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In a Nutshell... If the patient has undergone the main NHS Continuing Healthcare (CHC) assessment and the multidisciplinary team (MDT) responsible for completing the Decision Support Tool (DST) has determined that they are ineligible for funding, you have the right to challenge this decision through the formal appeal process. The appeal process provides individuals with the opportunity to dispute the outcome and ensure that their case is thoroughly reconsidered. The appeal process typically involves four distinct stages. These stages allow for increasing levels of scrutiny, with the possibility of escalating the appeal if necessary. Read more below. |
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1️⃣ Informal Discussion
At the beginning of the appeal stage, the local Integrated Care Board (ICB) will attempt to resolve concerns through an informal discussion between the individual found ineligible for funding and/or their representative, and an ICB representative. This step aims to address issues without escalating to the next stage. If the decision remains unchanged, you have six months to request a Local Resolution meeting. Upon receiving this request, the ICB has three months to review the decision. It can be helpful to understand the ICB’s reasoning at this stage, as it can guide the arguments for why the decision is incorrect, which will then be presented during the Local Resolution panel meeting. |
3️⃣ Independent Review Panel (IRP)
After an unsuccessful Local Review decision from the Integrated Care Board (ICB), you have six months to request an Independent Review Panel (IRP) appeal. The IRP is the next stage in the NHS Continuing Healthcare appeals process and is managed by NHS England (NHSE). The panel, which includes an independent Chair and experienced health and social care professionals, examines both the appeal and the ICB’s decision, ensuring the process was sound. Preparation is crucial, as the panel will review all relevant evidence, including the Decision Support Tool (DST) and Multidisciplinary Team (MDT) deliberations. The IRP allows the individual or their representative to contribute and receive independent clinical advice. |
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2️⃣ Local Resolution Meeting
The next stage in the appeal process is the Local Resolution meeting. This is for individuals who are dissatisfied with the outcome of the informal discussion or who choose to proceed directly to Local Resolution. Managed by the ICB, the Local Resolution meeting is a formal meeting where individuals can present their reasons for dissatisfaction. The ICB panel, typically composed of nurses and/or managers, will listen to the appeal and may adjust the levels of need on the Decision Support Tool (DST), potentially changing the funding decision to “eligible.” The meeting should conclude with a written record of discussions and agreed next steps. Professional support during this stage is crucial, as failing to secure funding can lead to continued care fees and a lengthy wait before the next appeal stage is processed. |
4️⃣ Parliamentary and Health Service Ombudsman
The final stage of the appeals process is the Parliamentary and Health Service Ombudsman (PHSO) stage. Appeals to the Ombudsman must be made within 12 months of receiving written notification of the outcome from the Independent Review Panel (IRP). While the Ombudsman cannot reverse the decision made by the Board or the Integrated Care Board (ICB), they can investigate procedural irregularities or failings that occurred during the earlier assessment processes. Specifically, the PHSO can examine how the IRP handled these irregularities and/or failings. Possible outcomes of an appeal to the PHS Ombudsman include recommendations for a re-assessment or the referral of the case back to the Board or ICB. It’s important to note that there are no set timescales for the Ombudsman to complete their investigation, and any re-assessment or re-referral will add considerable time to the overall length of the appeal process |
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