How do I appeal an NHS Continuing Healthcare funding decision?

Appealing an NHS Continuing Healthcare decision can be time-consuming (people can wait for months, or even years) and very distressing for individuals and their families.

The appeals process can appear extremely complex especially as the lack of guidelines in the National Framework means that Integrated Care Boards (ICBs) conduct appeal hearings in very different ways across the country and there is a lack of information available to patients to help them through the process.

Worryingly, this lack of guidance has resulted in 55% of professionals surveyed by the CHC Alliance, (a group of 13 organisations who believe NHS Continuing Healthcare needs to improve) revealing that they didn’t feel confident enough in their own knowledge to offer people information or advice regarding the appeal process.

The Alliance has also reported that many of the people they have contacted took the decision not to appeal the decision “not because they feel the decision was correct, but because they are too distressed and exhausted to go through the complex appeals process.” (page 17, CHC Alliance’s ‘Continuing to care? Is NHS continuing healthcare supporting the people who need it in England?’ report).

Our advice is to always use an expert to guide you through the process. The process for securing continuing healthcare funding can be challenging and many individuals without experience in the area struggle to deal with it themselves. In these circumstances the assistance of an expert with experience relating to NHS Continuing Healthcare can pay dividends.

If you do not agree with the decision that has been reached by the NHS panel, then the decision can be appealed.  This must be backed by evidence to support why you feel that the decision reached was flawed.

There are several options available to you:

1. Initial Checklist assessment

Bear in mind, if you don’t get through the initial Checklist, whilst you are unable to appeal the outcome, you can request that another Checklist assessment is undertaken by asking the ICB to reconsider its decision.

If the decision remains the same after the ICB has reconsidered it, you have the right to access the NHS complaint procedure. This is a 2-stage process which consists of:

• Sending a written complaint to the ICB detailing the reasons you feel entitled to a full assessment and why you disagree with the Checklist outcome. You should provide as much evidence as possible and specify which areas of need (domains) you disagree with. (A PDF of an example checklist is available here).
• If the ICBs response leaves you dissatisfied, you can refer your complaint to the Parliamentary and Health Service Ombudsman.

2. Decision Support Tool

If you are denied funding at the full Decision Support Tool stage, you can submit an appeal, in writing, to your local ICB who undertook the assessment.  These details should be provided to you in the outcome letter you receive that sets out the negative funding decision following the continuing healthcare funding assessment. You must list all your reasons – with evidence – for disagreeing with the decision to deny continuing healthcare funding.

The basis for appealing a decision can be either that the procedural process was not correctly followed, and / or the evidence was incorrectly weighed against the levels of need awarded, and the wrong decision was reached based on this evidence i.e. the patient’s needs are complex, intense, and / or unpredictable in their nature and as such are primarily health needs.

3. Local Dispute Resolution process

Should the Local Dispute Resolution process uphold the ‘ineligible’ decision, the next step is to request an Independent Review Panel to be convened at regional level.

4. Independent Review

If the Independent Review also finds you ineligible for funding, you can request NHS England undertake an appeal and convene an independent appeal panel.  If you remain dissatisfied with the outcome following NHS England level you may approach the Parliamentary and Health Service Ombudsman for a case review and / or a full independent investigation.

Once you receive the letter informing you of the ICB’s decision you have six months from the date of the letter to initiate an appeal and request a review of the decision. The ICB has a further three months from the date of your request to undertake this appraisal and complete the local review stage. It is worth noting however that this process can take up to a year to complete, the time it takes varies greatly across geographical locations.

When the local review stage has been completed, you have a further six months from the day you are notified to request an Independent Review Panel (IRP).

Within three months of your request for a review, NHS England should convene the Independent Review Panel. At the IRP, three decision makers must work together to decide on the outcome of your appeal. The panel should be headed by an independent Chair and should also include a health and a social care professional who must not be from the same ICB who made the initial decision.

We have witnessed first-hand how NHS Continuing Healthcare assessors consistently try to downplay and underscore obvious health needs and re-categorise them as social care needs.

Clients inform us that they have spent many upsetting hours in continuing healthcare assessment meetings disputing the difference between health and social care needs with assessors determined to withhold funding. Many clients ultimately receive the news that their relative doesn’t qualify for funding as their need for care isn’t health based despite clear evidence in the form of medical records and care plans to the contrary.

The desire to withhold funding shouldn’t come as a surprise, as it allows the NHS to pass responsibility for funding care to the local authority, where the person will be means tested and then, if they exceed the funding threshold of having assets over £23,250, told they must self-fund their care. But, by its very essence, medical services provided by the NHS are free to residents in the UK so if there is a clear healthcare need, care should be provided for free.

Click on the video below to watch ‘What can you do if you don’t agree with the CHC assessment outcome?’