CHC appeal process: what happens after a refusal
If your local Integrated Care Board (ICB) refuses NHS continuing healthcare (CHC), it can leave you with uncertainty about funding, timescales and what your options are. The CHC Appeal process is the formal route for challenging that funding decision and is usually relevant where the assessment did not reflect the evidence, the National Framework was not applied correctly, or needs were treated as social care when they were primarily health needs.
A CHC appeal is not always necessarily the right step, and if the refusal is clearly supported by the records, you may decide not to pursue it. However, if the decision letter does not reflect what is actually happening day to day with your loved one’s care, the appeal process for CHC funding may be the appropriate route.
In this blog, we’ll explore what happens during the CHC appeal process, and the support available to you:
What Is the CHC Appeal Process?
The CHC appeals process is initiated after an ICB refuses NHS CHC funding following a full assessment.
CHC is intended for those whose needs are primarily health-related, with eligibility determined under the National Framework for NHS CHC and NHS-funded Nursing Care, using evidence gathered from health and care records, and assessed using the Decision Support Tool (DST).
A decision of ineligibility ICB has decided your relative does not meet the eligibility criteria at that time, based on the evidence provided. The outcome letter should confirm the decision, enclose a copy of the completed Decision Support tool which sets out the rationale, explain how to request a review of the decision and confirm the deadline.
Families have the right to challenge a funding decision and ask the ICB to reconsider whether it followed the correct process, and whether the evidence supports its conclusion.
Does CHC Continue During the Appeal Process?
If CHC funding was refused, payment will not begin simply because you are appealing. Usually, you need to continue funding care through private payment, local authority arrangements, or other support options available to you while the appeal is ongoing.
If CHC was previously in place and then withdrawn, it can be more complicated.
In some cases, temporary arrangements might be made while the dispute is being considered, but you should not assume this will happen. You must ask the ICB, in writing, what decision has been made about interim funding, what will be paid and from what date, and what happens if the appeal later succeeds. Be sure to keep clear records of invoices and correspondence throughout.
Step-by-Step: The Appeal Process for CHC Funding
The appeal process for CHC funding usually follows set stages, although the wording my differ depending on your local ICB.
Review of the Decision Support Tool (DST)
You should receive a copy of the completed DST with the outcome letter. This document will be essential to your appeal so if you don’t have a copy, make sure to request one without delay.
The DST is often where issues arise, as errors can occur where needs are understated, risks are minimised or language in the DST does not reflect the realities of day-to-day nursing care. A strong appeal is grounded in evidence: you will need to obtain copy of the care and GP records and use these to demonstrate why the information in the DST is incorrect or incomplete.
Review the DST carefully, making note of anything you believe is incorrect, with reference to the relevant records.
Lodge your Appeal
You have six months to challenge the decision from the date on the outcome letter; this timeframe is statutory. Some ICBs will attempt to impose a shorter deadline but this is incorrect and should be challenged. Make sure to check the wording on the outcome letter and contact the ICB immediately if the deadline is shorter than 6 months.
Local Resolution
There are two stages to the appeal process: Local Resolution (ICB) and Independent Review (NHS England); almost without exception, you must go through Local Resolution before requesting Independent Review.
The National Framework advises ICBs to devise their own processes for dealing with appeals locally. As such, each ICB has a slightly different local resolution policy.
Generally speaking, almost all ICBs now have a two-stage local resolution process: Stage 1 is an informal meeting, which does not have the power to alter the decision; stage 2 is a formal meeting, which can overturn the decision
A local resolution meeting is often the first formal stage, and its purpose is to look again at the refusal and consider whether the decision was reached fairly, in line with the National Framework. Here, you can raise concerns about missing evidence, factual inaccuracies or reasoning that does not match the records. This stage should result in a written response.
Independent Review Panel (IRP)
If local resolution doesn’t resolve the dispute, you can request an Independent Review by NHS England, which convenes a panel called an Independent Review Panel, or IRP. The IRP considers whether the National Framework was properly applied and whether the decision-making process was fair and reasonable, based on the evidence available.
What Happens at an Independent Review Panel (IRP)?
An IRP considers whether the ICB followed the correct process and applied the eligibility criteria correctly, in accordance with the Framework. The panel is always chaired independently and includes experienced health and social care professionals who are independent of the ICB that made the original decision.
You can submit written evidence, including care home records and relevant clinical documents. Possible outcomes include the original and relevant clinical documents being upheld, or a recommendation that CHC should have been awarded.
Do You Need Professional Support With a CHC Appeal?
You can pursue the CHC Appeal process yourself, but it is evidence-heavy and tightly linked to how the National Framework is applied in practice. At Farley Dwek, we support families with clear CHC appeals advice and representation, working closely with experienced former NHS nurses to strengthen how the evidence is presented.
We can also support families with MDT advocacy services.
For more information on how Farley Dwek can support you, please contact us on 0161 272 5222 or email help@farleydwek.com.
FAQs
How Long Does the CHC Appeals Process Take?
Timescales can vary by ICB, the complexity of the issues and how quickly evidence can be obtained and reviewed. Local resolution can take months, and if the case proceeds to an IRP, it can take even longer.
Why has CHC funding been denied?
CHC is refused because the ICB concludes that the primary need is not for healthcare. However, this may be because the DST is inaccurate, the criteria have been improperly applied, or the care records do not clearly capture day-to-day risks and interventions.
