Humber and North Yorkshire Integrated Care Board

3. Ms C complains NHS England’s (NHSE) independent review panel (IRP) upheld Humber and North Yorkshire Integrated Care Board’s (the ICB) decision that her father, Mr D was not eligible for NHS continuing healthcare (CHC) funding on 25 November 2022. She disagrees with its consideration of the cognition domain, the four key characteristics and the well managed needs principle.

4. Ms C says as a result her father was not eligible for NHS CHC funding. This has had a financial impact on the family and her father’s care.

5. Ms C wants NHSE to reconsider its decision that her father was not eligible for CHC funding.

6. On 21 September 2021 Mr D was found eligible for CHC funding. On 9 June 2022 Mr D had a review of his eligibility. The outcome was Mr D had a decrease in his care needs and a full assessment was required.

7. On 25 November 2022 the ICB completed a decision support tool (DST). A DST is a document which helps to record evidence of an individual’s care needs to determine if they qualify for CHC funding. The DST found Mr D was not eligible for NHS continuing healthcare (CHC) funding.

8. On 29 November 2022 the ICB sent its outcome letter.

9. On 22 May 2023 the family appealed the outcome.

10. On 5 October 2023 a local resolution meeting (LRM) took place. On 8 November 2023 the ICB sent its outcome letter. Mr D remained ineligible for CHC funding.

11. On 4 June 2024 the family requested an IRP. On 21 August 2024 NHSE held an IRP. The IRP upheld the ICB’s decision. On 24 September 2024 NHSE sent its outcome letter.

12. On 7 October 2024 Ms C sent NHSE an email and said she had not received the outcome letter. On the same day NHSE resent the outcome letter to her.

15. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong when NHSE made its decision.

16. Before we discuss our decision, we would like to explain some information about how an IRP reaches its decision and what this means for how we look at it. NHSE guidance says an individual receiving care, or their representative may apply for an IRP to review a ICB’s decision to decline CHC funding.

17. Whether or not an individual is eligible for NHS continuing healthcare funding is a discretionary decision. It is our role to decide whether NHS England’s IRP acted in line with the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care (July 2022) when it considered whether Mr D was eligible for CHC. The National Framework sets out the principles and processes ICBs and NHS England should follow when considering if someone is eligible for CHC.

18. We cannot consider the discretionary decisions the IRP made when it decided on eligibility. This includes the decisions it makes based on clinical judgement and clinician’s opinions. We can only consider if the IRP has followed the National Framework. This means we can only uphold a complaint about a CHC eligibility decision if we find the IRP did not follow the National Framework when it made its decision.

19. The IRP reviews if the ICB should have found the person to have a primary health need and therefore be eligible for CHC. It also reviews the ICB’s procedures when it was coming to its eligibility decision to make sure it was acting in line with the National Framework. If the IRP does find the ICB made a mistake, it can:

• recommend the ICB reconsiders if the patient had a primary health need, and • recommend the ICB addresses any procedural faults the IRP identified.

20. To help us reach a decision, we have carefully considered the information Ms C provided alongside the file the IRP considered. When we look at a complaint about an IRP, we consider if it took into account all the relevant information when it made its eligibility decision. Ms C has told us she disagrees with its consideration of the cognition domain, the four key characteristics and the well managed needs principle.

Evidence

21. We can see the IRP had access to all the information the ICB used to make its decision. This included the following:

• Summary of Mr D’s case including a chronology of events • Decision support tools • Checklist • Local resolution documentation • Care home records • Care plans • GP records • Speech and language therapy letter • Social care assessment

22. We also have a copy of the IRP’s report. The report documents the submissions Ms C and her mother gave in person.

23. Mr D was admitted to a care home on 13 April 2022 from a rehabilitation unit following his hospital admission. In January 2023 he was moved to a different care home nearer to the family at their request.

24. Ms C says the IRP did not consider all the evidence which included the medical records, emails and the family’s evidence contradicting the CHC nurse assessors. Ms C says there was no care plans, they were blank. They were not filled in because staff were not expecting Mr D to stay long term.

25. We have looked at the information in the IRP report and considered how the panel discussed all the available evidence when it considered the disputed domains. We can see at the IRP meeting the IRP chair explained it would be considering the DST assessment dated 25 November 2022 and it would only be considering and taking into account evidence from the three months prior. We can see the care plans are dated from 12 June 2022. The daily care records are from 24 August 2022 to 12 January 2023.

26. We can see the IRP gave Ms C and her family the opportunity to provide verbal evidence during the meeting and it had access to her written submission. We can see the IRP took into account their views throughout its review and in the care domains. This is detailed in section 7 and 9 of the IRP report which outlines the family’s view on the domains and the four key indicators.

27. We can see the IRP had access to information detailing Mr D’s needs. There is no obvious omission in the documents or evidence. The IRP considered the information in the care records, GP records, social service records and local resolution records. It is clear the IRP had access to the all the information the ICB used to make its decision.

28. We are satisfied there is no indication of a failing in how the IRP established all the appropriate and relevant clinical facts. We think the IRP acted in line with the National Framework here.

Care domains

29. Ms C has told us she disagrees with the IRP’s consideration of the cognition domain.

30. Ms C says her father’s needs in this domain were moderate.

31. The DST descriptor for moderate says:

‘Cognitive impairment (which may include some memory issues) that requires some supervision, prompting and/or assistance with basic care needs and daily living activities. Some awareness of needs and basic risks is evident. The individual is usually able to make choices appropriate to needs with assistance. However, the individual has limited ability even with supervision, prompting or assistance to make decisions about some aspects of their lives, which consequently puts them at some risk of harm, neglect or health deterioration.’

32. The ICB said Mr D’s needs in this domain were low and the IRP weighted it as low.

33. The descriptor for low says:

‘Cognitive impairment which requires some supervision, prompting or assistance with more complex activities of daily living, such as finance and medication, but awareness of basic risks that affect their safety is evident.

OR Occasional difficulty with memory and decisions/choices requiring support, prompting or assistance. However, the individual has insight into their impairment.’

34. Ms C says her father suffered a head injury and irreversible brain damage in his youth and a stroke which impacted his cognition. She said her father needed support, prompting and an advocate. Ms C says a medical discharge letter in 2022 suggested possible cognitive decline but this was never addressed.

35. We can see from the IRP report the panel had a discussion about Mr D’s needs in the cognition domain. Ms C gave an account of her father’s needs. The IRP weighed this up her concerns to see whether a higher weighting may be appropriate.

36. The IRP acknowledged the family’s concerns that Mr D had issues with his memory and required assistance and prompting. It said Mr D had awareness of risks but it acknowledged he interpreted information differently because of his head injury and cognitive impairment. It said Mr D could make decisions on what to eat or wear but he did need a lot of support with any care decision. The family said Mr D did recognise family members. He could have memories of things that didn’t happen. The family said he was mostly but not consistently oriented to time and place. It said there was a request to assess Mr D’s capacity but this was not carried out.

37. We think the IRP acted in line with the National Framework when it considered Mr D’s needs in this domain. The IRP looked at the available evidence and said why it could not say Mr D’s in this domain were moderate.

38. The social care assessment said Mr D was able to express his views. There was no deprivation of liberty order in place and one was not required. In the DST staff detailed how Mr D was able to express his views, wishes, preferences and could say when he wanted to go to bed or get up. The daily care records show Mr D understood and was able to consent to personal care. Staff did not observe any confusion. It said he sometimes had difficulty finding words when he was tired. The care plan dated 9 June 2022 said Mr D was oriented to time, place and person and had insight into his needs. He was able to express pain and identify the location. This was evaluated monthly and remained unchanged on 28 October 2022.

39. The DST says Mr D said ‘sometimes people try to help me finish a sentence and I feel like saying I haven’t got dementia’. It said he had thought about standing up in the shower when the carer had left but SW pointed he had correctly assessed the risk and had not stood. We understand Ms C disagrees with this and says her father did not stand because he wasn’t able to reach the grab rail.

40. We acknowledge the IRP’s analysis in this domain is brief. It would have been better if some of the details in the care records were included in the report. However, the IRP looked at the available evidence and said why it could not say Mr D’s in this domain were moderate.

41. The IRP acknowledged although Mr D’s cognition was impaired it was still sufficient for him to make decisions about aspects of his life such as how he spent his time. It acknowledged his delight in the company of his family and his interest in sport and social activities.

42. The IRP acknowledged the family’s view that Mr D occasionally had difficulties with memory and making decisions/choices. The IRP said Mr D had insight into his impairment and a low level of need was appropriate in this domain.

43. We recognise Ms C disputes the weighting of this domain. It appears the IRP considered this domain in line with the National Framework and DST descriptors. We can see no indications of a failing.

Four key characteristics

44. The IRP applies an eligibility test to help it make a decision about an individual’s CHC eligibility. This is what we refer to as the ‘primary health need’ test. The National Framework separates this test into four key characteristics: nature, intensity, complexity and unpredictability. This test is used to establish if the quantity or type of an individual’s care needs are more than what the local authority can provide. This indicates they have a primary health need, which in turn indicates they are eligible for CHC.

45. The National Framework sets out questions for the IRP to consider to help establish a person’s level of need. They are outlined in ‘Practice Guidance 3, When identifying a primary health need, how should the four key characteristics be approached?’ (PG3). The National Framework is clear the questions it provides are not meant to be strictly applied and are there to guide the IRP’s considerations. We use these questions when we are looking at whether the IRP properly considered the four key characteristics of Mr D’s needs.

46. Ms C has told us she disagrees with the IRP’s consideration of the nature, intensity and complexity key characteristics. We have therefore looked at how the IRP considered these characteristics.

Nature

47. Section 3.3 of the practice guidance within the National Framework describes nature as ‘the characteristics of both the individual’s needs and the interventions required to meet those needs’.

48. In line with paragraph 59 of the National Framework, in the IRP’s consideration of nature we would expect to see analysis of: ‘The particular characteristics of an individual’s needs (which can include physical, mental health or psychological needs) and the type of those needs. This also describes the overall effect of those needs on the individual, including the type (quality) of interventions required to manage them’.

49. Section 3.3 also lists questions prompts for factors that should be considered (though not specifically and individually answered) for the nature characteristic:

• How does the individual or the practitioner describe the needs (rather than the medical condition leading to them)? What adjectives do they use?

• What is the impact of the need on overall health and well-being?

• What types of interventions are required to meet the need?

• Is there particular knowledge/skill/training required to anticipate and address the need? Could anyone do it without specific training?

• Is the individual’s condition deteriorating/improving?

• What would happen if these needs were not met in a timely way?

50. Ms C disagrees with the IRP’s consideration of the nature characteristic.

51. The IRP report shows the panel considered Mr D’s needs and how this impacted him. It’s decision in the nature indicator is clear and presents a full picture of how Mr D’s needs were met. The IRP focussed on Mr D’s individual needs rather than his diagnosed medical condition.

52. The IRP looked at the type of care Mr D needed to keep him safe and well. The report set this out in detail. The IRP acknowledged Mr D had a range of care needs and required care and support 24 hours a day. The IRP said he had high weightings for his needs across four care domains. These were the nutrition, mobility, drug therapies and medication and the altered states of consciousness domains. The IRP discussed Mr D’s needs across these domains.

53. The IRP said Mr D had a good appetite and was interested in food and would choose his meals from the menu. The IRP said Mr D appear to cough after eating and his family were concerned about the risk of aspiration. The IRP said he had a history of dysphagia and required supervision to ensure he did not choke on or aspirate his food.

54. The IRP acknowledged Mr D was completely immobile and was cared for in his room most of the time. The IRP said he needed two carers to move him using a sling hoist from his bed to a chair. He was repositioned every four hours. The IRP said due to his decreased mobility he was at lesser risk of falls.

55. The IRP acknowledged due to Mr D’s epileptic seizures from childhood he could not administer his medication himself. A registered nurse or trained staff would administer all his medications. He was prescribed rescue medication to be used following a seizure and his epilepsy medication was time critical. Following a seizure Mr D did require skilled intervention to maintain his airway. He also had oral medication to be used if a seizure lasted longer than five minutes. This was administered by either a registered nurse or trained care staff.

56. The IRP acknowledged Mr D had a moderate level of needs in continence and skin domains. It said Mr D was incontinent and required assistance with bowel movements. Staff checked his skin regularly and applied barrier creams. The IRP acknowledged at the time of the DST Mr D’s skin was intact.

57. The IRP said Mr D had a low level of needs across the breathing, communication, psychological and emotional, cognition and behaviour domains. It acknowledged the family’s view that Mr D had episodes of breathlessness which responded well and his communication was good. The family reported some episodes of low mood. The IRP said Mr D’s was warm and friendly and engaged requiring no treatment for his low mood. He displayed no challenging behaviour such as shouting, throwing objects. It acknowledged this was apart from some alleged inappropriate touching.

58. The IRP said care staff did not need any specialist training to provide Mr D care interventions. He was able to tell staff what his wishes were. The care provision did not take longer than usual. He did not require one on one care or close supervision in order for his care needs to bet met. The IRP said if his care needs were not met in a timely manner Mr D could be uncomfortable but this could be easily remedied. The IRP said the level of skill required to meet Mr D’s needs was not over and above what a local authority could provide.

59. We think the IRP considered all the relevant factors, including the family’s evidence, when it decided the nature of Mr D’s needs did not indicate he had a primary health need. We are satisfied it acted in line with the National Framework

Intensity

60. Section 3.4 of the practice guidance within the National Framework says intensity ‘is about the quantity, severity and continuity of needs.’

61. In line with the National Framework, we would expect the IRP’s consideration of the intensity indicator to ‘relate both to the extent (‘quantity’) and severity (‘degree’) of the needs and to the support required to meet them, including the need for sustained/ongoing care (‘continuity’)’.

62. Section 3.4 also lists questions prompts for the intensity characteristic:

• How severe is this need?

• How often is each intervention required?

• For how long is each intervention required?

• How many carers/care workers are required at any one time to meet the needs?

• Does the care relate to the needs over several domains?

63. Ms C disagrees with the IRP’s consideration of the intensity characteristic. She says the combined effect of her father’s needs increased the intensity of the care he required.

64. We can see the IRP looked at the right things. It had a discussion about the intensity of Mr D’s needs. It acknowledged Mr D had care needs across 11 care domains. He did not have a severe level of need in any of the domains. He had a high level of needs in the nutrition, mobility, drug therapies and medication and altered state of consciousness care domains. The IRP He had a low level of need in the breathing, communication, psychological and emotional needs, cognition and behaviour care domains.

65. The IRP said Mr D required care 24 hours a day, seven days a week to meet his care needs. Mr D had dysphagia and required supervision when eating to ensure he did not choke on or aspirate his food. He required two care staff to move him using a sling hoist and he was repositioned every four hours. He required his prescription to be administered by a nurse or trained care staff. Following a seizure he would require skilled intervention to maintain his airways. If his seizures lasted more than five minutes he had medication which was administered by a nurse or trained care staff. Care staff had to check his skin regularly and apply barrier creams. The IRP said the care records do not show his care provision took longer than usual to provide.

66. We can see the IRP considered Ms C’s concerns that her father’s needs were of a level of intensity which indicated he had a primary health need. It weighed them up before it made its decision about the intensity indicator. The IRP acknowledged Mr D required some supervision and monitoring of his general health and safety. He also need help with daily activities. However, the IRP said he did not need sustained care or ongoing care/continuity. It said his health interventions were appropriately managed by care home staff with assistance from his GP and core NHS services such as SALT when needed. This on occasion included the hospital.

67. We acknowledge the IRP’s analysis in the intensity characteristic is brief. It referred to its consideration of Mr D’s needs in section 7 and the table in section 8 of the report. It could have included these details in the intensity section. However, the IRP considered the available evidence and decided Mr D’s care needs did not require care or intensity of interventions over and above what care staff could provide.

68. We think the IRP considered all the relevant factors when it decided the intensity of Mr D’s need did not suggest he had a primary health need. We are satisfied it acted in line with the National Framework.

Complexity

69. Section 3.5 of the practice guidance within the National Framework says complexity ‘is about the level of skill/knowledge required to address an individual need or the range of needs and the interface between two or more needs.’

70. In line with the National Framework, in the IRP’s consideration of complexity indicator we would expect to see analysis of: ‘how the needs present and interact to increase the skill required to monitor the symptoms, treat the condition(s) and/or manage the care. This may arise with a single condition, or it could include the presence of multiple conditions or the interaction between two or more conditions. It may also include situations where an individual’s response to their own condition has an impact on their overall needs, such as where a physical health need results in the individual developing a mental health need.’

71. Section 3.5 lists the question prompts for the complexity indicator:

• How difficult is it to manage the need?

• How problematic is it to alleviate the needs and symptoms?

• Are the needs interrelated?

• Do they impact on each other to make the needs even more difficult to address?

• How much knowledge is required to address the needs?

• How does the individual’s response to their condition make it more difficult to provide adequate support?

72. Ms C disagrees with the IRP’s consideration of the complexity characteristic. Ms C says the combination of her father’s risk of aspiration, recurrent infections, seizure activity, immobility and skin integrity demonstrated a high level of complexity. She said his needs are interrelated.

73. We can see the IRP looked at the available evidence. Ms C gave written and verbal evidence for the IRP to consider. The IRP had a discussion about the complexity of Mr D’s need. It said there was some interaction of his needs in the care domains. This included his needs in the continence and skin domain. However, it said there was not a sufficient impact to have made Mr D’s needs more difficult to address. It said Mr D had epilepsy and was at risk of seizures. It said care staff provided care for this without medical intervention. Mr D had rescue medication for his epilepsy but the IRP said at the time leading up to the DST this was not administered.

74. The IRP said Mr D’s needs on a daily basis did not require increased skill or knowledge for his care to be provided. It said GP and hospital intervention were used as and when required. The IRP said Mr D’s care interventions were not difficult to provide.

75. We recognise that Mr D had a range of care needs and required care and support to manage his needs. But the complexity characteristic is concerned with whether they needed knowledge or skills beyond what would be expected of a care professional to do that. There is no indication that was the case for Mr D. We know he needed a level of care but this was not difficult to provide. Although his needs interlinked over some domains, there was no complexity in them.

76. The IRP considered and weighed up the evidence before making its decision. We consider the IRP considered all the relevant factors when it decided the complexity of Mr D’s needs did not suggest he had a primary health need. We are satisfied it acted in line with the National Framework.

Unpredictability 77. The final key characteristic of a person’s level of need is unpredictability. The National Framework defines it as ‘the degree to which needs fluctuate and thereby create challenges in managing them. It also relates to the level of risk to the person’s health if adequate and timely care is not provided. An individual with an unpredictable healthcare need is likely to have either a fluctuating, unstable or rapidly deteriorating condition.’

78. Section 3.6 of the practice guidance within the National Framework says unpredictability ‘is about the degree to which needs fluctuate and thereby create challenges in managing them. It should be noted that the identification of unpredictable needs does not, of itself, make the needs ‘predictable’ (i.e. ‘predictably unpredictable’) and they should therefore be considered as part of this key indicator.’

79. Section 3.6 lists the question prompts for the unpredictability indicator:

• Is the individual or those who support him/her able to anticipate when the needs might arise?

• Does the level of need often change? Does the level of support often have to change at short notice?

• Is the condition unstable?

• What happens if the need isn’t addressed when it arises? How significant are the consequences?

• To what extent is professional knowledge/skill required to response spontaneously and appropriately?

• What level of monitoring/review is required?

80. Ms C disagrees with the IRP’s consideration of the unpredictability characteristic. Ms C says her father’s needs were unpredictable. She says he had unpredictable seizures, aspiration and renal problems.

81. The IRP report shows the IRP considered the unpredictability of Mr D’s needs. We can see it had the unpredictability prompts in mind to inform its discussions. It acknowledged Mr D had care needs. The IRP said there was no evidence Mr D’s needs changed at short notice. Care staff due their familiarity with Mr D were aware of changes in his presentation and could anticipate his care needs if required. However, this did not led to a rapidly change in the level of support they provided Mr D in order to meet his needs.

82. Staff were able to anticipate his care needs but this was not on a frequent basis. The IRP said Mr D’s needs were stable and he did not require monitoring over and above the supervision that was in place for all the care home residents. The IRP said he did not have a fluctuating or rapidly deteriorating condition to say he had a primary health need.

83. There was no evidence that staff needed additional training to provide necessary care. If a person has unpredictable needs, we would expect to see their care needing frequently or sudden changes. That was not the case for Mr D. The IRP described why his needs were not unpredictable.

74. We think the IRP considered all the relevant factors when it decided the predictability of Mr D’s needs did not indicate he had a primary health need. We are satisfied it acted in line with the National Framework.

Well managed needs principle

84. Ms C disagrees with how the IRP’s considered the well managed needs principle.

85. Paragraph 208 of the National Framework says:

‘When undertaking NHS Continuing Healthcare reviews, care must be taken not to misinterpret a situation where the individual’s care needs are being well managed as being a reduction in their actual day-to-day care needs. This may be particularly relevant where the individual has a progressive illness or condition, although it is recognised that with some progressive conditions care needs can reduce over time.’

86. We can see the IRP took into account Ms C’s evidence about her father’s needs into account. There is no evidence it marginalised his needs. The IRP described how staff managed his continence, skin, mobility, nutrition and medication needs to ensure he was safe, which it must do to make decision about the four key characteristics. It detailed how Mr D’s needs could be met with care and monitoring.

87. We can see no indication the IRP said any of his needs were lower than they should have been because of how the carers met them. The report shows the IRP’s application of the well managed needs principle was supported by the evidence available and in line with the National Framework.

Procedural concerns

88. Our role is to look at how NHSE considered Ms C’s concerns and not the actions of the ICB directly. This is because we would expect the IRP to have acknowledged any errors by the ICB that the complainant raised with NHSE, considered the impact and made recommendations.

89. We recognise Ms C is of the view the procedural issues she raised had an impact on the overall eligibility decision. But it is important to note NHSE’s decision supersedes all previous eligibility decisions. Therefore, procedural issues only have a direct substantial effect on the overall eligibility decision in exceptional circumstances

90. We can see at the IRP the family raised concerns about the ICB process, details of which can be found at section 14 to 16 of the report. The family raised concerns that when Mr D moved to care home following his hospital discharge the nurse assessor told them she would carry out a review of Mr D’s care plans to ensure his needs were met. However, the family said they were not aware this was a review of Mr D’s CHC eligibility and were not invited to the meeting.

91. At the IRP hearing the ICB said families are not normally invited to reviews. It said a family is informed of the review and a conversation takes place prior to the meeting and post to ensure a holistic view. It accepted this did not happen on this occasion and said the nurse assessor was no longer with them.

92. The family said Mr D had communication difficulties and would struggle to communicate and needed support with making care decision. The family said at the time of the review the care plans were blank and not filled in because staff did not expect him to stay long term. The family confirmed it did not receive a copy of the review until they requested it in December. The ICB apologised to the family for its experience. It explained it was common at the time for people to say in care homes for six weeks before moving to other care homes.

93. The family said the nurse assessor decided a new DST was needed but did not have enough information to determine that Mr D’s need had changed. The family said they were not able to prepare for the DST as they were told it was just a meeting. The nurse assessor handed them a blank DST for them to follow the process. The family said they did not have the opportunity to raise their concerns. The ICB apologised for the family’s experience and explained it did not make its decision until it had gathered all discussed the evidence.

94. The IRP considered the family’s concerns and said it was dismayed to hear about the family’s experience. It acknowledged the ICB’s apology and explanation that this was not its usual practice. The IRP said this was a training issues and acknowledged the nurse was no longer with the ICB.

95. The IRP recommended the ICB reviewed the way it conducted DSTs to ensure the family is included and all views including the families are voiced at the DST meeting. This sharing would demonstrate to the family there is a discussion between all parties and decisions are jointly made between the ICB and local authority.

96. We are satisfied the process issues found by the IRP would not make a difference to the eligibility decision. It would not have changed its overall decision that Mr D was not eligible for CHC. This is because the IRP fully considered the evidence presented in respect to the domains of care and the nature, intensity, complexity and unpredictability of those needs. This is how it weighs up all the evidence to determine whether the person has a primary health need.

Summary

97. The IRP showed it applied the National Framework when it considered Mr D’s CHC eligibility.

98. We recognise Ms C’s account and that she disagrees with the IRP’s decision. We do not wish to take away from her account or what she has told us about her father’s needs. We thank her for bringing the complaint to us for consideration.

1. We have carefully considered Ms C’s complaint about how NHS England (NHSE) looked at her NHS continuing healthcare (CHC) claim for her father, Mr D. We have seen no indication that anything went seriously wrong when NHSE made its decision.

2. We are sorry to hear are sorry to hear about Ms C’s concerns. We understand how the CHC process is a frustrating and a lengthy process. We have reviewed the relevant evidence and are satisfied NHSE made its decision in line with the National Framework.