NHS Continuing Healthcare: How to appeal a decision

Paying for a care home in the UK can be very expensive, with some forced to sell their homes to pay for care.  So being awarded NHS Continuing Healthcare (CHC) which covers the full cost of your health and social care can make a huge difference.

It’s estimated 77% of adults over 45 are not aware of NHS Continuing Healthcare, and for those who do know about it, only around 33% of applications are accepted. Whether this is down to a lack of understanding amongst healthcare professionals or the complex application form, it means many people are missing out on the support they are entitled to. 

In most cases, funding runs completely smoothly and those eligible will receive the support they are entitled to. However, in some cases people are missing out on financial support due to mistakes that are out of their control. Or they are simply not aware of the help available. 

What is NHS Continuing Healthcare?

NHS Continuing Healthcare (CHC) is a care package available to people in England, Wales and Northern Ireland with primary health needs. It is not means tested. So it doesn’t matter what amount of money, savings or capital you have. If you are eligible, the NHS will cover the full cost of your health and social care.

NHS CHC can be used to fund care in a whole host of settings, including your own home and in residential or nursing care.

Who is eligible for NHS Continuing Healthcare?

If you have a ‘primary health need’, you’ll be entitled to funding through CHC. A primary health need is not defined by the condition itself, but rather how it impacts on your life. To be eligible, your health needs must be ongoing and impact your day-to-day life. 

Does NHS Continuing Healthcare cover dementia?

Because the decision to award CHC isn’t based on a specific condition, it’s not possible to give a definitive yes or no answer as to whether a person living with dementia will qualify for the funding. The decision will be based on how dementia affects the type and level of care a person needs.

The most important thing is to make sure you, or a loved one, have received a formal diagnosis of dementia. Many symptoms of the condition, especially in the earlier stages, are primarily linked with social needs, such as maintaining independence and relationships. A diagnosis will make sure that the impact dementia has on your health care needs is properly acknowledged, improving the likelihood of being awarded CHC. 

Why are people missing out on NHS Continuing Healthcare?

Whilst many people have been awarded CHC without a problem, there have recently been a worrying amount of reports of people, particularly those living in care homes, being incorrectly assessed by the NHS and missing out on the funding they are entitled to.

This has resulted in families unnecessarily paying out for care home fees despite them being eligible for 100% funding. At a time when most households are facing financial pressures, this has undoubtedly led to a huge amount of stress and hardship which could have been avoided.

There are a number of reasons this could be the case, including the rigorous application process and the complex NHS Continuing Healthcare assessment.

‘Process can be lengthy and complicated’

Stephen Lowe, group communications director at Just Group, a retirement specialist, says:

“Continuing Healthcare was introduced to provide financial support for people suffering from ongoing significant physical and/or mental health needs. However, the system has been dogged by a low level of understanding among patients and health professionals, a complicated application and assessment process, and a postcode lottery on implementing the framework. 

“It is little wonder that the package has remained the NHS’ best kept secret despite the enormous potential value of a successful application.”

If you have not yet applied for CHC and think you could be eligible, Mr Lowe offers the following advice:

“Continuing Healthcare provides an important and highly valuable safety net for people. Given the significant sums of money at stake it’s certainly worth applying for, but the process can be lengthy and complicated. 

“People applying will often find themselves navigating a labyrinthine system when they’re already emotionally stretched, so it’s worth consulting a professional care adviser who understands the system and can help fight your corner.”

How to appeal NHS Continuing Healthcare assessment

If you think you, or a loved one, are eligible for NHS Continuing Healthcare and have had an application rejected or have not received funding, it is possible to claim back your entitlement retrospectively. 

If you have had an application rejected and disagree with the outcome, the first step should be to appeal the process. You can do this by speaking to the NHS Continuing Healthcare team, whose contact details you should have been provided during your application or assessment. 

To be successful, you will need to prove that you, or your loved one, are/were eligible for CHC. In most cases, you will be able to claim for a back payment of up to a year. 

However, you may be able to claim further back if one or more of the following applies:

• You were never told about NHS Continuing Healthcare
• You were not informed about the appeals process
• You were misled about the funding

You have six months to appeal

If you are appealing a decision, you have around six months from the date your claim was rejected to begin your appeal. 

You should bear in mind that medical records will be assessed if you go ahead with an appeal. Although the appeals process does go through the NHS and not the Courts, it could be worthwhile to speak to a solicitor who can act on your behalf.

Lisa Morgan manages the care home fee recovery team at Hugh James Solicitors.

She says “Integrated Care Boards (ICB) in England will review unassessed periods of care back to April 2012. The authority will look back at someone’s care needs in the past to decide whether they should have received CHC care at the time. This is the case even if the person in care has since died. 

She warns: “Challenging Continuing Healthcare can be a hard and long slog. However, the Department of Health statistics show that 22% who challenge at ICB level are successful, with a further 30% at national level.“

Family of Kathleen Pearson refunded £40,000 

Hugh James Solicitors, successfully appealed in the case of Kathleen Pearson.

“Kathleen Pearson, the late mother of Paul Pearson, suffered from Alzheimer’s in the last few years of her life. She was moved to a care home where her son Paul and his wife Jill were told she would have to self-fund the care costs.

“Mrs Pearson’s health continued to deteriorate whilst in care and was unable to communicate, was totally dependent on staff for all activities of daily living, such as continence care, skin care and administration of medication. She demonstrated resistive and challenging behaviour. 

“The family requested a current assessment, but it was not forthcoming. Mr and Mrs Pearson contacted us and we proceeded with the current assessment and a retrospective review. Following significant delays, Mrs Pearson was deemed eligible, and the NHS met her ongoing care fees, which meant she did not pay the £2,500 per month in care fees. 

“A retrospective review was also completed and following a number of appeals, it was agreed Mrs Pearson had been eligible for NHS Continuing Healthcare for a year and refunded her estate over £40,000 in wrongly paid care fees and interest,” says Lisa Morgan.

Hugh James Solicitors offers families a choice of a ‘no win no fee’ Contingency Fee Agreement and an hourly rate basis. 

“The Contingency Fee Agreement is popular with our clients as it provides certainty; they know exactly what will be charged if we win the case and it makes no difference how much time is spent pursuing the claim to a successful conclusion. In addition, there is peace of mind that if they pursue the claim and lose, they do not pay us anything.”