Can the CCG overturn a recommendation made by the MDT?

What does the Framework say?

The Framework says that the multidisciplinary team’s recommendation is to be followed unless there are exceptional circumstances . The Practice Guidance notes say that the CCG decision-making process should not have the function of overturning recommendations. If the recommendations are not followed, this should be for clearly articulated reasons, and because of exceptional circumstances (and not because of budgetary constraints).
The exceptional circumstances include:

  •  where the DST is not completed fully (including where there is no recommendation)
  •  where there are significant gaps in evidence to support the recommendation
  •  where   there is an obvious   mismatch    between   evidence   provided   and the recommendation made
  •  where the recommendation would result in either authority acting unlawfully.

If the CCG feel there are exceptional circumstances, they must send the DST sent back to the MDT with a full explanation of  the relevant matters to be addressed. Although the Framework does not specifically state this, it would be assumed that once the items have been rectified – and if a recommendation is still made by the MDT for eligibility – the CCG would then accept that.   However, the Framework states that ultimately responsibility for the eligibility decision rests with the CCG.

References
NF Paragraph 91.   The CCG may choose to use a panel to ensure consistency and quality of decision- making. However, a panel should not fulfil a gate-keeping function, and nor should it be used as a financial monitor. Only in exceptional circumstances, and for clearly articulated reasons, should the multidisciplinary team’s recommendation not be followed. A decision not to accept the recommendation should never be made by one person acting unilaterally.

92.   The CCG may ask a multidisciplinary team to carry out further work on a Decision Support Tool if it is not completed fully or if there is a significant lack of consistency between the evidence recorded in the Decision Support Tool and the recommendation made. However, the CCG should not refer a case back, or decide not to accept a recommendation, simply because the multidisciplinary team has made a recommendation that differs from the one that those who are involved in making the final decision would have made, based on the same evidence.

93.   CCGs should not make decisions in the absence of recommendations on eligibility from the multidisciplinary team, except where exceptional circumstances require an urgent decision to be made. The final eligibility decision should be independent of budgetary constraints, and finance officers should not be part of a decision-making panel.

94.    As part of their responsibility to ensure consistent application of the National Framework, a CCG may review the pattern of recommendations made by multidisciplinary teams, in order to improve practice. However, this should be carried out separately from the approval of recommendations in individual cases. END

The Practice Guidance Notes from the National Framework clarify:

40.2  CCG decision-making processes should not have the function of:

•     financial gatekeeping

•     completing/altering DSTs

•     overturning recommendations (although they can refer cases back to an MDT for further work in certain circumstances – see below).

PG 41 What are the ‘exceptional circumstances’ under  which  a CCG or panel might  not accept  an MDT recommendation regarding eligibility  for  NHS continuing healthcare?

41.1   Eligibility  recommendations  must  be  led  by  the  practitioners  who  have  met  and assessed the individual. Exceptional circumstances where these recommendations may not be accepted by a CCG include:

•     where the DST is not completed fully (including where there is no recommendation)

•     where there are significant gaps in evidence to support the recommendation

•     where   there is an obvious   mismatch    between   evidence   provided   and the recommendation made

•     where the recommendation would result in either authority acting unlawfully.

41.2   In such cases the matter should be sent back to the MDT with a full explanation of  the relevant matters to be addressed. Where there is an urgent need for care/support to be provided, the CCG (and LA where relevant) should make appropriate interim arrangements without delay. Ultimately responsibility for the eligibility decision rests with the CCG.

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One Response to Can the CCG overturn a recommendation made by the MDT?

  1. Pingback: Can CCGs overturn NHS Continuing Healthcare eligibility | Care To Be Different

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