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Annual Report of the Ombudsman 2003

Chapter 2 - Northern Area Health Board - Domiciliary Care Allowance

I was unhappy about the outcome of an application for Domiciliary Care Allowance in the Northern Area Health Board in respect of a child suffering from Asperger's Syndrome. As well as resolving the complaint I have also highlighted the need for consistency in approach to the decision making process for the allowance throughout the health board system.

Domiciliary Care Allowance (DCA) is a monthly allowance payable in respect of children from birth to the age of 16 who are so severely physically or mentally handicapped that they require continuous care and attention which is substantially in excess of that normally required by a child of the same age. Eligibility for the allowance is determined not necessarily by the diagnosis of a condition but rather by reference to the degree of additional care and attention which follows as a result. The evidence submitted to health boards in support of an application for DCA can come from the child's consultant, GP, speech therapist, school or indeed, from the child's parents themselves. Applications are assessed by the Senior Area Medical Officers (SAMO) working within the health boards.

I received a complaint against the Northern Area Health Board from a man whose son had been diagnosed as suffering from Asperger's Syndrome at two years and ten months. His parents applied for DCA and had been awarded it from the date of application. The Board had, however, refused to backdate the allowance to the child's second birthday as was provided for in the guidelines governing the payment of DCA at the time. The reason given was that there was no independent medical evidence to support the contention that the child required care and attention substantially in excess of that normally required by a child of the same age prior to the date of application.

The child had been medically assessed at the age of two years and had been referred to a Consultant in Developmental Paediatrics for further examination. This Consultant had submitted a detailed report in support of the application for DCA confirming that the child had become lost for words and withdrawn from about 15 months of age, and that he had a significant communication disorder, with poor eye contact and limited interaction. She stated that the child appeared to be on the autistic spectrum and arranged for him to undergo a number of tests. These tests subsequently determined that the child was suffering from Asperger's Syndrome. The Consultant stated that, in her opinion, the child required care and attention in excess of his peers and that his family were going to need a great deal of assistance and support.

The complainant explained to me that while his son had formally been diagnosed with Asperger's Syndrome at the age of two years and ten months, this did not change the level of excess care and attention which his son required and had been receiving throughout his infancy. I asked that the Director of Customer Services and Appeals review the case in conjunction with the SAMO taking into consideration all of the information contained in the medical reports. However, the SAMO continued to hold the view that there was no objective evidence which would allow the Board to award the Allowance from the child's second birthday.

This case highlighted a particular issue in relation to consistency of decision making in DCA. The decision to grant or refuse the allowance is made by administrative staff, on foot of a recommendation by a SAMO. It is my experience that administrative staff feel obliged to accept the recommendation of the SAMO, effectively making him or her the decision maker in this type of case. Administrative staff do not consider themselves to be capable of assessing the contrasting views of the medical opinions in these cases. They would not see it as their role to evaluate the opinions of the SAMO and an applicant's medical advisor. They saw the SAMO's recommendation as a definitive statement. Effectively, unless there was some obvious error by the SAMO (e.g. the wrong person is named), there is no objective basis for them to reject the SAMO's recommendation.

In this particular case, there was medical opinion coming forward from the applicant that supported the claim that the child would have qualified for the allowance from age two. My staff had made enquiries of other health boards and confirmed that the allowance would, in fact, have been granted by them in the circumstances quoted. Following a further review of the matter by the Chief Executive Officer of the Board, the allowance was paid in respect of the child from the age of two and appropriate arrears paid.

The Department of Health and Children has initiated a review of the guidelines governing the award of DCA and I have highlighted to the review group the need for consistency in decision making and the articulation of reasons for decisions, particularly where there is conflicting medical opinion, as being issues of critical importance in their deliberations.

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