NHS funding appeals soar amid claims of injustice

The health service should fund care for those with complex needs but many say they are unfairly denied. By Sam Meadows

The number of people who challenge decisions on NHS-funded care has almost doubled in four years as more people feel the system is stacked against them. Under “continuing healthcare” rules, the health service should offer full funding, which isn’t means tested, to those with complex care needs in later life. This covers anything from severe Alzheimer’s to debilitating chronic health problems.

But a wide-ranging review of the system by the National Audit Office (NAO), conducted last year, found that just 18pc of applicants were approved after their first assessment. And the number of people who challenge those rejections is rising sharply.

Figures released under the Freedom of Information Act to Nockolds, a law firm, and seen exclusively by Telegraph Money show that the number of people who request a review by NHS England, the watchdog, has soared from 383 in 2014-15 to 753 in the past 12 months.

The initial assessments are carried out by the patient’s local clinical commissioning group (CCG), the body responsible for planning treatment. Experts said they feared that cashstrapped CCGs were being put under pressure to reject applicants to reduce the cost of funding – a clear breach of the rules.

According to the audit office, 160,000 people received continuing healthcare funding in 2015-16 at a cost to CCGs of £3.6bn. NHS England expects this bill to rise to £5.2bn by 2020-21 and has asked CCGs to make savings of £855m on continuing healthcare and nursing care by this date.

This will be done by reducing administration costs and regional variation in care spending.

Around one in six of those who challenge decisions are successful. But the review process can be lengthy and complicated. Mr Farley said NHS England was so inundated with appeals that in some cases it took up to a year to get a date for a review hearing.

Dan Winter, a partner at Nockolds, said it took resolve to get through what could be a wearing process. “It’s a very emotionally charged time for families and I think it’s the last thing they really want to deal with,” he said. “The ones who do appeal and go through the process are the minority. I think most people just give up.”

Critics have also raised questions over the independence of the review system. The first point of appeal is the CCG that conducted the first assessment, with the next being NHS England. The final option is the ombudsman.

Mr Winter said it was counterintuitive that the NHS oversaw almost the entire disputes process. “Our clients find it really hard to get their head around this part of it. It seems that no one who is truly independent is looking at this at any stage of the dispute,” he added.

Andrew Farley of Farley Dwek, a law firm that specialises in continuing healthcare decisions, said: “How can it be right that the holders of the purse strings are the very ones who assess you? There’s no independent arbitrator – that one body is judge and jury.”

A spokesman for NHS Clinical Commissioners, the body that represents CCGs, acknowledged “considerable variation” in how the criteria were applied and said the current framework used by CCGs for assessments was too complex.

She added: “It is important that the process of considering and deciding eligibility does not result in any delay to appropriate care being put in place.

“This is why we have been engaging with NHS England and the Department of Health on behalf of our members to create a simplified and consistent framework, which will be operational from October and should result in more timely decisions being made.”