A few years ago Beacon’s caseworkers began supporting a couple whose son had recently suffered a serious road traffic accident, leaving him with multiple life-long physical and mental health needs resulting from his brain injury. Following a significant period of time in hospital during which the young man underwent multiple life-saving operations, he was discharged to a specialist long-term care facility, in receipt of an extensive care package. This care package was initially fully-funded by the NHS who assessed him as having a ‘primary health need’ due to the extent of his intensive and complex care needs. However, following a review of his eligibility for NHS Continuing Healthcare just a few months later, the NHS withdrew that funding and he became subject to the Local Authority means tested system, which required a significant monthly financial contribution from his family as well as placing a high financial burden on the Local Authority.

Beacon’s caseworkers conducted a full review of the case at the request of the young man’s family, looking at the various assessments and considering the clinical evidence used to determine his eligibility status. We were convinced that the NHS had acted unreasonably in their decision to cease funding in this particular case. We appealed that decision, building a case on both clinical grounds and also against the procedures used by the NHS to make their eligibility decision, because we suspected that undue commissioner influence had been exerted on the decision-making panel, which should have been completely free of financial pressure. The Strategic Health Authority upheld our concerns when presented with the evidence and instructed the Primary Care Trust to re-assess the young man with a current and retrospective assessment dating back to the point in which NHS funding had stopped.

Beacon’s approach to managing appeals involves working alongside the NHS rather than against them wherever possible so that we can resolve issues quickly and effectively, and so we worked with the PCT in identifying relevant specialist clinicians, ensuring that they contributed their expert clinical opinions to the new assessment. We also ensured that this time around the health and social care professionals most knowledgeable about the young man’s care needs were involved in making a recommendation regarding the primary health need test. In doing so, we arranged for the young man’s highly complex psycho-cognitive needs to be re-assessed. The new NHS continuing healthcare assessment was of considerably better quality than the previous one but due to the need to involve a greater number of specialists in the multidisciplinary process, it took over a year to complete. However, the eligibility decision again went against our client as he was told that he did not have a primary health need. In the meantime his family were struggling to cope with the pressure of meeting the high cost of his care fees.

Again, our caseworker was convinced that the PCT had not understood the complexity of the young man’s cognitive function which was quite different in its manifestation to that of a dementia patient, and also masked by ‘learnt phrases’. Two professional clinical opinions had been submitted alongside the assessment, both of which were at odds with each other. The opinion supporting our analysis provided evidence-based conclusions whereas the other appeared to be based more on assumptions and contained a number of inaccuracies, seeming to underplay the complexity of the young man’s care needs. We again took the case back to the Strategic Health Authority for an Independent Review with a robust and comprehensive case presentation, and on this occasion the independent panel agreed with our arguments and our specialist clinical evidence, and awarded eligibility with full retrospective NHS funding for the entire period, and for the next year.

In total this case took almost three years to resolve and required 50 hours of casework (a total cost to our client of £4,000 plus VAT), but resulted in restitution of over £250,000.

Date of original upload: 8 September 2015