sunset

Why a retrospective application for funding? My mother worked most of her life and paid her full due of National Insurance contributions. All she ever got from the NHS was free prescriptions after retirement, a colonoscopy when she was admitted to hospital and of course free continence pads. When she really needed help with her Alzheimer's illness in her hour of need, the medical profession generally made it worse, rather than better. At that time the NHS really did not recognise Alzheimer's as an illness, rather that it only needed social care, which clearly wasn't the case. In 2003, a report by the NHS Ombudsman found that many patients in care homes may have been unlawfully refused care funding because local Health Authorities were using over-restrictive assessment criteria which were not in line with an important Court of Appeal judgment (Coughlan 1999). As a result, SHA's were asked to review cases back to 1996. I naturally started the process of submitting my mother's case.

Coughlan

The Coughlan case is very relevant. The formal Judicial Review findings can be found HERE. For a general summary of the implications of Coughlan click HERE.This summary also considers the guidelines issued to Health Authorities from the Department of Health subsequent to Coughlan. The judgment in Coughlan clearly establishes that where a person's primary need is for health care, and that is why they are placed in nursing home accommodation, the NHS is responsible for the full cost of the package. Whilst much of the debate has concentrated on nursing home placements, it must be recognised that eligibility for NHS funded care is not relevant to the location in which that care is provided. Those people cared for in their own homes or residential homes whose primary need is for health care are also be eligible for NHS funded care. Because it is quite relevant in determination of the 'health' criterion, Pam Coughlan's daily regime is reproduced HERE. The original reference is HERE.

Initial Appeal, Suffolk PCT

As a result of the Coughlan case, the Health Service Ombudsman asked Strategic Health Authorities and Primary Care Trusts to review the criteria used by the NHS and the way those criteria are applied, since 1996. in deciding whether people were eligible for free care in nursing homes or elsewhere. In carrying out that review, the Ombudsman drew attention to the need to take into account the guidance issued by the Department of Health and her own findings. She went on to say that efforts should be made to remedy any consequent financial injustice. She chose a start point of 1 April 1996 as that was when it first became mandatory to have written criteria. In October 2004 I applied for retrospective continuing care funding for my mother. the Department of health put a deadline of November 2007 on claims for CHC funding prior to April 2004. Norfolk, Suffolk and Cambridgeshire SHA then provided a procedural document of of the process. I was warned of a considerable backlog of cases but as I had not heard anything by 2009 I contacted the SHA. Unfortunately it transpired that my documentation had been lost in the post but because I originally applied before the cut-off point the review process did go ahead after some initial diversionary tactics from he NHS. The NHS then set about compiling a Needs Portrayal and Contemporaneous record of my mother's care. This was compiled by Sue H. whom we met with for an initial discussion in March 2012. It would appear that there were some 600 pages of data and from the summary presented, it was clear that I was totally unaware of much of my mother's care, I had been very much kept in he dark. This further resolved my determination to proceed. As a result of discussions with Sue H., I was sent assessment sheets produced by her, in which she clearly states my mother was not eligible for CHC funding BEFORE the review had even taken place! I was surprised by this, I couldn't see any relationship to Coughlan but decided to wait for the proper review The CHC Panel review took place in May 2012 which I attended. I was told by Sue H. that I would just be 'sitting in' on the Panel's deliberations. It didn't turn out like that. Basically I was 'interrogated' about my mother's dementia which on the face of it was farce because they had all the review data in front of them and I didn't. The Review notes summarise the discussion. The Panel decision was to refuse funding.....my mother did not meet the eligibility criteria. The Panel assessment sheets plus the 'Primary Needs Test' documentation are found HERE. I would welcome an explanation of how these decision documents relate to the Couglan decision.
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