Introduction
People living in care homes or receiving care at home may be able to receive Continuing NHS Healthcare funding to meet the cost of their care needs. Health Boards, who all requests for funding should be made to in the first instance, will need to look at each person’s care needs in detail to decide whether or not their ‘primary need’ is for healthcare. If a ‘primary healthcare need’ exists, the Health Board must meet the costs of that person’s care and/or make suitable arrangements for their healthcare needs to be met.
You can ask your local Health Board to assess the needs of a person currently receiving care and/or request an assessment of past care needs. However, there is now a one year rolling cut off period for past care claims and claims for care before that period will no longer be looked at. You may have to wait some time for your claim to be looked at.
What we can do
If you think that a decision by the Health Board to refuse Continuing NHS Healthcare funding for you, your relative or a person you look after is not right, we may be able to help you. We can usually look at your complaint if:
- A request for an assessment or review was unreasonably refused or has been unreasonably delayed
- The process of assessment of your claim was significantly flawed;
- The reason for refusing funding was illogical, flawed, or not based on evidence
What we cannot do
We cannot:
- Undertake our own assessment of health care needs;
- Help you make a claim for Continuing NHS Healthcare funding (there are other organisations who may do this – see ‘further information’ below);
- Tell you whether Continuing NHS Healthcare funding should have been granted or replace the Health Board’s decision and direct them to pay Continuing NHS Healthcare funding.
Issues to bear in mind
If we uphold your complaint we may make recommendations to the Health Board about what they should do. This may include a request to carry out a new assessment of healthcare needs, or to hold a new panel to consider your appeal.
Further information
You may like to think about contacting the following organisations for advice:
Age Cymru can provide information and advice. You can contact them by phone on 08000 223 444 or there is more information on their website – www.agecymru.org.uk
MIND can provide help and advice on a range of mental health issues contact by phone on 0300 123 3393 or there is more information on their website – www.mind.org.uk
The Alzheimer’s Society can provide help and support. You can contact them on 0300 222 1122 or there is more information on their website – www.alzheimers.org.uk
Llais can provide advice and support with making a complaint. You can contact them on 02920 235 558 or there is more information on their website – www.llaiswales.org.
Details of your local Health Board can be found at www.wales.nhs.uk/directory.cfm
Details of the process for claiming continuing NHS healthcare can be found at http://www.cciss.org.uk/home
Contact us
If you are not sure whether we would be able to look into your complaint, please contact us on 0300 790 0203 or ask@ombudsman.wales
Also available in Welsh.