NHS Dorset

4. Mr H complains NHSE (Southwest) Independent Review Panel (IRP) upheld the ICB's decision that his mother Mrs B was not eligible for CHC funding on 13 November 2024.

5. Specifically, he says the IRP wrongly upheld the ICB's decision in the breathing, continence and drug therapies domains. He says it failed to act in line with the National Framework.

6. Mr H says as a result, Mrs B and her family have been left responsible for fees the NHS was liable for.

7. Mr H would like the IRP to repeat his mother's assessment and recognise she was eligible for CHC funding.

8. Continuing healthcare is a package of health and social care funded by an integrated care board (ICB) for people who have a primary health need. The ICB decides if a person has a primary health need by doing an assessment. A multidisciplinary team (MDT) considers their needs using a decision support tool (DST). If the ICB decides the person does not have a primary health need, so is not eligible for CHC, the person or their representative can appeal the decision. This is first locally to the ICB and then to NHSE.

9. Mrs B was discharged to the care home from the hospital when she contracted pneumonia. She has advanced dementia, idiopathic congenital megacolon and other comorbidities.

12. It is our role to decide whether NHS England’s IRP acted in line with the National Framework when it considered whether Mrs B was eligible for CHC. The National Framework sets out the principles and processes ICBs, and NHS England should follow when it considered if someone is eligible for CHC.

13. 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 think the IRP did not follow the National Framework when it made its decision.

14. 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 made 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 found.

15. When we look at a complaint about an IRP, we consider if it considered all the relevant information when it made its eligibility decision.

16. The National Framework says ICBs, and NHS England should use the DST to decide a person’s CHC eligibility. The DST looks at a person’s care needs in 12 areas. These are what we refer to as the domains. Each domain is broken down into levels of need and can range from ‘no needs’ to ‘high, ‘severe’ or ‘priority,’ depending on the domain. It also describes each level of need to guide clinicians. We call these the descriptors. Mr H has told us he disagreed with the IRP’s consideration of his mother’s needs in three of the domains: breathing, continence and drug therapies domains.

Breathing

17. Mr H considered his mother’s needs in this domain were high. The IRP weighted this domain as no needs.

18. Mr H says the IRP did not properly consider the link his mother’s constipation episodes had on her breathing. On 23 September 2024 his mother had an oxygen saturation of 94% as a direct result of her idiopathic congenital megacolon (ICM) but the IRP omitted this from its consideration. Her condition was not always properly managed which impacted her breathing. The IRP would not consider evidence he had showing the interactions that he emailed shortly after the meeting.

19. The IRP considered Mrs B’s medical conditions, constipation and the effects they may have had on her breathing. It said there was no evidence she had shortness of breath in the review period or a prescribed inhaler. It referenced an incident on 13 November 2024 where Mrs B’s oxygen levels were 94 to 97% and determined this was an acute episode. It did not reference the episode on 23 September 2024 in its report.

20. The DST descriptor for no level of need in this domain is:

‘Normal breathing, no issues with shortness of breath.’

21. The DST descriptor for a high level of need in this domain is:

‘Is able to breathe independently through a tracheotomy that they can manage themselves, or with the support of carers or care workers. OR Breathlessness due to a condition which is not responding to treatment and limits all daily living activities’

22. From the records we can see the effects Mrs B’s ICM had on her and know in some cases this condition can lead to shortness of breath. Our role is to ensure the IRP followed the National Framework to assess if there was a primary breathing need at the time of review.

23. At the time of the DST, Mrs B was not suffering with any chronic respiratory issues, shortness of breath or breathing difficulties. While co-existing conditions may impact other areas for the purpose of this part of the assessment that does not mean there is a distinct ‘need’ in this area.

24. To assign a "high" weighting, the IRP required evidence that Mrs B routinely needed respiratory equipment, or that another condition significantly debilitated her breathing and restricted daily function or created a barrier to care. The IRP evaluated the interaction between her ICM and breathing. Her care records suggest her breathing did not particularly restrict or impact her daily activities.

25. Two infrequent instances of low oxygen saturation and breathlessness do not demonstrate a high level of need. Typically, a higher weighting requires the specific need to occur so frequently that it is characterised in the entire review period.

26. Based on Mrs B’s records, we do not think her needs would not meet the "high" weighting in line with the National Framework.

27. We understand how strongly Mr H feels about the weighting of this domain. We have seen the IRP considered the evidence in line with the National Framework we therefore will take no further action.

Continence

28. Mr H considered his mother’s needs in this domain were high. The IRP weighted this domain as moderate.

29. Mr H says his mother’s ICM caused life-threatening conditions the care home poorly managed. He highlighted instances where she remained constipated for three to eight days with minimal clinical oversight. He argues that a lack of specialist referrals does not negate the needs being present. He says the IRP minimised her condition by not showing how her worsening constipation required stronger medication during the review period.

30. Mr H has outlined incidents he says demonstrates Mrs B’s bowel function was decreasing between 13 September 2024 and 12 March 2025. The ICB communicated its decision 10 March 2025. The ICB considered the DST from 3 November 2024, it would not consider evidence after this period.

31. The IRP noted Mrs B was doubly incontinent and prescribed laxatives. It described her needs as presenting in a routine manner that did not require specialist support. It highlighted that while she had gone to hospital for manual evacuation, she was critically unwell at that time, so it was not reflective the nature of her daily needs. She did not require manual evacuation once she was better.

32. The DST descriptor for a moderate level of need in this domain is:

‘Continence care is routine but requires monitoring to minimise risks, for example those associated with urinary catheters, double incontinence, chronic urinary tract infections and/or the management of constipation or other bowel problems.’

33. The DST descriptor for a high level of need in this domain is:

‘Continence care is problematic and requires timely and skilled intervention, beyond routine care (for example frequent bladder wash outs/irrigation, manual evacuations, frequent re-catheterisation).

34. When we review the records, we do not think the IRPs consideration was wrong. While Mrs B did have a condition that presented needs this assessment is meant to determine the severity, complexity and intensity of a person’s present needs. For the IRP to weight this domain as high it would have needed to see examples where her constipation presented unmet needs or were of a nature that could not be met by planned care.

35. While Mrs B was at times constipated, doubly incontinent, required monitoring, pads and creams, there were no instances in the review period where her needs could not be met under the local authority. Whether she was escalated as she should have been by the care home is a separate service issue that would still not inherently mean she had a primary health need.

36. We understand Mr H’s concerns about Mrs B’s condition. Having a diagnosis, even one that is progressively deteriorating would not necessarily mean someone would be weighted higher in that domain. Carers were able to meet Mrs B’s needs and there were no examples of frequent bladder flushes, manual evacuations being required outside of her hospital admission or carers heavily relying on specialist support to manage her care.

37. After considering the evidence in Mrs B’s records, we have seen the IRP considered the evidence in line with the National Framework. We think its decision that she had a moderate level of continence need is reflected in the evidence and DST descriptors.

Drug therapies and medications

38. Mr H considered his mother’s needs in this domain were severe. The IRP weighted this domain as low.

39. Mr H says Mrs B had constant, poorly controlled pain. Her conditions included intractable breast pain (since 2005), chest and throat pain, migraines, and nurse-monitored dyspepsia (a broad term for persistent or recurrent discomfort in the upper abdomen). Medical records also show she had a conservatively managed renal cyst causing upper abdominal pain. Mr H argues that her inability to reliably communicate her pain should not equate to a low level of need. Additionally, she was prescribed constipation suppositories that should have been administered by a nurse at discharge but never received them.

40. The IRP says Mrs B was prescribed paracetamol, as required, and laxatives. The care home had not requested stronger analgesia nor was there indication she was in any significant pain. No medications were time critical or needed oversight of a specialist. She was compliant with her medication regime, and her prescriptions were largely unchanged from when she went to hospital.

41. The DST descriptor for a low level of need in this domain is:

‘Requires supervision/administration of and/or prompting with medication but shows compliance with medication regime. OR Mild pain that is predictable and/or is associated with certain activities of daily living. Pain and other symptoms do not have an impact on the provision of care.’

42. The DST descriptor for a severe level of need in this domain is:

‘Requires administration and monitoring of medication regime by a registered nurse, carer or care worker specifically trained for this task because there are risks associated with the potential fluctuation of the medical condition or mental state, or risks regarding the effectiveness of the medication or the potential nature or severity of side-effects. Even with such monitoring the condition is usually problematic to manage. OR Severe recurrent or constant pain which is not responding to treatment. OR non-compliance with medication, placing them at severe risk of relapse.’

43. In this domain, the IRP was required to focus strictly on Mrs B's pain, required medications and the complexity or time-critical nature of their administration. While co-existing comorbidities are common, they do not automatically form a primary health need.

44. To weight this domain as severe the IRP would have needed to see Mrs B had such severe and time critical medication needs that a specialist needed to regularly intervene or oversee how her drugs were administered and monitor how she responded to this for example. We cannot see that this was the case, nor that she was in such severe and recurrent pain that it was a serious and frequent cause for concern.

45. Mr H also suggests that missed suppository prescriptions may have caused his mother undue harm and the fact this was missed does not mean there was not a present need however, it also would not mean there was a severe need in this domain. Even if a carer needed to oversee the administration of the suppositories there is nothing to indicate this would have been so delicate of a procedure that Mrs B would have required serious monitoring or critical counter treatments to offset the risk of harm from this. Carers or nurses generally overseeing medication administration is routine in nature and commonly falls under the local authority.

46. When we consider the complaint and records here, we think the IRPs decision was in line with the National Framework.

47. It is clear much of Mr H’s concerns stem from the quality of care his mother received, which he believes negatively influenced the outcome of the IRP. It is not the IRP’s role to scrutinise past care decisions. Instead, the IRP assesses the records to determine if an individual’s needs could be reasonably characterised in a way that demonstrates a primary health need. We think it did this to form a view in line with the National Framework.

48. We appreciate Mrs B was entirely dependent on the care she received, and we do not wish to undermine the challenges care staff faced in meeting her needs, especially in relation to her medications, continence and breathing. We understand why Mr H asked us to look at this, and we can see why he highlighted the points he did. We do not wish to take away from this with our decision.

1. We have carefully considered Mr H’s complaint about how NHS England reviewed the local integrated care board (the ICB) decision not to give his mother, Mrs B, NHS funded continuing healthcare (CHC). We have seen no indication NHS England did anything wrong when it concluded the eligibility decision was correct.

2. We are sorry to read Mr H’s account of his mother’s health, and we can clearly see the impact her dementia had on her. We are sorry to read Mrs B never fully recovered after going to hospital, and how she became more reliant on the care she received.

3. We have reviewed all the relevant evidence, and we are satisfied NHS England acted in line with the National Framework for continuing healthcare.