NHS health care: Resolving disagreements

In you are not considered to meet the eligibility criteria for continuing NHS care or disagree with the band of nursing care you have been assessed as needing, you should first discuss it with the relevant PCT manager. There will be a manager responsible for continuing NHS health care and a nursing care co-ordinator with responsibility for RNCC assessments.

If discussions with the PCT do not resolve the issue, you have three options -request an independent review or make a formal complaint following the NHS complaints procedure or both.

Independent review

You can request an independent review (IR) of a decision, by applying in writing to the appropriate SHA if:

• you disagree with the decision that your needs do not meet the local eligibility criteria for continuing care;
• after a reassessment by the nursing care co-ordinator, you still disagree with the nursing band you have been assigned.

You should be informed of your right to request a review when you are notified of the outcome of your assessment.

An IR can only be used if you are dissatisfied about:

• the procedures followed by the PCT in reaching the decision about whether you meet the eligibility criteria;
• the application of the criteria in relation to the decision.

This route cannot be used if you disagree with the criteria themselves.

Review panels are convened by the SHA to which the PCT belongs. The SHA does not have to convene a review panel. Government guidance gives them the right not to convene a panel if your assessed needs fall well outside the eligibility criteria. Before taking a decision, the PCT should seek the advice of the chairman of the panel. If the request is refused, you must receive a full written explanation of the reason and be reminded of your rights under the NHS complaints procedure.

If a panel is convened, you have the right to an advocate, i.e. an independent person who can help you put forward your point of view.

The aim should be to complete the review procedure within two weeks of the request being made. If you are in hospital awaiting discharge, you have a right to remain in hospital while the review procedure is being conducted.

The role of the panel is advisory. However, while its decisions are not formally binding, the expectation is that its recommendations will be accepted in all but very rare circumstances.

The outcome of the review, with reasons, should be communicated in writing by the SHA to the person requesting the review (this could be the patient, a relative or carer) and any other relevant parties - the PCT, the hospital trust, hospital consultant, GP and other relevant clinicians.

NHS complaints procedure

• You should use the NHS complaints procedure if you wish to challenge:
• the content of the eligibility criteria rather than their application;
• the decision not to grant an independent review;
• the decision not to fully fund continuing NHS care in a care home, once you have been through the review procedure above.

The Patient Advice and Liaison Service (PALS) for your local PCT can give details about the NHS complaints procedure. If you would like an independent advocate to help you to make an official complaint, your PALS should also be able to give details about the local Independent Complaints and Advocacy Service (ICAS). Your local Age Concern may also be able to help with advocacy. NHS Direct will be able to let you know how to contact your local PALS

You can make a complaint in writing to the Chief Executive of the PCT and ask for it to be investigated using the NHS complaints procedure. You should receive a response to your complaint in writing within 20 working days. You should also be advised that if you are unhappy with the response, you can ask for an Independent Review (IR). This is not the same as the independent review of decisions conducted by the local continuing care review panel in section 7.1

The Independent Review stage of the NHS complaints procedure became the responsibility of the Healthcare Commission (HC) when The National Health Service (Complaints) Regulations 2004 came into force on 30 July 2004. The HC is the independent regulator of NHS, independent and voluntary healthcare in Englandand will have no links or loyalties to the SHA or PCT concerned with a case. This change is designed to bring true independence to the IR stage of the complaints procedure.

Independent review may involve up to three stages – an initial review of your complaint and a response by a member of the HC complaints team; an investigation should this be deemed necessary and finally the right to request a panel review. This is explained in much more detail in a comprehensive leaflet– ‘Unhappy with the way your complaint has been handled by the NHS?’ –produced by the HC. This leaflet, which includes an independent review request form, features on the HC website (see section 8.1). You can email are quest for this leaflet to [email protected] or call the complaints helpline on 0845 601 3012 (local call rate). Complaints that cannot be resolved by the HC may be referred to the Health Service Ombudsman.

Health Service Ombudsman

If you remain unsatisfied following an IR, you can refer the matter to the Health Service Ombudsman.

The Ombudsman can investigate complaints about:

• poor service;
• failure to provide or purchase services you have a right to receive;
• administrative failures;
• care provided by an NHS professional.

The Ombudsman does not have to investigate every complaint. Before the Ombudsman will look into your complaint, she will usually expect the local resolution and independent review stages to have been completed by the PCT or NHS Trust, unless it would be unreasonable to expect you to do so.

If a decision is made to investigate your complaint, a full investigation is carried out which may take several months. After the investigation is completed you and the NHS body will be sent a report of the findings. If your complaint is found to be justified, the Ombudsman will seek an apology or other remedy.