A new hurdle on the troubled road of retrospectives – managing complaints and disputes

By Art Calder

It regularly features at the top of the ‘worry list’ for senior commissioners. The challenge of retrospective claims for continuing healthcare funding, which falls to often poorly resourced teams, cannot be over-estimated. A total of 66,000 claims were filed in 2012 and CCGs continue to work through the hundreds of cases on their books. The final deadline of March 2017 for the completion of all reviews is now not all that far away.

Enormous efforts are being made to clear the backlog and meet the forthcoming deadline. For many, outsourcing has been a viable and effective solution. We have worked with CCGs in London, the south coast, the west of England and the north-east. At CHS Healthcare, I lead a team of nurse assessors and case managers specialising in continuing healthcare and this enables us to manage process cases efficiently and diligently. The work varies according to commissioner needs – in some instances, what is required is an expert view, advice or case summaries. Equally, we may be asked to screen cases and as part of that process, meet with families and / or claimants to explain our recommendations and documents.

While many CCGs are making very good headway through their retrospectives backlog, a new risk has arisen. I understand that of the unsuccessful claims currently having been processed, 30 to 45 per cent have exerted the right to dispute decisions made by the NHS teams. Appropriate management of complaints and disputes is of course vital, but may divert resources from continuing to process existing claims. When managing claims in dispute, CCGs need to be mindful of the principle (in light of the recent Morecombe Bay enquiry) that ideally a complaint should not be processed by the same person or team who dealt with the original claim. This will create a further challenge for continuing healthcare departments in terms of judging what they are able to resource and what work needs to be out-sourced.