How to navigate the NHS Continuing Healthcare system – and identify when you need help
NHS Continuing Healthcare (CHC) is a fully funded package of care provided by the NHS outside of hospital settings for individuals who have significant ongoing health but also social care needs. It can be provided either at home or in a care home, and it is available to everyone who needs it, regardless of income or assets.
When are you likely to need an NHS CHC assessment?
Someone may need an assessment after they leave hospital, if it becomes clear they have ongoing health-related care needs. In this case, they will usually be assessed after discharge and a period of recovery.
But they may also need an assessment for CHC even if they are already in a care home or receiving care at home. It all depends on the extent and severity of their care needs and whether they are primarily healthcare related.
While many people go through this assessment process without any professional help, many others run into problems. They feel they are not being fully included in the process or that their views on the care needed are being ignored or downplayed.
Get in touch if: you feel you are being unfairly treated or marginalised at any stage of the process. Depending on the needs, we can look at your case and provide
- an assessment of its strengths and/or weaknesses
- advice and guidance, or
- full advocacy.
1. The initial screening (checklist)
Usually called the CHC checklist, this is done by a health or social care professional (such as a nurse or social worker). It helps quickly evaluate whether the individual is eligible for a full assessment for NHS CHC. The checklist briefly summarises their health and care needs across various domains such as mobility, communication, nutrition, psychological and medication and scores these A, B, or C according to broadly how much and what kind of care they need.
If this checklist scores “positive” (2 or more domains scored as A, 5 or more domains scored as B, or one A and 4 B, or one “priority” domain scored A), they are then entitled to a full assessment by a Multi-Disciplinary Team (MDT).
You can find the government checklist guidance here or check out our Resources section for free factsheets and useful links.
Get in touch if:
- you think an individual should have had a checklist but has been denied one
- their checklist was inaccurate and they were wrongly denied a full assessment.
They may be eligible retrospectively for an “unassessed period of care”. We can carry out a full assessment of the paperwork to assess your chances of success.
2. The full assessment (Decision Support Tool)
This is a comprehensive evaluation of all the individual’s care needs across a range of physical and mental healthcare domains. It is conducted by a multidisciplinary team (MDT), which usually includes a nurse trained in CHC assessments and a social worker at least. The assessment must be person-centred, listening carefully to the views of the individual and any supporting family members. It must be holistic and wide-ranging, consider how different needs interact, and take into account the views of any health and social care professionals involved in the care. The members must strive to reach agreement when scoring the 12 domains, with scores ranging from No Needs to High, Severe or Priority in different areas.
The MDT should assess the needs in great detail, focusing on:
- The nature of the needs
- The severity and frequency of the needs
- The complexity of care needs and the challenges carers face in meeting them
- The unpredictability of the needs.
The MDT will input all this information into a document called a Decision Support Tool (DST) to help decide whether the individual has a “primary health need”. This means that the healthcare needs are of a kind, intensity, complexity or unpredictability that they are beyond what the local authority can legally provide. In completing this tool, the team must have regard to the National Framework for NHS Continuing Healthcare which sets out precise parameters to ensure consistency and fairness.
The MDT will send the DST to the individual’s local Integrated Care Board (ICB) which manages NHS funds with a recommendation as to whether they are eligible for NHS Continuing Healthcare. In most cases the ICB is expected to follow the recommendation of the MDT.
You can find the government guidance on the DST here, or check out our Resources section for free factsheets and useful links.
Get in touch if: you believe the MDT
- failed to follow the National Framework in administering the procedure
- failed to record all the evidence discussed in the meeting
- ignored or marginalised your verbal evidence or that of others, or
- failed to give adequate explanation for its decisions.
We can review the DST and assess your chances of succeeding at appeal.
3. Preparing for the assessment meeting (MDT)
The MDT will usually be very strict in insisting that any statements about the person’s needs are backed up by solid evidence. This is likely to be in the form of daily care records, care plans, risk assessments, medical records and any specialist assessments. But it should also take into account any verbal evidence supplied by the carers and family members. In reality, written evidence usually carries far more weight. So it is vital you gather as much clinical documentation as you can about the extent and severity of the care needs, the challenges in meeting these and whether the condition makes the care needs unpredictable. It is also vital to ensure that the care records fully reflect the amount of time, skill and attention carers are putting in to meeting the needs and managing any risks to the individual themselves or to others. This will help determine if there is a primary health need.
For more information on preparing for an MDT, check out our Resources section with free factsheets and useful links.
Get in touch if:
- you would like us to cast a professional eye over your evidence ahead of an assessment,
- you need written representations to be sent to the ICB ahead of the meeting, or
- you need someone to represent you in the meeting itself.
4. An eligible outcome
If the ICB’s decision is that the individual is eligible, it must cover the full cost of their eligible needs or in some cases, enter into an agreement with the local authority to share the cost. The ICB will be responsible for drawing up a personal care and support plan which will outline the type and level of care required and the setting in which the care will be delivered (e.g., at home, in a care home, etc.). This should usually be put in place within 28 days.
Get in touch if:
- you have received an eligible outcome but you have not succeeded in getting a personal care and support plan.
5. What can you do if you have an “ineligible” outcome
You have six months to appeal an ineligible outcome via a local review process carried out by the ICB itself. This is worth doing if you believe the DST is not an accurate reflection of the individual’s needs at the time of the MDT. The appeal panel, made up of different assessors, should look at the evidence anew as well as any further evidence you can provide and come to its own decision on whether there was a “primary health need” at the time.
Find details of how to contact your local ICB here. For more information on how to appeal, check out our Resources section with free factsheets and useful links.
Get in touch if:
- you are not sure if you have sufficient grounds for an appeal to the ICB and need a professional opinion on your chances of success;
- you need help drafting an appeal; or
- you would like professional representation at the meeting.
6. Appealing to NHS England
If you believe the ICB Appeal panel has failed to adequately address the isues you raised or has continued to give an inaccurate or incomplete picture of the needs, you can appeal to NHS England. It will convene an Independent Review Panel. This panel should look at your whole case from the beginning with fresh eyes. You must fill in the relevant forms giving your grounds for appealing and provide all the evidence you think is relevant.
If you are still unhappy with the outcome, you may be able to appeal to the Parliamentary and Health Services Ombudsman (PHSO).
For more information on Independent Review Panels, go to the NHS website. Find more information on the PHSO here. Or check out our Resources section with free factsheets and useful links.
Get in touch if:
- you are not sure if you have sufficient grounds for an appeal to NHS England and need a professional opinion on your chances of success.
- you need help drafting an appeal for the Independent Review panel; or
- you would like professional representation at the meeting.
7. Reviews of eligibility
NHS Continuing Healthcare will be subject to regular reviews – usually at least annually. The review should look at whether the person’s care needs are still being met, but it will also check whether the needs have changed to such an extent that a full eligibility reassessment is required. We know from experience that ICBs will often carry out a full reassessment of eligibility just because the needs appear more stable, even if this is purely because they are being well-managed. (Well-managed needs are still needs.) It is therefore vital to prepare fully for an NHS CHC review and not assume it will be a mere formality.
For more information on NHS CHC reviews, check out our Resources section with free factsheets and useful links.
Get in touch if:
- you want to challenge a review that has wrongly identified a change in needs
- you are facing a full reassessment and need help preparing.
8. What to do if your funding is withdrawn
NHS CHC reviews can lead to unfair withdrawals of funding. This is where the ICB claims the needs have reduced, even when you know they have not and that the consequences of removing the care package are potentially catastrophic. For more information on what to do if this happens, check out our Resources section with free factsheets and useful links.
Get in touch if
- you feel that NHS CHC funding has been withdrawn without justification and you wish to appeal this decision. (Withdrawals can be appealed in exactly the same way as initial denials of funding, both at local and national level as in Points 5 and 6 above.)
Posted by Rosalind Hughes, Founder, Just Caring Legal, on 05/02/2025
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