user placement agreement between the ICB and Simplified Staffing. It was completed on 18 November 2024. The cost of the care package shows a tier three carer was commissioned. A second service user placement agreement between the ICB and Simplified Staffing. It was completed on 9 December 2024. The cost of the care package shows a tier three carer was commissioned.

67. A third service user placement agreement between the ICB and Simplified Staffing. It was completed on 10 January 2025. The cost of the care package shows a tier three carer was commissioned. A fourth service user placement agreement between the ICB and Simplified Staffing was completed on 4 June 2025. The cost of the care package shows a tier three carer was commissioned.

68. We consider the ICB had commissioned tier three carers. Mrs E complains during this period on occasions Simplified Staffing did not provided tier three. We considered if the ICB’s commissioning of Simplified Staffing was in line with guidance and standards.

69. The four agreements listed above were ‘Any Qualified Provider’ (AQP) agreements.

70. The NHS Confederation, July 2011 explains:

‘Background to AQP AQP allows patients to choose, where appropriate, from a range of qualified providers who are licensed to provide safe care and treatment, and select the one that best meets their needs.

Qualification of providers Before providers can compete to offer a service, they need to be accredited. This is to ensure that they meet the quality standards and the appropriate pricing. A potential provider would therefore be accredited/licensed to provide a particular service or services. A provider is qualified under AQP on confirmation that they: • are registered with the CQC • agree to the tariff that the • receive no guarantees of • can demonstrate a track • agree to the terms and (and Monitor from 2013) where required commissioner is willing to pay (or national tariff where applicable) volume or payment record of delivery of the service (or pass due diligence if new to the market) conditions of the standard NHS contract, incorporating any local commissioner quality requirements or service specifications • sign up to managing potential conflicts of interest explicitly and transparently, ensuring patients are aware of their right to choose and options (especially if a GP practice). Patients can choose from amongst all the providers who have met these requirements’

71. We have also considered South West London CCGs NHS Continuing Healthcare and Funded Nursing Care Choice and Equity Policy, It says:

‘Collaborative commissioning arrangements SWL CCGs (ICBs) are part of a collaborative procurement arrangement - the Pan London Continuing Healthcare ‘Any Qualified Provider’, managed by the London Purchased Healthcare Team.’

72. Our advisor explains the tender process for the AQP is a stringent and detailed process involving submission of proof of purpose, site visits, testimonials, financial information, due diligence checks and interviews. The ICB identified a care provider on its AQP list that said it could meet the care needs of the individual and asked them to establish a package of care for the individual.

73. We understand it is concerning if Simplified Staffing provided staff on days which were not at the level it had agreed. Simplified Staffing has signed the agreement which said it will provide a carer of a certain level of expertise (Tier 3). The ICB followed their AQP process and identified a care provider to deliver the package of care required. We have seen no indication of a failing in the work carried out by the ICB.

Review meeting

74. Ms E complains following the ICB’s decision in August 2024 the ICB ignored a request for an urgent ICB review as well as a joint review meeting. Ms E confirms on 30 September 2025 they emailed the ICB in the early summer of 2025 about these issues.

75. Ms E emailed the ICB on 20 July 2025 following advice from Beacon. She requested a review meeting.

76. We have seen on 9 October 2025 the ICB emailed Ms E to arrange a joint meeting with the local authority, ICB and care agencies.

77. We have seen in the records this meeting took place on 24 October 2025.

78. We have seen it took the ICB two and a half months to confirm a joint review meeting would take place. There is no specific timescale an organisation is given to arrange a meeting. We acknowledge this timescale may have been longer than Ms E was hoping for. Our view is the ICB did accept Ms E request for a joint review meeting and the timescale was reasonable. We cannot say she was ignored.

79. We thank Ms E for bringing her complaint to us. We hope this statement explains how we have carefully considered her complaint.

1. We have carefully considered Ms E’s complaint about NHS South West London Integrated Care Board (the ICB). We recognise her complaint is important to her. We understand it has been ongoing for a long time and how challenging the continuing healthcare processes can be.

2. We have seen the ICB acted in line with national guidance. We have not found it got anything seriously wrong in its decision making. Our decision is not intended to detract from your account or experience.