How do I challenge an NHS Continuing Healthcare refusal?

A refusal of NHS Continuing Healthcare is not final, and the appeal route is well trodden. Work through the stages in sequence — NHS England will not convene a panel before local resolution, and the Ombudsman will not look at it before both are exhausted.

The three stages

1. Local review by the ICB. Request it in writing, normally within three months of the decision letter. Ask at the same time for the completed Decision Support Tool, the checklist and the minutes of the multidisciplinary team meeting — you are entitled to them and cannot argue the case without them. The review should finish within three months.
2. Independent Review Panel through NHS England, chaired independently of the ICB, examining both the process and the eligibility decision.
3. Parliamentary and Health Service Ombudsman, which can investigate maladministration: no assessment offered, the wrong version of the tool used, unreasonable delay, or misapplication of the National Framework.

What actually changes a decision

Reviews turn on documentary evidence of daily reality: care home daily records and turn charts, incident logs of falls, choking, aggression or absconding, medication administration records showing frequent changes, GP and specialist letters written for the review, and your own diary of a typical week including nights.

Then attack the reasoning. The strongest and most common ground is that the multidisciplinary team applied the Decision Support Tool mechanically — adding up domain levels and stopping — rather than standing back and asking whether the nature, complexity, intensity and unpredictability of the needs together amount to a primary health need. That overall judgement is required by the National Framework, and a panel that never made it has misdirected itself. Other recurring grounds are exclusion of the family from the meeting, scoring from an out-of-date assessment, and treating needs as "social" merely because a care assistant rather than a nurse happened to meet them.

Throughout, you have the right to have a family member, carer or advocate present. Where the person lacks capacity and has nobody to speak for them, an Independent Mental Capacity Advocate must be instructed — a failure to do so is an error of law and a ground of challenge in itself. Free help is available from NHS Complaints Advocacy providers, Age UK and the CHC Alliance.

One point to hold on to: where an existing award is being reviewed, the care package must not be reduced or stopped while the process runs, unless there is an urgent safety reason. If it is, object in writing the same day — that is a separate and more serious failing than the eligibility decision.