IMCA involvement in accommodation decisions and care reviews
NHS continuing healthcare eligibility assessments and reviews
Assessments for NHS continuing healthcare funding must be undertaken by PCTs when ongoing health services may be needed. For example, assessments should be carried out:
- when a person is discharged from hospital
- if a person's physical or mental health deteriorates significantly
- before the NHS pays for some or all of the costs for a care home place.
NHS continuing healthcare can be provided in any setting, including registered care homes or a person's own home. Where a person is assessed as needing continuing healthcare this should be reviewed within three months of the initial decision, and then at least every year. One aspect of such reviews is to ensure the person's needs are being met. The person's eligibility for continuing healthcare may also be reassessed.v
The outcome of both assessments and reviews could be a change of accommodation for the person. Therefore the statutory duty to instruct an IMCA to support and represent the person for either an assessment or review may apply.
Practice guidance published by the Department of Health (2010b) states that an IMCA should be instructed as soon as there is a preliminary view that the outcome of the assessment is that a change in accommodation is likely. It also states that the final decision should not be made until an IMCA report has been considered by the decision-maker. While it may be possible for either a local authority or PCT to instruct the IMCA, the guidance suggests good practice is for the PCT undertaking the continuing healthcare assessment to do this.
When an IMCA is instructed because there may be a change in accommodation, they should support and represent the person in relation to the accommodation decision. Their role is not to represent the person during the eligibility assessment.
If an IMCA has been unable to resolve any serious concerns about the outcome of the accommodation decision, this can be addressed through the usual routes. In some cases it may be appropriate for the IMCA to challenge the outcome of the eligibility assessment where this directly informed the accommodation decision (e.g. if the person has to move because they are no longer eligible for continuing healthcare).
Eligibility decisions are not 'best interests' decisions. Therefore it would be wrong to argue that an eligibility assessment was not in a person's best interests. Instead, the IMCA may wish to question whether adequate attention was given to a person's needs, or how the eligibility criteria were interpreted in the specific case. If disputes about eligibility cannot be resolved informally, one option is for the IMCA to ask the strategic health authority to undertake a review.
PCTs are expected to be proactive in ensuring that advocacy services are available to people who may be eligible for continuing NHS healthcare (DH 2010b). This includes using the discretionary power to instruct an IMCA when undertaking care reviews for people whose accommodation is funded by the PCT under NHS continuing healthcare. It would also include making available other advocacy services to specifically support people during eligibility assessments as this is outside the IMCA's role.