Lesley Griffiths, Minister for Health and Social Services
This was published under the 2011 to 2016 administration of the Welsh Government
Continuing NHS Healthcare (CHC) describes a package of care arranged and funded solely by the NHS, for those whose primary care need is health-based. In some cases, where eligibility for CHC was inconsistently applied, individuals can apply for a retrospective reimbursement of costs they contributed to their care. Under arrangements for retrospective CHC claims introduced in June last year, a Project Team in Powys (teaching) Health Board manages claims submitted up to 16 August 2010 across Wales. Claims submitted after this date are dealt with by the relevant Health Board.
The management of retrospective CHC claims is a complex, yet important and sensitive task. I appreciate the individual circumstances in each case and the varying local approaches in managing these claims, make it impractical and potentially misleading to measure all aspects of performance. I have, nonetheless, asked Health Boards to provide me with information to demonstrate the extent of their progress in managing these claims.
The Project Team at Powys Health Board have received a total of 2,519 retrospective claims. As part of their initial scrutiny of these cases, Powys closed 536 claims owing to insufficient proof of payment or legal authority to justify the claim. A further 244 cases have been processed to completion, of which 85 cases were found fully eligible for reimbursement, 141 partially eligible and 18 ineligible. 1,739 cases are, therefore, outstanding, of which 1,121 cases are under active investigation. £1,038,759 has been reimbursed to claimants to date.
Under processes set out in the Welsh Government’s 2010 CHC Framework, 1,232 post-August 2010 claims were submitted to Health Boards and 53 have been processed to completion. Of those, 21 cases were fully eligible for reimbursement, 16 partially eligible and 16 ineligible. 97 are currently under active investigation and £346,166 has been reimbursed to claimants.
I expect Health Boards to manage these claims effectively and to time. I have set out particular requirements and milestones for the Powys Project Team to manage all their claims by June 2014, as agreed with the Public Service Ombudsman for Wales. The Welsh Government’s role has been to provide strategic direction to Health Boards through the CHC Framework and guidance on eligibility for Continuing Healthcare. My officials are working with the Project Director of the Powys Project Team on the targets to be met at key stages over the coming months and more widely with all Health Boards to ensure robust audit and performance management arrangements for these claims are in place.
More broadly, the NHS is working to ensure eligibility decisions are correct first time, clear and well-documented so retrospective reviews become a thing of the past. The Welsh Government will support this by introducing more effective arrangements for retrospective claims, including a rolling cut-off date for future claims.
I also recognise existing arrangements regarding the provision of CHC services need to be considered carefully. The Wales Audit Office (WAO) is currently undertaking a National Study on the effectiveness and implementation of current CHC arrangements. Its findings will be made available in the Spring and will contain recommendations for Welsh Ministers as well as for Health Boards and Local Authorities. My officials are working with the WAO to identify and discuss emerging issues as part of this process. I will take forward my own commitment to undertake a review of the CHC Framework and address outstanding issues related to it as soon as recommendations made by the WAO are available next Spring.