How to Appeal an NHS Continuing Healthcare Funding Decision

NHS Continuing Healthcare Funding (CHC Funding) decisions may not always go the way you or your relative were hoping. In fact, this time-consuming process can often put people off appealing at all.

It’s a difficult area to navigate because your approach depends on the circumstances of the assessment you are appealing and the particular Clinical Commissioning Group (CCG) which will be responsible for your appeal.

The National Framework for Continuing Healthcare provides broad guidelines to the CCGs as to how they should address appeals against NHS Continuing Healthcare Funding decisions, such as the need to offer a meeting with the appellate to discuss any concerns regarding the assessment. CCGs will nevertheless often have a local policy in place to achieve consistency in dealing with appeals.

Time Limits

It’s very important that you are mindful that there are strict time limits to exercise your right of appeal. National guidance indicates that the time limit is 6 months from the date of the decision letter you receive from the CCG. Some CCGs will seek to impose much shorter timeframes. Whilst this is improper and contrary to best practice, it is important that you address this with the CCG and we recommend seeking professional advice as soon as possible.

We offer an extensive service that provides complete clarity on how to go about the appeals process.

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How to Appeal an NHS Continuing Healthcare Funding Decision

Initial Checklist Assessment

As stated above, the Continuing Healthcare Funding appeal process depends on which stage you are at in your application. If you or your loved one has been turned down for NHS Continuing Healthcare Funding, you should receive a decision outcome letter which explains the reasons for the decision and provides details of your associated right of appeal and how to go about doing this.

The Continuing Healthcare Checklist is the first stage in determining whether an individual is entitled to free care. You cannot appeal to the outcome of this stage, but you have the right to access the NHS complaint procedure. This will consist of:

  • A written letter of complaint sent to the CCG, with the reasons why you feel you’re entitled to a full assessment. Make sure you provide as much evidence as you can at this stage and specify the areas you disagree with.
  • Once you have exhausted the NHS complaints process, you can seek out the assistance of the Parliamentary and Health Service Ombudsman.

Decision Support Tool

The Decision Support Tool is completed once the individual has passed through the Checklist stage and needs a full eligibility assessment.

The CCG should enclose with the decision letter a copy of the Decision Support Tool, so that you can see the basis for the assessment and decision taken.

Unfortunately, in our experience, some CCGs will fail to provide this and should this be the case, you must contact the CCG immediately to request a copy as without this document you will not be in a position to articulate proper grounds for appeal.

We always recommend that you communicate your appeal in writing. Make sure your letter confirms that it is to serve as an appeal and confirms the date of the Decision Support Tool you are appealing.

You should always set out your reasons for making an appeal in as much detail as possible. If you can’t include everything, for example, because you are still waiting for more information, state this in your letter and confirm that you reserve your right to make further representations once you have received the relevant information or evidence.

You should give consideration to:

  • Why you are unhappy with the decision
  • Whether you feel any of the needs in the Decision Support Tool have been assessed too low
  • Whether you have any concerns over the way the assessment was handled. Were your views taken into account? Did the assessors look at all available evidence, such as care plans and daily care records?

Local Disputes Resolution

Before a Continuing Healthcare Funding appeal can be escalated further, the local dispute resolution process should be invoked to resolve the matter. CCGs operate differently depending on where you are geographically, and so each will have their own localised dispute resolution procedure.

Simpson Millar can represent you at this stage, helping you to evidence your claim in the best possible way.

Independent Review

Similarly, if your appeal has been unsuccessful with the CCG and you wish to make a final appeal to NHS England to ask for an Independent Review of the decision, it’s important that you reiterate any arguments to NHS England which have not been satisfactorily resolved.

NHS England will also want to hear about the process the CCG has followed and may ask you to provide a statement setting out your experiences of the process, as well as your views about the individual’s needs.

We can assist you with all aspects of NHS Continuing Healthcare appeals and will consider any evidence you have, both from the family and care provider in order to present your appeal in the best way.

Because we know the process, the law and relevant guidance we can advise you which arguments are best to focus on.

For more information see Tips for Attending Local Resolution Meetings and Independent Review Panels.

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