Appealing a Negative CHC Decision: What You Need to Know!

So, you’ve attended a Multi-Disciplinary Team (MDT) meeting and the Decision Support Tool (DST) was completed by the Integrated Care Board (ICB). The 12 Care Domains were assessed, and you were presented with the four Key Characteristics used to determine eligibility for NHS Continuing Healthcare (CHC) funding.

Chances are, you didn’t agree with parts of the assessment—or maybe the whole decision not to award funding felt completely off the mark. You may have even turned to the National Framework for NHS Continuing Healthcare to try to make sense of it all. If you haven’t already, here’s the link: National Framework for NHS Continuing Healthcare (Updated July 2022)

Still feeling confused? You’re not alone.

CHC is complex, and even professionals say it takes many years of experience to fully understand. If you’re baffled by the terminology, the process, or how decisions are made—don’t worry. Most people feel exactly the same way.

What Happens After the MDT?

After the MDT, you should receive:

• A letter confirming the outcome, and
• A copy of the DST

⚠️ Tip: Always request a copy of the DST if one isn’t sent automatically. You’re entitled to it, and without it, you won’t know how the decision was reached. It’s usually sent via secure email, but you can ask for a printed copy if needed.

Thinking About Appealing? Here’s What You Need to Know

You have 6 months from the date of the decision letter to launch an appeal. Make a note of that deadline – miss it, and you may lose your right to challenge the decision. So, diarise carefully!

But don’t rush into it. Before starting your appeal:

• Gather evidence
• Learn as much as you can about the CHC process
• Read the National Framework (linked above), and
• Explore helpful resources (our Care To Be Different website has helpful guides for each Care Domain).

Useful documents include:

• Specialist letters and assessments
• Hospital discharge summaries
• GP records

The Two Stages of Appeal

1. Local Review (via your local ICB)
2. Independent Review (currently via NHS England but expected to change in the future).

Stage 1: Local Review

To begin, notify your ICB of your intent to appeal. They may send you a questionnaire before setting a date for a Local Review Meeting (LRM).

What to expect:

• The meeting is usually held via Microsoft Teams (but you can request an in-person meeting if necessary).
• You’ll meet with the local CHC team who made the original decision.
• You’ll be asked to explain:
  • Why you’re appealing,
  • Which care domains you disagree with, and
  • What evidence supports your case.

The language used in the DST can be technical and full of qualifiers, which can make it hard to tell whether the correct levels of need were applied. The ICB may argue for a lower level of need than is appropriate.

You’ll also need to comment on the four Key Characteristics, which form the crux of eligibility. These are typically found at the back of the DST.

This part of the process can be particularly tricky without in-depth knowledge of how the National Framework and DST are supposed to work. Without expert input, appeals at this stage often fall short as families are bamboozled by the NHS process and don’t understand what they need to do, or how to present their appeal, to be successful.

That’s where we come in.

We, and our associated company, Farley Dwek Solicitors, can guide you through the LRM from start to finish, handling the heavy lifting, research, and representation – giving you the best shot at success.

Stage 2: Independent Review

If the Local Review doesn’t go your way, don’t lose hope. You can escalate your appeal to NHS England via an Independent Review Panel (IRP).

The IRP is made up of:

• One representative from the local authority (not involved in your case),
• One from the NHS (but not your local ICB who completed the DST), and
• An independent chairperson.

This panel ensures your case is reviewed without local financial pressures or misinterpretations of the NHS National Framework. In some cases, a medical specialist may be brought in to offer additional input – though they won’t have a vote.

You’ll be invited to give your views and explain why the previous decision was incorrect. This can be daunting, especially without expert representation.

Important:

The IRP is your final opportunity to appeal within the NHS system. If we haven’t supported you at the LRM stage, we strongly recommend contacting a specialist in this area, such as Farley Dwek, as soon as possible after receiving the outcome, as they typically need at least six months to gather evidence, prepare detailed written submissions, and represent you effectively. This is an area that you cannot rush, however, wrong you feel the LRM decision was.

To mount a successful appeal, good preparation is essential and the longer you have to get your case together, the better. Don’t leave it until the 11^th hour otherwise, you may come unstuck when battling the skilled ICB’s advocate who will seek to staunchly defend their decision to refuse you funding.

We recommend you:

• Collate care and GP records
• Submit a comprehensive written appeal report to NHS England
• Attend the IRP meeting (or get a professional advocate if you can).

Still Not Successful? There’s One Final Option

If the IRP doesn’t uphold your appeal, you can escalate your concerns to the Parliamentary and Health Service Ombudsman (PHSO).

PHSO Complaint Info

However, the PHSO can only investigate procedural errors – not disagreements over clinical judgment. Given that much of CHC rests on clinical interpretation, this final stage offers only limited grounds for success.

That’s why we recommend you seek help as us as early as possible – ideally before the MDT stage, but certainly by the LRM or IRP stage.

Common Pitfalls to Watch Out For

CHC decisions can go wrong for many reasons, including:

• DST completed in the wrong setting (e.g., in hospital, or before someone has settled into new accommodation or adjust to new medication)
• Incorrect team members at the MDT (e.g., no family representative, missing social worker, no relevant specialist)
• Key evidence overlooked or lack of agreement between MDT professionals
• LRM upholding errors made by the MDT without proper scrutiny
• Needs not properly considered – either because they’re not being met or are being underestimated
• Limited opportunity for families to present their case

We come across new pitfalls regularly, so if something feels not right, it’s worth questioning.

The Bottom Line

CHC is a complex, often overwhelming process, especially when you’re already navigating the emotional and practical challenges of a loved-one’s care. But you don’t have to face it alone.

We know what makes a strong appeal and how to put your case forward in the most effective way possible. Whether you’re just starting out or you’re deep in the appeals process, we’re here to help.

Resources and Support

• The National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care
• Search ‘MDT’ on our Care to be Different website for more blogs and insights
• Buy our book: How To Get The NHS To Pay for Care
• Contact us:
  • ✉️ Email: enquiries@caretobedifferent.co.uk
  • Call: 0161 979 0430
  • Get professional advice from Farley Dwek Solicitors
  • ‍⚕️ Access our Nurse Advice Helpline