Refused CHC funding? What to do next

What should I do first after a CHC refusal?

Start by working out which decision you are challenging, because the route depends on it. If the screening itself came back negative, meaning a full assessment was refused at the Checklist stage, you can ask the ICB to reconsider. The guidance says the ICB "should give this request due consideration, taking account all of the information available, and/or including additional information from the individual or carer, though there is no obligation for the ICB to undertake a further Checklist" (Checklist guidance, paragraph 25). If the person has since had a full assessment and the ICB has decided they are not eligible, the ladder on this page applies. If NHS Continuing Healthcare itself is new to you, our guide to what NHS Continuing Healthcare is explains the funding and the process from the start.

Before you write a single line of challenge, get the papers the decision was built on. Ask the ICB for the completed Decision Support Tool, the multidisciplinary team's recommendation and the rationale behind it, and the care records the team relied on: care plans, medication charts, falls records, district nurse notes and anything from the GP or hospital. The refusal letter itself should tell you how to challenge it. The Framework says the ICB "should also explain the arrangements, and timescales, for dealing with a request to review an eligibility decision where the individual or their representative disagrees with it" (National Framework, page 67). If your letter does not, ask for that information in writing.

Here is the ladder in one view.

How does local resolution work?

Local resolution is the first formal step, and every ICB is required to offer it:

"All ICBs must have an NHS Continuing Healthcare local resolution process. They should therefore develop, deliver and publish a local resolution process that is fair, transparent, includes timescales."

National Framework, page 67

There is no national deadline for asking for local resolution. Each ICB publishes its own process and its own timescales, and the Framework says ICBs "should deal with requests for review in a timely manner" (National Framework, page 67). So the two documents that govern this stage are your refusal letter and your ICB's published local resolution policy. Find the policy on the ICB's website, note any time limits it sets, and put your request in writing early rather than waiting on a limit you have not confirmed.

A strong local resolution request is specific. Go through the completed Decision Support Tool domain by domain and say, for each disputed domain, what level was given, what level the written descriptor supports, and which records show it. Point at needs the assessment scored low because good care keeps them quiet, at fluctuation the assessment day did not show, and at records the team never saw. A letter that names domains, levels and evidence gives the ICB something concrete to review.

What is the Independent Review Panel?

If local resolution does not settle the matter, the case can leave the ICB. The Framework says that "where it has not been possible to resolve the matter through the local resolution procedure, the individual may apply to NHS England for an independent review of the decision" (National Framework, page 68). NHS England can refer a case back for further local resolution first, or take it straight to review where local processes "would cause undue delay" (National Framework, page 68).

The panel's remit is narrow, and it is worth reading before you apply. It reviews two things only:

"(a) the primary health need decision by an ICB; or (b) the procedure followed by an ICB in reaching a decision as to that person's eligibility".

National Framework, Annex D, paragraph 2

It does not cover the content of the eligibility criteria themselves, the type or location of a care offer, the content of an alternative care package, or the treatment and services the person received. Those complaints go through the NHS complaints procedure instead (National Framework, Annex D, paragraph 4). NHS England's public guide adds two more exclusions: an ICB's refusal to consider a request for a full assessment after a negative Checklist, and the calculation of a redress payment (Independent Review guide, page 2). NHS England may also decline to convene a panel at all, and it expects to do that only "where the individual falls well outside the eligibility criteria" (Annex D, paragraph 11).

The application form must go back within six weeks. NHS England's guide does not state which event starts the six weeks, so check the form you are sent for the date it names, and treat that date as firm.

The application form also carries a rule that catches many families out. NHS England's guide says: "This is your final opportunity to provide further information and you cannot introduce additional information at a later stage in the process" (Independent Review guide, page 4). New evidence is admissible "only ... if it would be reasonable to have expected the ICB to have obtained and/or considered this evidence when conducting your assessment and making its decision, but it failed to do so" (page 4). So the form is the moment to put in everything that matters, organised and complete.

On timing, NHS England's own guide says "the process typically takes three-to-six months" (Independent Review guide, page 5). Individual cases can run shorter or longer than that.

Can I go to the Ombudsman?

Yes, after the independent review stage. The Framework states the route:

"Following an independent review panel, if the original decision is upheld but there is still a challenge the individual has the right to make a complaint to the Parliamentary and Health Service Ombudsman."

National Framework, page 70

The Framework states no time limit for taking a complaint to the Ombudsman. The Ombudsman applies its own rules on when it will accept a complaint, so check those rules on the Ombudsman's website before you rely on any timescale, and complain sooner rather than later.

What arguments actually matter?

Eligibility turns on whether the person has a primary health need, judged through the twelve domains of the Decision Support Tool and the four characteristics of need. Our guide to the CHC eligibility criteria walks through that test in full. At the challenge stage, three arguments from the Framework's own text do most of the work.

The first is well-managed needs. Needs that are met by good care can look small on the day of an assessment, and the Framework closes that gap directly:

"The decision-making rationale should not marginalise a need just because it is successfully managed: well-managed needs are still needs. Only where the successful management of a healthcare need has permanently reduced or removed an ongoing need, such that the active management of this need is reduced or no longer required, will this have a bearing on NHS Continuing Healthcare eligibility."

National Framework, page 51, paragraphs 162 to 166

If a domain was scored low because carers, equipment or medication keep the need under control, that is the paragraph to quote, next to the records that show what the care actually involves.

The second is the four characteristics: nature, intensity, complexity and unpredictability. Nature covers what the needs are and the type of interventions they require. Intensity covers how much support they take and how continuously. Complexity covers how needs interact and the skill required to manage them. Unpredictability covers fluctuation and the risk if timely care is missing (National Framework, pages 23 to 24, paragraph 60). The Framework adds: "Each of these characteristics may, alone or in combination, demonstrate a primary health need, because of the quality and/or quantity of care that is required to meet the individual's needs" (National Framework, page 24). A challenge that maps the person's real days onto those four words speaks the language the panel must use.

The third arises when the decision went against the assessment team's own recommendation. The Framework is direct about how rarely that should happen:

"Only in exceptional circumstances, and for clearly articulated reasons, should the multidisciplinary team's recommendation not be followed."

National Framework, "Decision-making on eligibility for NHS Continuing Healthcare by the ICB", page 54

It adds that an ICB should not reject a recommendation simply because its own decision makers would have reached a different view on the same evidence. If the records you requested show the multidisciplinary team recommended eligibility and the ICB decided otherwise, ask in writing for the exceptional circumstances and the clearly articulated reasons. If they are missing, say so in the local resolution request.

For evidence, the Framework names the tool itself: "It may be necessary to ask the provider to complete a detailed diary over a suitable period of time to demonstrate the nature and frequency of the needs and interventions, and their effectiveness" (National Framework, page 51). Ask the care provider to keep that diary, and keep your own alongside it. Short, dated, factual entries showing what happened, how often and what the carers had to do carry more weight than general statements. If you want a structured picture of where the case stands first, our free screener asks 18 plain-English questions about the same areas of care and takes about three minutes.

What about the costs while we challenge?

Care must not simply stop because a decision is disputed. The Framework's core principle is this:

"There should be no gap in the provision of care. People should not find themselves in a situation where neither the NHS nor the relevant local authority (subject to the person's means and the person having needs that fall within the eligibility criteria for care and support) will fund care, either separately or together."

National Framework, page 22

The same principle holds while an independent review is pending: "No individual should be left without appropriate support while they await the outcome of the review. The eligibility decision that has been made is effective while the independent review is awaited" (Annex D, paragraph 12). In plain terms, the refusal stands while you challenge it, so the current funding arrangement, whether that is council funding or self-funding, continues until a review changes the decision.

There is one refund rule to know about, and it concerns delay rather than the refusal itself. The Framework expects the time from the ICB receiving a positive Checklist to its eligibility decision not to exceed 28 calendar days in most cases (National Framework, page 55). Where the ICB took longer without justification, the person is later found eligible, and the person or the council paid for care in the meantime, the ICB "should ... refund directly to the individual or the local authority, the costs of the services from day 29" of that period up to the date of the decision (Annex E, paragraph 9). The refund is due unless the ICB can show the delay came from circumstances beyond its control, such as waiting on third-party records. Disputes about that redress go through the NHS complaints process rather than the Independent Review Panel (Annex E, paragraph 20). So if eligibility is later established on review, check the dates and raise the refund.

Running this ladder means records requests, a domain-by-domain case, deadlines tracked across months and letters that cite the Framework accurately. Some families do all of it themselves. If you would rather share the load, our Case Manager runs this process with families, step by step, with every letter grounded in the Framework's own words. This page is legal information, not legal advice.