The complainants, Mr P, Mr H and Mr S, complained about delays in the determination of retrospective claims for NHS funded continuing healthcare.[1] At the time the complaints were made to the Ombudsman, none of the complainants had received a determination of their claim.
The Welsh Assembly Government (as it then was) set up a system whereby retrospective claims submitted to individual health boards between August 2010 and April 2014 (known as “Phase 2 cases”) were mostly transferred to Powys Teaching Health Board (“the Health Board”) to be determined. In June 2014 the Welsh Government issued guidance indicating that such claims should take no longer than two years to process. In 2016 the Health Board introduced a new, two stage, process for the management of the large number of outstanding Phase 2 cases. This involves a preliminary review of the claim, which may result in a full review being carried out of a shorter period than that requested.
Mr P’s claim was made to Cardiff & Vale University Health Board on 17 May 2013, and was transferred to the Health Board in July 2014. On 17 August 2017 Mr P was notified of the outcome of the Stage 1 review of his claim, and that the Stage 2 review would be of part of the period claimed.
Mr H’s claim was made to Aneurin Bevan University Health Board on 13 March 2013, and was transferred to the Health Board in July 2014. On 18 August 2017 Mr P was notified of the outcome of the Stage 1 review, and that the Stage 2 review would consider the whole of the period claimed.
Mr S’s claim was made to a local authority on 13 September 2013, and was transferred to the Health Board in July 2014. On 16 August 2017 Mr S was notified of the outcome of the Stage 1 review, and that the Stage 2 review would consider part of the period claimed. Mr S’s claim has now been disallowed.
The Ombudsman found that the failure to determine the claims within the recommended timeframe, or even within a reasonable time, was maladministration. The complainants suffered the injustice of not knowing whether their claims would succeed and, if they were successful, the delay in receiving reimbursement for the costs incurred. He recommended that the Health Board apologise to the complainants, and make a payment of £125 to each in recognition of the considerable delay they had experienced.
The Ombudsman also recommended that the Health Board make a similar payment to each claimant whose claim had not been reviewed as at 7 September 2017 and who had waited in excess of two years from the date of the claim being accepted by the relevant Health Board.
The Health Board agreed to implement the recommendations.
[1] A package of care arranged and funded solely by the NHS for individuals outside of hospital who have ongoing health care needs