NHS Continuing Healthcare Denied? How to Appeal a CHC Decision

NHS Continuing Healthcare (CHC) is a fully funded care package for adults in England with complex, ongoing health needs. CHC pays for nursing home, residential care, or home care without any means-testing. But the eligibility process is complex, the assessments are often flawed, and tens of thousands of people are wrongly denied CHC funding each year.

If you or someone you care for has been refused CHC, you have the right to appeal. This guide explains how.

What Is NHS Continuing Healthcare?

NHS CHC is distinct from local authority social care. When a person qualifies, the NHS — through the local Integrated Care Board (ICB) — funds the full cost of care, whether at home or in a care home. There is no means-test and no care cap.

Eligibility is determined by a two-stage process:

1. Checklist assessment — a brief screening tool. If a person meets the threshold, they proceed to a full assessment.
2. Full assessment using the Decision Support Tool (DST) — a multi-disciplinary team (MDT) assesses needs across 12 care domains (behaviour, cognition, communication, psychological/emotional, mobility, nutrition, continence, skin integrity, breathing, drug therapies and symptom management, altered states of consciousness, and other significant care needs).

A person qualifies for CHC if they have a primary health need — meaning that their care needs are primarily driven by health rather than social or personal care.

Why CHC Is Denied

Common reasons for CHC denial include:

Incorrect application of the primary health need test. ICBs frequently underrate the severity and nature of health needs in the DST, resulting in a failure to identify a primary health need.

Needs scored too low. The 12 domains are rated from "no needs" to "priority" (the highest level). Errors in scoring — particularly under-rating needs as "low" or "moderate" when evidence supports "high" or "severe" — are extremely common.

Social care framing. ICBs sometimes frame health needs as social care needs to avoid CHC responsibility, despite the fact that the nature of a need (not just its severity) determines primary health need.

Inadequate MDT assessment. If the MDT does not include appropriate clinical professionals, or if the person's own views and evidence are not properly considered, the assessment may be flawed.

Checklist gatekeeping. Some ICBs apply the checklist too restrictively, preventing eligible people from reaching the full assessment stage.

The CHC Appeal Process

Step 1: Request a Review

You can challenge a CHC denial at the local ICB level. Request a local resolution review in writing. Ask the ICB to:

• Provide the completed DST and all assessment documents
• Explain specifically why a primary health need was not found
• Confirm the composition of the MDT that conducted the assessment

Submit this request within three months of the decision (though ICBs may still consider later requests).

Step 2: Submit Evidence for Review

Gather medical and care evidence to challenge the domain scoring:

• GP and specialist letters describing the nature and severity of health needs
• Hospital discharge summaries, nursing records, or care home logs
• A care diary documenting daily health interventions
• Your own written account and that of family carers
• Clinical opinion from independent professionals if possible

For each domain where you believe the score is wrong, cite the specific evidence that supports a higher rating.

Step 3: Request an NHS England Independent Review Panel

If local resolution fails, you can request an Independent Review Panel (IRP) through NHS England. The IRP is composed of independent members and a clinical representative. The panel reviews the assessment process and can recommend a re-assessment.

Submit your IRP request to NHS England within six months of the local resolution decision.

Step 4: Escalate to the Parliamentary and Health Service Ombudsman

If the IRP recommendation is not acted upon, or if procedural failures continue, you can complain to the Parliamentary and Health Service Ombudsman (PHSO). The PHSO can investigate maladministration and recommend remedial action, including backdated CHC funding where eligibility should have been established earlier.

Retrospective CHC Claims

If a person received care in the past but was never assessed for CHC, a retrospective claim may be possible. The NHS has specific processes for retrospective assessment, though these are complex and time-limited. If you believe a deceased family member should have received CHC funding, contact the ICB to enquire about retrospective review.

Fight Back With ClaimBack

ClaimBack helps families navigate NHS CHC appeals with structured written submissions, evidence frameworks, and guidance on the review process. Whether you need help with a local resolution request, an IRP submission, or an ombudsman complaint, ClaimBack can support you.

Start your CHC appeal with ClaimBack

Related Reading

• How to Write an Insurance Appeal Letter
• Internal vs External Insurance Appeal: What's the Difference?
• How to Use the Insurance Ombudsman