Decision : Closed after initial enquiries
Decision date : 17 Jun 2019
The Ombudsman's final decision:
Summary: The Ombudsmen will not investigate Ms Z’s complaint about the funding arrangements for care of her mother, Mrs Y, who has complex needs. Ms Z says that disputes over funding between the Council and CCG delayed provision of appropriate care, and caused distress and anxiety to her and Mrs Y. The Ombudsmen should not investigate her complaint, as it is unlikely an investigation will be able to achieve anything further for her.
- Ms Z complains that disputes over funding between the Dorset County Council (the Council) and Dorset Clinical Commissioning Group (the CCG) led to her mother, Mrs Y, not receiving the care she needed for a period of almost two years. Ms Z says that full funding of Mrs Y’s care through continuing healthcare (CHC) was wrongly removed. She says the subsequent joint funding arrangement between the Council and CCG was inadequate and did not meet Mrs Y’s needs.
- Ms Z says this caused significant distress to Mrs Y, who has complex needs, including a need for overnight care. She also says it had an impact on her as she is closely involved in her mother’s care. Ms Z also explained there was a financial impact, as they were being asked to fund some of the care which they were unable to afford, and were going overdrawn. Ms Z said this caused her a great deal of anxiety as she worried they were going to run out of money, and that the caring set-up they had, which was mostly stable and reliable, was at risk.
The Ombudsmen’s role and powers
- The Ombudsmen provide a free service, but must use public money carefully. They may decide not to start or continue with an investigation if they believe:
- it is unlikely they could add to any previous investigation by the bodies, or
- they cannot achieve the outcome someone wants.
(Health Service Commissioners Act 1993, section 3(2) and Local Government Act 1974, section 24A(6), as amended)
How I considered this complaint
- I have considered information provided by Ms Z, over the telephone and in writing. I have also considered information provided by the Council and CCG.
- I have also considered Ms Z’s comments on a draft version of this decision.
What I found
- In 2011, Mrs Y was awarded CHC funding following discharge from hospital. CHC is a package of ongoing care that is arranged and funded by the NHS where a person has been assessed as having a ‘primary health need’. A person’s local CCG is responsible for assessing their eligibility for CHC and providing the funding.
- Mrs Y’s CHC funding continued until 18 July 2017. At this time, a reassessment was done, and the CCG entered into a joint funding agreement with the Council for Mrs Y’s care. The CCG said “although DCC [the Council] and Dorset CCG could not agree eligibility at this point, the formal dispute process commenced. Throughout this period both statutory bodies have continued to fund Mrs Y’s care.” However, Ms Z said the new funding arrangements were not adequate, and Mrs Y was being asked to make up a shortfall from her own funds, which she could not afford. She said Mrs Y’s needs were beyond what the Council could fund.
- If, after a full multidisciplinary assessment a person disagrees with the CCG’s decision that they are not eligible for CHC, they can ask the CCG to review its decision. If they disagree with the outcome of the review, they can appeal to an Independent Review Panel (IRP) organised by NHS England.
- Ms Z appealed the decision to withdraw CHC. She also complained to the Ombudsmen. In February 2019, while our assessment of the complaint was ongoing, an IRP was held. The Panel found that the CCG decision to withdraw CHC had been incorrect, and that Mrs Y was entitled to CHC funding. The Panel agreed with Ms Z that Mrs Y’s needs “exceeded what a Local Authority can lawfully provide”. Full CHC was awarded, backdated to 18 July 2017 when the reassessment was done, and paying for Mrs Y’s care in future. The Panel also said that any service user contribution from 18 July 2017 would be reimbursed or any debt cleared.
Complaint about the Council
- Ms Z felt that the care plan prepared by the Council during the period of joint funding was inadequate. She said it did not take into account the real budget that was needed to meet Mrs Y’s needs, or things like transport, as Mrs Y became very agitated if she did not leave the house regularly. Ms Z said her mother needed a further needs assessment, but this did not happen. Ms Z felt the Council had purposely left her alone to make the situation so difficult that Mrs Y would need to go into a care home.
- The Council accepted that a Care Act assessment was overdue, as the last assessment took place in June 2017. However, the Council said that the CHC appeal process had superseded this, which is why it did not go ahead with the assessment. I recognise that Ms Z felt that she was left alone without input from the Council during this time. The Council said they had tried to resolve the situation by arranging for a senior adult social care manager to speak to Ms Z. The Council also told us that a carer’s assessment was completed for Ms Z in May 2018, and reviewed in February 2019. From this, it seems that some support and input was provided to Ms Z, although I recognise that she felt this was not sufficient, given her key concerns about the budget and worries about the care set-up.
- I recognise that a Care Act assessment may have helped Ms Z feel more listened to, and that lack of an assessment caused distress and uncertainty for her. However, we are unable to say whether, had an assessment been done, it would have resulted in additional support being put in place for Mrs Y. This is because CHC was applied due to Mrs Y’s primary health need, rather than her social care needs. The Panel clearly stated that Mrs Y’s needs were above what a local authority could fund. Therefore, even if Mrs Y had had the Care Act assessment that was due, it is not clear whether the Council would have been able to provide extra social care support following an assessment, given that Mrs Y’s needs were health-related.
- As a result of her complaint, Ms Z wanted Mrs Y’s care to be fully funded and the care she needed provided, including overnight care. However, since she brought her complaint to the Ombudsmen, Mrs Y has been awarded CHC following an appeal by Ms Z. This decision has addressed Ms Z’s concerns about funding, as it will refund any payments made and clear any outstanding balance, as well as funding Mrs Y’s future care.
- I recognise that Ms Z and Mrs Y experienced a great deal of distress and anxiety as a result of the joint funding arrangements during the period complained of. However, even if the Ombudsmen were to investigate this in its own right, it is unlikely they could achieve anything further for Ms Z.
Request for additional financial remedy
- In response to my draft decision statement, Ms Z explained that she felt there was still an injustice to her that had not been addressed by the CHC appeal decision. She said that during the period of joint funding, she had incurred her own costs for administration, fuel, washing and other day to day expenditure linked to caring for Mrs Y, which would not be remedied by the CHC decision.
- This outstanding concern would be a complaint about the CCG alone. Therefore it is not one that the Joint Working Team could consider, but should be considered by PHSO. However, before considering whether it should look at the complaint, PHSO would expect Ms Z to have requested individual financial remedy from the CCG, so that PHSO can then look at how the CCG dealt with her request. Therefore if Ms Z wants to pursue this part of her complaint, she would need to first raise the issue of her costs with the CCG.
- The Ombudsmen will not investigate Ms Z’s complaint about funding arrangements for Mrs Y’s care. An investigation by the Ombudsmen is unlikely to achieve anything further for Ms Z and Mrs Y.
Investigator’s final decision on behalf of the Ombudsmen
Investigator's decision on behalf of the Ombudsman