Summary: We will not investigate Mr X’s complaint about assessments for continuing healthcare and disability-related expenditure. On the continuing healthcare matter, this is because we cannot consider NHS matters. On the disability-related expenditure matter, this is because the injustice is insufficient to warrant an investigation by the Ombudsman.

The complaint

1. Mr X complained the Council said he needs to pay towards his care needs. Mr X said the NHS should fund his care through continuing healthcare (CHC).
2. Mr X also complained the Council’s financial assessment was calculated incorrectly.

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The Ombudsman’s role and powers

3. The Local Government Act 1974 sets out our powers but also imposes restrictions on what we can investigate.
4. We investigate complaints about councils and certain other bodies. We cannot investigate the actions of bodies such as the NHS. (Local Government Act 1974, sections 25 and 34(1), as amended).
5. We investigate complaints about ‘maladministration’ and ‘service failure’, which we call ‘fault’. We must also consider whether any fault has had an adverse impact on the person making the complaint, which we call ‘injustice’. We provide a free service, but must use public money carefully. We do not start or continue an investigation if we decide any injustice is not significant enough to justify our involvement.

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How I considered this complaint

6. I considered information provided by Mr X.
7. I considered the Ombudsman’s Assessment Code.

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My assessment

8. Health care is free of charge. Social care is not. An Integrated Care Board (ICB) is an NHS organisation responsible for arranging and funding NHS services in its local area. If an ICB decides someone’s care needs relate to health care rather than social care, the NHS will pay for the care. This is continuing healthcare (CHC). A service-user who receives CHC does not have to make a contribution towards their care costs in the way they might have to for social care. The ICB, not the Council, decides whether someone receives CHC.
9. In terms of the CHC matter, the Council said it completed several CHC checklists for Mr X. CHC checklists are the first step in the CHC process to see if a person qualifies for a full assessment of their eligibility for CHC. The Council usually then passes the checklists to the ICB, which is an NHS organisation responsible for arranging and funding NHS services in its local area. The ICB will then decide if it should do a full assessment to see if the person is eligible for CHC.
10. The Council said that when completing the most recent checklist, Mr X did not consent for the Council to share the checklist with the ICB. The checklist found that Mr X did not qualify for a full assessment.
11. The Council said to Mr X a new CHC checklist could be completed, which he could consent to being shared with the ICB. If Mr X is unhappy with the decision of that checklist, he would then have the right to appeal to the ICB about this.
12. Although the Council completed the checklists, the ICB makes decisions about whether to award CHC. We cannot investigate the actions of NHS organisations, including the ICB.
13. In terms of the financial assessment, the Council said unless CHC funding is awarded, Mr X’s needs to contribute to his care and support. There is no fault in that. Social care is not free.
14. The Council said it recognises it did not fully explore disability-related expenditure (DRE) with Mr X. DRE is an allowance for the extra expenses that occur because of disability or a long-term health condition. DRE is usually assessed as part of a broader financial assessment. The Council said it could have explained the process to him more clearly and could have provided him with more support.
15. We acknowledge Mr X’s dissatisfaction that the Council did not explore DRE more fully earlier. We also acknowledge this has caused him some concern and effort in pursuing this matter. However, the DRE process would always involve some degree of effort.
16. On balance, the injustice caused to Mr X by the Council’s delay in fully exploring DRE is not sufficient to warrant an investigation by the Ombudsman.
17. The Council has since explored DRE with Mr X and its decision was that that he still had to pay a contribution towards his care. This decision was made after Mr X raised his complaint with the Ombudsman and if he disagrees with this, he should initially raise a complaint with the Council about this matter.

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Final decision

18. We will not investigate Mr X’s complaint. On the CHC matter, this is because we cannot consider NHS matters. On the DRE matter, this is because the injustice is insufficient to warrant an investigation by the Ombudsman.

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Investigator's decision on behalf of the Ombudsman