Follow-up report highlights ongoing issues with retrospective claims for Continuing NHS Healthcare

29 Jan 2015 - 12:00am

Some good progress but approach to those seeking re-imbursement of care home fees still a concern. 

There has been a positive response from the Welsh Government to many of the issues raised and recommendations previously made by the Auditor General and the National Assembly’s Public Accounts Committee. However, the approach to clearing retrospective claims for Continuing NHS Healthcare remains a concern, according to a report released today by the Auditor General for Wales.

The report, which follows up on findings from June 2013, looks at how the NHS is performing in managing Continuing NHS Healthcare. Continuing NHS Healthcare is a package of care provided to people who are assessed as having a primary health need. These care packages can include the funding of care home fees. Individuals are able to request retrospective reviews seeking reimbursement for care home fees where they feel they could have been eligible for a continuing healthcare package.

The report found that the Welsh Government has taken a number of important steps since June 2013, including the launch of a revised National Framework for Continuing NHS Healthcare backed by a staff training programme, and strengthened leadership and oversight. These provide the basis for ensuring people across Wales are dealt with fairly and consistently. Public information has been expanded and this will help people better understand this complex topic. 

The Powys Project (a national project set up to deal with retrospective claims), successfully reviewed the 2,525 claims that it received up to 15 August 2010. Since that date the NHS has received a further 4,092 claims, many of which were received in response to the announcement by the Welsh Government of a July 2014 cut-off date for claims relating to a period between 1 April 2003 and 31 July 2013. The majority of the claims received since 16 August  2010 are now being dealt with by the Powys Project but a significant number are the responsibility of health boards. The report raises important concerns over the approach to dealing with these claims. Specifically:

  • the Powys Project, although it has demonstrated its ability to deliver, now faces an even greater challenge in processing its share of the current claims;
  • health boards have failed to agree and report meaningful and accurate information on the progress being made with claims; and
  • some health boards have not demonstrated that they are able to deal in a timely way with the claims they are responsible for and some claimants are being dealt with unreasonably.
  • The report concludes that the Welsh Government needs to take a stronger and more directive role with health boards to improve and speed up the processing of retrospective claims and to meet deadlines that it has set. The Welsh Government has accepted and is to address the main concerns raised in the report, which recommends a number of specific actions designed to ensure that:
  •  information is available to monitor progress with retrospective claims;
  • individual health boards are allocating appropriate staff resources to processing retrospective claims;
  •  health boards provide adequate funding for the Powys Project to support its work;
  • people are dealt with fairly when asked to provide proof they have paid care home fees; and
  • public information is promoted as widely as possible.

The Auditor General, Huw Vaughan Thomas, said today: ‘Today’s follow-up report shows that there have been some good successes but that work remains to be done to ensure a step change in how some health boards deal with retrospective claims. The Welsh Government needs to strengthen its role in managing Continuing NHS Healthcare to ensure that claims are dealt with as quickly and efficiently as possible.’