NHS Continuing Healthcare Appeals: Local Resolution

This guide is to help you understand how you can challenge decisions about NHS Continuing Healthcare (CHC) that you do not agree with. We have also produced a more detailed ‘Appeal Protocol’ which we can send you by post or email if you contact us.

Midlands and Lancashire Commissioning Support Unit (MLCSU) manages retrospective reviews and appeals on behalf of your Clinical Commissioning Group (CCG). We will provide guidance and support to you, and we will try to resolve your dispute as soon as we can. If you have a question or concern about your case, you can contact us at any time.

Stages of the Local Resolution Procedure

You can appeal against a decision you do not agree with for three reasons:

  • You disagree with the outcome of the DST
  • The process used was in line with the National Framework
  • The assessment did not consider the right evidence

You should appeal within six months of the date on the letter telling you the outcome of your assessment. We can sometimes accept appeals later than this in exceptional circumstances.

When we receive your appeal, we will send you an acknowledgement within five working days. We will then send you a questionnaire and ask you for some supporting documents that we need to progress your appeals. We will ask you to return this to us within 28 days. When we have got this, we aim to complete your appeal within three to six months.

At this stage, your case will be allocated to a Clinical Nurse Reviewer who will contact you to discuss your appeal and clarify things for you. When we have established the appeal can go ahead, we will request records from various places such as Care Homes, GP’s, Local Authorities, Hospitals, District Nurses and Mental Health teams. If they cannot provide records, we will let you know.

When your case is ready to proceed, we will contact you and invite you to a Local Resolution meeting (LRM). This could be a ‘virtual’ meeting, through a teleconference, or you could send us your points in writing rather than attend. Someone can represent you if you wish.

Local Resolution Meeting (LRM)

The LRM will discuss your reasons for requesting an appeal, understand the care domains you do not agree with and consider whether the process was properly followed. They will also make sure that all relevant information was taken into consideration during the CHC assessment.The LRM will try and address any questions but there are some things they cannot consider such as who delivered the care and how well it was managed, or the behaviour and knowledge of the professionals involved. This could possibly be looked at if you decide to make a complaint.

Your completed appeal questionnaire and the completed Decision Support Tool (DST) will be the basis of the discussion and we suggest you bring copies with you to the LRM.

Once your case had been heard and discussed by the Local Resolution team the open session of the meeting will end. The team will then have a closed session to consider your case. They will then make a funding recommendation and complete a Local Resolution report.

Outcome of the Local Resolution Meeting

The LRM recommendation will be verified by a Clinical Lead Nurse; final approval will be obtained from the CCG, and we will then send you the outcome. The possible decisions are:

  • Uphold the original decision
  • Partially uphold the original decision
  • Overturn the original decision.

The decision letter we send you will also include a summary of the discussion at the LRM and reasons for the decision. We aim to get this to you within eight to twelve weeks.

If CHC Funding is awarded, we will ask you for ‘proof of payment’ so your care fees can be reimbursed. In some instances, we will make the payment to the care home and they will reimburse you. If so, we will explain in the eligibility letter we send you.

If your appeal in not successful and you remain dissatisfied, we will tell you how to contact NHS England to request an Independent Review of the LRM’s decision.

What you should expect and what we expect from you.

We understand that an appeal can be sensitive and emotional. We will always treat you with dignity and respect and we will try to make it as straightforward as possible. We also expect you will treat our staff fairly and reasonably throughout your appeal. We have an MLCSU charter which sets this out in more detail. You can find it on our website or ask us for a copy.