• Phil Austen-Jones

Done something wrong, CCG? Don't worry, just say it is "Local Governance Procedures"

Following the abysmal Local Resolution Meeting, we wrote to Heather Hauschild, Chief Officer of West Hampshire CCG, to highlight the serious failings in the process, ie accepting that the January 2018 review should have determined on-going eligibility for NHS Continuing Healthcare, but ignoring due and fair process by pre-determining the outcome using an unlawful clinical assessment by the Head of Continuing Healthcare.


I will explain how Heather Hauschild responded to this later.


The main focus of this blog post is the response we received from West Hampshire CCG to our complaint regarding the January 2018 review. The letter also includes their response to further questions relating to the November 2017 review.


I very much wish I could go through every aspect of the letter. If I were employed by the NHS, I would be ashamed of its contents - the unevidenced responses, the lies, the misinformation, the dodge tactics, the omissions and, as we later found out, the lack of understanding of key issues. However, to break the entire letter down would be a mammoth task for both me, as the author, and you, as the reader. As such, I will focus on some of the key issues that haven’t been addressed in earlier blog posts.


“The case review document completed on 23 January 2018 has been considered by the Continuing Healthcare team. The assessment details that a change in need was evident within the psychological, communication and continence domains suggesting that a full decision support tool would be appropriate to ensure that Mrs Austen-Jones’s package of care is appropriate and also that a primary health need is still evidenced.”


Point 1 – Two of those scores were ‘maybe lower’. Only one went down (from Moderate to Low).


Point 2 – Using the same methodology of the CCG, the mobility domain score increased to High. But they didn’t mention that one in their response.


Point 3 – There was still a Priority in Altered States of Consciousness.


Point 4 – There were still two Severe scores in Cognition and Medication.


Point 5 – The Breathing domain was incorrectly assessed and would likely to be Severe or Priority. Instead, it was graded as No Needs (for someone who stops breathing and needs urgent assistance to restart).


Point 6 – The reviewer at the January 2018 review did not believe that the case needed to go to a Multi-Disciplinary Team (MDT) meeting to reassess eligibility, but it was “Simply the guidelines”.


Point 7 – At the Local Resolution Meeting, the Head of Continuing Healthcare stated, “I agree, that two severe and a priority would indicate a Primary Health Need.” She also agreed that there was no evidence in the January 2018 review meeting that my wife would not meet criteria for NHS Continuing Healthcare.


I would love to hear from West Hampshire CCG to understand how the Head of Continuing Healthcare has switched from saying that the case should not have been referred to MDT, to claiming in writing that it was the correct decision.


“The request for senior clinical management support in response to the concerns raised at the review is considered to be an appropriate escalation; this is in line with local governance procedures to ensure consistency of decision making.”


Note that this letter was signed off by Ellen McNicholas, WHCCG Director of Quality and Nursing, on behalf of the CCG. The CCG has repeatedly informed me that their complaint investigations were “robust”. Hmmm…


If anyone can explain to me how this statement regarding “local governance procedures” is anything other than a outrageous lie to cover up failings and force us to an unnecessary MDT to reconsider eligibility at a time of major cost cutting at the CCG, please let me know.


I have spent years asking for the evidence of these procedures. Having failed to produce them for a long time, West Hampshire CCG finally came up with “Supervision by line managers is standard practice in the NHS,” along with references in an April 2017 consent form to “Quality assurance & monitoring.” But I have become quite adept at interpreting West Hampshire’s communications, so I asked for the documents that relate to this. How did they reply?


“WHCCG have advised they do not have a management supervision policy but good line management practice for a staff member would be to contact their line manager if they have a case they wish to discuss.”


So, there are no “local governance procedures”. They do not exist. In any case, just because a staff member may want to discuss a case with a senior, under data protection law, they cannot do so unless they anonymise the data or obtain consent from the patient or their representative (or under the Mental Capacity Act).


Please, if anyone can get a response from West Hampshire CCG as to how this is not a lie, please let me know.


“Subsequent to your meeting, the Head of Continuing Healthcare has reviewed both the joint operational policy and the standard operating procedures in conjunction with the national framework for NHS Continuing Healthcare as agreed. All of these area aligned in stating that the outcome of the review will determine whether the individual’s needs have changed and that will then determine whether the package of care may have to be revised or the funding responsibilities altered. There is no reference to ‘minor changes’ in any of the reviewed policies and procedures.”


Well, I cannot fault this statement in terms of accuracy. It is correct. Just a shame that it omits the key point. The documents are all aligned in stating that an MDT to re-review eligibility should only be determined if the change in need indicates that eligibility is in doubt. This is in accordance with the law (The NHS Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) Regulations 2012 – Paragraph 21 (2)(b)). The reference to ‘minor changes’ refers to the January 2018 reviewer saying that the guidelines state that any minor change must go to MDT.


“As agreed at your complaint meeting, the Head of Continuing Healthcare has reviewed the paperwork from the November 2017 review and is satisfied that this is reflective of Mrs Austen-Jones’ needs as presented at the time.


For context, following receipt of the November 2017 review report, we challenged it for being factually inaccurate (and ‘by coincidence’, helped to back up the reviewer’s change of view that an MDT was required). We used our recording of the meeting to evidence the major inaccuracies in the report.


The response seems reasonable. She has looked at our claims and determined that the report is reflective of this. If only that were true. Two things here:


Point 1 – An internal email states, “I have reviewed the documentation from the family regarding the November review paperwork and compared it to the previous review in April. From this, I am satisfied that the November review paperwork is reflective of the needs presented at the time of the review.” How on earth does a comparison with the April 2017 review indicate that the reviewer recorded everything appropriately, especially when the reviews were conducted in completely different manners and the review reports are completely different in length (5 pages vs 19 pages) and detail.


Point 2 – If the November review report is accurate, then how come the following was stated in the same response letter to us? “Unfortunately, the case coordinator was not able to easily identify the seizure presentation because of this. The team are sorry that assumptions were made which impacted on the way in which the altered state of consciousness domain was assessed.”


“In regards to your email of 15 February 2017 [sic – should say 2018], the team confirm that following the case review of 8 November 2017 and subsequent review on 23 January 2018, the Clinical Commissioning Group have received recommendations from the case coordinators that the care provision for Mrs Austen-Jones includes significant elements of social care associated with welfare services.”


Where to start?


First of all, the level of social care is irrelevant in NHS Continuing Healthcare. The only question is whether there is a Primary Health Need. If there is, and in our case it is 24/7, then the NHS covers all costs. Take away the social care elements, health care is still needed 24/7, as confirmed by the medical experts.


Secondly, we never raised the issue of social care in the package. This strongly indicates the desire of the CCG to reduce the package to make savings.


Thirdly, our letter of 15 February 2018 was regarding the inappropriate actions of the Head of Continuing Healthcare and the complaint manager at the Local Resolution Meeting, with particular reference to pre-determining the outcome. The letter was sent to Heather Hauschild, as Chief Officer of West Hampshire CCG. What did she do about our complaint? Gave it to the complaint manager to deal with. Hence the lack of response to the pre-determined outcome.


AND FINALLY


Prior to the November 2017 review, we requested a copy of the April 2017 review report. The day after receiving it, I emailed to state that there were “a few amendments that we would like to highlight.” We were advised to raise these with the case coordinator at the review meeting. Under data protection law, factual inaccuracies must be changed upon request. However, the case coordinator refused to even look at the April review report, never mind listen to the amendments that we were requesting (they were minor, such as timings that carers arrive). The response from West Hampshire CCG…


“The role of the case coordinator on 8 November 2017 was to complete a review of Mrs Austen-Jones’s current needs. The team apologise that the administrator advised that the notes completed from the previous review in April 2017 would be discussed and amended. It would not be appropriate under the Nursing and Midwifery Code of Conduct for that case review to be amended by another clinician. The team would like to reassure you that the comments you made to the document subsequent to the meeting were noted within Mrs Austen-Jones’s case file."


So, according to West Hampshire CCG, it would be a breach of the NMC Code of Conduct for clinician to amend a review done by another clinician. Yet they continue to this day to claim that it was appropriate for a senior manager to invoke unevidenced amendments to the January 2018 review which led to significant impact the overall needs. This is despite the Head of Continuing Healthcare stating in the Local Resolution Meeting, “I acknowledge that what was said to you in the meeting differs from the review paperwork that has now been completed. I will take that back as not best practice. So that’s not something that should happen. It should be that the outcome from review that is agreed with the relatives or the patient themselves and that’s the outcome that is then taken forward.”


I guess I must be missing the local policy/guidance that allows the CCG to pick and choose which policies to follow and when.


My next blog post will go further into the complaint response from West Hampshire CCG and the subsequent communication. To date, West Hampshire has yet to reply to me with any factual inaccuracies within my blogs, including this one. This doesn’t surprise me as I can evidence everything that I have said. On the same note, no one from West Hampshire CCG nor Hampshire County Council expressed to me concern about the actions that I am highlighting. You would have thought that someone would be questioning it rather than ignore the failings. But, as said by Gruenter and Whitaker, “The culture of any organisation is shaped by the worst behaviour the leader is willing to tolerate.”


My story is just one of many, many thousands. If you wish to share your story, please contact me. I am looking to support people in making public their own cases so that the injustice is highlighted and the disgraceful, and often unlawful, behaviour of CCGs, is exposed, along with the failings in Social Services, the PHSO and the NMC.

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