How do I challenge a refusal of NHS continuing healthcare?

NHS Continuing Healthcare pays for all of a person’s care, including care home fees, where their primary need is a health need. There is no means test and no capital threshold, which makes a wrong refusal extremely expensive for the family — and refusals are common enough that they should never be accepted without scrutiny.

The grounds that succeed

Eligibility turns on the primary health need test, assessed through a checklist and then a Decision Support Tool completed by a multidisciplinary team. Look for:

• Domain scores set too low against the evidence in care records, or the nature, intensity, complexity and unpredictability of needs not properly weighed.
• The wrong legal test — for example treating a diagnosis, a setting, or the fact that a need is "well managed" as decisive.
• A rushed assessment on hospital discharge. Where someone is not clinically stable enough for their long-term needs to be judged, the assessment should be deferred, not resolved against them.
• No independent advocate. Where the person lacks capacity and has no family or friends to represent them, an IMCA must be instructed — a failure is an error that can be raised in the complaint.

The escalation route

1. Local review by the ICB — request it in writing, within the timescale in the decision letter, setting out each disputed domain with reference to the records.
2. Independent Review Panel convened by NHS England.
3. The Parliamentary and Health Service Ombudsman, once the NHS process is exhausted.

Get the full assessment paperwork, care home daily records and GP notes early — challenges are won on contemporaneous evidence of what the person actually needed day to day.

Two things families often miss

Anyone can request a checklist assessment in writing to the ICB; you do not need a professional referral. And where care was paid for privately during a period when no proper assessment was carried out, a retrospective claim can recover those costs, in some circumstances reaching back to 2012 — though the further back it goes, the harder the evidence becomes. If funding is later reduced or withdrawn, the package must not stop before the review process concludes, except for urgent safety reasons.