Appeals Process - The Local Dispute Resolution Meeting (LDRM)
This is your first chance to appeal their decision not to fund the Applicant’s request for funding (the Decision Support Tool). This stage is the least formal review of the application and its merits. The people in attendance and the precise format of the appeal meeting vary from CCG to CCG, but should always have a representative from both Health (NHS) and Social Care (Your Local Authority).
You should be supplied with a copy of your relatives DST well in advance of the meeting taking place. Indeed it is best practice to send a copy of the completed DST together with the ‘outcome letter’ informing you of the initial decision not to fund.
If clients come to us at this stage the first thing we undertake is a forensic review of the medical notes and record together with the care setting daily notes and records to establish exactly where the correct scoring sits and we also address the 4 Key Indicators (Nature, Intensity, Complexity and Unpredictability. Both a clinician’s view and that of a Lawyer are invaluable at this stage. If after a LDRM you are still unsuccessful, you have the right to appeal again and go to Independent Review Panel.
This stage of appeal is one of the very few areas of law or regulation where those organisations which denied the funding also hear the appeal. We are firmly of the view that this is inherently unfair and offensive to the principles of natural justice. If an organisation makes a decision which is legitimately contested, it is our contention that the legal rule against bias should apply. In law the phrase “Nemo judex in causa sua” (or “nemo judex in sua causa”) is a Latin phrase that means, literally, “no-one should be a judge in his own case.” It is a principle of natural justice that no person can judge a case in which they have an interest. The rule is very strictly applied to any appearance of a possible bias, even if there is actually none: “Justice must not only be done, but must be seen to be done” – but this is not – clearly the case with appealing a decision to deny funding to the elderly and vulnerable.
Appeals Process – Independent Review Panel (IRP)
If, the Local Dispute Resolution Meeting decides that the decision not to fund stands – which is more often than not the outcome of an LDRM, there is a further stage of appeal. This is the IRP or Independent Review Panel stage. This is far more formal than the Local Dispute Resolution Meeting and, more importantly, it is not heard by the CCG but by NHS England.
The panel that hears these appeals is made up of :
An Independent Chair supplied by NHS England
A representative from an independent CCG
A representative from a Local Authority
There can also be a clinical advisor in attendance on occasion
It is not uncommon for a Note Taker to be in on the meeting to make a record of the meeting.
As these meetings are fairly formal, submissions relating to appeal are best made in a structured, logical manner informed by the grounds of appeal which may be procedural or factual or both. If after this appeal stage you are still unsuccessful, you will appeal to the Parliamentary Health Service Ombudsman.
Having a Lawyer and Nurse fighting your corner at
this stage can be a real game changer.
When we represent clients at this stage, we focus on the medical and procedural submissions to panel, leaving you to tell the panel about who your relative really was behind the paperwork. We work closely with clients in preparation for the Independent review Panels.
Appeal to The Parliamentary Ombudsman
If the Independent review Panel confirms ineligibility for funding, the last stage of appeal before the matter receives judicial scrutiny before a judge in court is an appeal to the Parliamentary Health Service Ombudsman.
This appeal is paper exercise and is undertaken without any formal hearing. Submissions on the appeal should be structured into those relating to the procedure, followed by any factual disputes and supporting evidence drawn from relevant medical and care notes.
Having represented many clients at this stage we find that it is more likely to result in an overturning of the decision not to award funding than the Local Dispute Resolution Stage. If we believe your application has merit, we will draft the appeal for you, send you the appeal in draft form before sending the appeal to the Parliamentary Health Service Ombudsman.
We are able to support you every step of the way with your application for Continuing Healthcare Funding from Checklist to final appeal. If at any point in the process we feel that the application lacks merit in terms of clearing the hurdles of the assessments, we will be frank and offer advice in those terms.