A retrospective review follows a request from an individual or their representatives for an assessment which may look back a number of years and is the approach adopted to deal with requests for previously un-assessed episodes of care.  Whilst a review may involve an assessment of current needs, the review is predominantly a paper based assessment for a period in the past.  It will be undertaken by an experienced Nurse Assessor with access to patient healthcare records and nursing/residential home care notes.  The review may be conducted because an individual has never been assessed, has not been assessed in recent years or has passed away before an assessment was undertaken.

NHS Continuing Healthcare (CHC) is the name given to a package of care which is arranged and funded solely by the NHS for individuals outside of hospital who have ongoing healthcare needs.  To qualify for CHC an individual must have a ‘primary health need’ which is assessed using the National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care published 1 October 2007(revised 2009 and 2012).

Following the deadlines announced by the Department of Health for the receipt of claims for retrospective reviews for the period 1st April 2004- 31st March 2012, Surrey Downs Clinical Commissioning Group (CCG) who took over responsibility as Host for the Surrey CCGs from Surrey PCT, received an unprecedented number of requests for reviews. All requests have been acknowledged and recorded in chronological order of receipt by the CCG and are being progressed through each stage of the review process.  Unfortunately the high volumes have meant that we are unable to process all of the claims as quickly as we would have hoped and there are inevitable delays caused by the number of claims reaching each stage at the same time. We estimate that claims may take between 2 – 3 years to complete, although this estimate is only a guide. This is a national issue and Surrey Downs CCG is currently reviewing processes and aligning resources to reduce the time taken in the medium term.

The team can only accept requests for periods since 1st April 2012.

The Process

The retrospective process initially involves the collecting of information by completion of a questionnaire and consent; this will include obtaining confirmation of authority to act on behalf of the individual evidenced by production of a Power of Attorney or Grant of Probate or Will detailing the Executors of an estate if the individual is deceased.  The CCG also required certified copies of ID to support the consent.

Once all of this information is received, the paperwork which has been submitted will be reviewed by an experienced Nurse Assessor who will complete a screening process.  This will look at the initial evidence to consider whether a full assessment for NHS CHC is necessary.  We will normally write to the applicant following this initial screening to advise of the next stage in the claim process.

If an individual is still alive, the initial screening may highlight that a current assessment of needs is required, this will be arranged, and the individual’s representative will be invited to attend.  Once the outcome of any assessment is known the effect of the outcome on the retrospective request will be reviewed and the team will contact the applicant to advise the next stage.

If on completion of the initial review , i t is determined that a full assessment for NHS Continuing Healthcare is necessary, then the CCG will need to collect a lot of evidence relating to the claim period from a number of different sources.  It is difficult for us to determine at this stage how long the review will take to complete as it will depend on the availability of this evidence, the length of the claim and the availability of Nurse Assessors at any given time to undertake the review itself. 

 All claims that have been acknowledged will be progressed and there is no need for you to chase to ensure it is progressed.  All claims are being handled in chronological order of receipt of completed paperwork as this is the only fair and equitable way to proceed. The team is happy to discuss your claim with you; we must advise that we will not be able to provide timescales for progression and completion, other than to confirm that at any specific time we have received all necessary information from you for the stage at which your claim is.

Once all of the required evidence is held the case will be allocated to a Nurse Assessor who has the appropriate skills and is trained in continuing healthcare. Due to the number of claims received there may be a considerable delay between receipt of all required evidence and allocation to a Nurse Assessor.  The assessor will scrutinize the evidence and compile a needs portrayal document, pulling together all the relevant information from the different sources of evidence to build up a comprehensive picture of the individual’s needs across the whole time period.  Once completed the assessor will share the Needs Portrayal document with the applicant and request confirmation of the content and invite any comments the applicant wishes to add.

Once completed and returned, the information will be used to apply the eligibility criteria.  If a claim period spans a number of years, then the eligibility criteria may need to be applied several times.  A recommendation will be made to a multi- disciplinary team (MDT) of professionals within the CCG who will consider whether the nature, complexity, intensity or unpredictability of the individual’s needs indicate a ‘primary health need’.

If the CCG decide that the individual was eligible for all or part of the period under consideration, the CCG will make arrangements to make a restitution payment in line with the Department of Health Redress Guidance.  Surrey Downs CCG calculates Redress by use of RPI (Retail Price Index).

If the CCG decide that the individual was not eligible for CHC funding for all or part of the period being considered, the decision will be sent to the applicant with details of who to contact should the applicant disagree with the decision.

If you have any queries with regard to Retrospective Reviews please This email address is being protected from spambots. You need JavaScript enabled to view it.the team or telephone 01372 201745.