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This is one of the most common questions families ask, and the honest answer is that it is harder than it should be, but not as hard as the NHS sometimes makes it appear. NHS Continuing Healthcare is a legal entitlement. It is not a discretionary fund or a benefits payment. If a person meets the clinical criteria, the NHS is legally required to fund their care. The difficulty is in getting that eligibility recognised. Why is NHS Continuing Healthcare difficult to obtain? Several systemic factors make NHS Continuing Healthcare applications challenging for families approaching the process alone: Assessments are conducted by NHS and local authority staff who work under budgetary pressure. Research consistently shows variation in how NHS Continuing Healthcare criteria are applied across different Integrated Care Boards (ICBs). The assessment uses complex clinical language and a structured framework that most families are not familiar with. It is easy for needs to be underscored by people who did not observe them day to day. Families are rarely told that they have the right to be present at the assessment, to contribute evidence, or to challenge the outcome. The process can take weeks or months, during which the person's care costs continue, creating financial pressure that pushes families toward accepting an unfair refusal. How many people are refused NHS Continuing Healthcare? A significant proportion of NHS Continuing Healthcare applications are refused at first assessment. However, a substantial number of those refusals are overturned on appeal. This tells us that a large number of people who qualify for NHS Continuing Healthcare are being incorrectly turned down at the first stage. The challenge is that many families accept a refusal without questioning it, either because they do not know it can be challenged, or because the appeals process feels daunting. What makes an NHS Continuing Healthcare application more likely to succeed? The single most important factor is whether someone is present at the assessment who understands the clinical framework and can ensure that the person's needs are presented accurately. This is typically a nurse advocate. Preparation also matters significantly. Gathering evidence (care records, GP letters, carer logs, assessments from community nurses) before the assessment, and knowing which domains are likely to be scored and why, can meaningfully change the outcome. Many NHS Continuing Healthcare refusals contain errors. Domains may have been scored too low, clinical evidence may not have been considered, or the unpredictability of the person's condition may have been underestimated. A nurse advocate can review the decision and advise whether there are grounds for appeal.

To qualify for NHS Continuing Healthcare, a person must be found to have a primary health need. The NHS National Framework sets out four specific criteria used to determine whether that primary health need exists. These four criteria are: nature, intensity, complexity, and unpredictability. A person does not need to meet all four. Meeting one, or a combination, at a sufficient level can be enough to establish eligibility. The assessors look at the overall picture. 1. Nature Nature refers to the type of care that is required. If a person's care needs require a level of clinical oversight, such as management of medications, complex wound care, or professional nursing intervention, this points toward a primary health need. The question is whether the care being delivered is primarily health-related, not just personal or social care. A person who requires frequent and skilled nursing input has a care need that is clinical in nature. 2. Intensity Intensity refers to the frequency, scale, and continuity of care required. A person who requires a large number of interventions across a 24-hour period, or whose care needs must be met continuously rather than at scheduled intervals, scores on intensity. This criterion captures situations where care needs are so frequent or constant that they cannot be met by a standard home care package or social care arrangement. 3. Complexity Complexity recognises that some individuals have multiple conditions or needs that interact with each other in ways that are difficult to manage. The interplay between conditions (for example, severe dementia combined with mobility problems, dysphagia, and behaviour that challenges) creates a level of complexity that requires skilled, co-ordinated clinical input. A person with a single straightforward condition may not score on complexity. A person whose conditions interact, escalate each other, or require careful balancing of different clinical interventions is likely to meet this criterion. 4. Unpredictability Unpredictability refers to the degree to which a person's needs fluctuate in ways that are difficult to anticipate and that could place the person, or others, at risk if not managed promptly and skillfully. This criterion is frequently underscored in assessments. A person who appears relatively settled on the day of their assessment may nonetheless have needs that are highly unpredictable. Episodes of acute distress, sudden deterioration, seizures, falls, or severe behavioural episodes all speak to unpredictability, even if none of these occurred during the assessment visit. How are these criteria applied? These four criteria are considered alongside the 12 domains of the Decision Support Tool (DST). The assessors look at the scores across all domains and ask whether, taken together, they establish a primary health need. Understanding how these criteria apply to a specific person's situation, and being able to articulate that case clearly in the assessment, is one of the most valuable contributions a nurse advocate can make.

The NHS Continuing Healthcare Checklist (formally known as Tool 11) is the first stage of the NHS Continuing Healthcare assessment process. It is a screening tool, not the full assessment, but it is one of the most important steps a family will face. What is the Checklist for? The Checklist is used to decide whether a person should proceed to the full Decision Support Tool (DST) assessment. A healthcare or social care professional completes it, usually a nurse, social worker, or occupational therapist. If the person scores above a set threshold, they are referred for a full NHS Continuing Healthcare assessment. If they do not, NHS Continuing Healthcare is declined at this stage, without any further review of their needs. What does it assess? The Checklist looks at 11 areas of need: Breathing Nutrition (food, drink, and swallowing) Continence Skin integrity (including wounds and pressure areas) Mobility Communication Psychological and emotional needs Cognition Behaviour Drug therapies and medication Altered states of consciousness Each area is rated as either None, Low, Moderate, High, or Priority. The overall pattern of scores determines whether the person progresses to the full assessment. When should the Checklist be done? The Checklist should be completed within 28 days of a referral. It can be triggered by a healthcare professional, a GP, a social worker, or by the family requesting it directly. Families can (and should) request an NHS Continuing Healthcare Checklist if they believe their loved one's needs may meet the threshold. A referral can be made directly to the Integrated Care Board (ICB) responsible for the area. What happens at the Checklist meeting? The Checklist is usually completed during a meeting or visit with the person being assessed. A family member or representative has the right to be present and to contribute information about the person's care needs. This is important. Professionals completing the Checklist often do not have a full picture of the day-to-day reality of a person's needs. A family member (or a nurse advocate) can ensure that the full picture is presented, not just what is recorded in clinical notes. Can the Checklist be challenged? Yes. A Checklist decision to screen someone out can be challenged. If the scoring does not reflect the person's actual needs, or if needs have been underestimated, there are grounds for review. Many families are incorrectly screened out at the Checklist stage. This is one of the most common points at which an experienced nurse advocate makes a critical difference to the outcome.

Yes, a Personal Health Budget (often called a PHB) is an alternative way of managing CHC-funded care. Instead of the NHS organising and paying for care directly, the person (or their representative) manages a budget and arranges their own care (as long as it meets agreed outcomes). A PHB gives families more control over who provides care, when, and how. However, budgets are sometimes set too low to actually meet the person's needs. If you are already in receipt of CHC funding and believe your PHB is insufficient, SG67 can review it.

Fast Track CHC is an urgent pathway that bypasses the standard two-stage assessment process. It is designed for situations where a person is rapidly deteriorating or approaching end of life (and cannot wait weeks for a full DST assessment). A clinician (typically a GP, consultant, or nurse) can complete a Fast Track Pathway Tool. If approved, CHC funding can be put in place within days rather than weeks. In cases where this pathway is used correctly, it can be the difference between a person spending their final weeks in an appropriate, fully funded care setting (or not). Who Qualifies? Qualification is determined by an individual's care needs, not their specific medical diagnosis. To be eligible, a registered healthcare professional must certify that the person has a rapidly deteriorating condition that may be entering a terminal phase. Examples: It is frequently used for individuals with terminal cancer, advanced dementia, or late-stage neurological diseases entering their final stages of life. Setting: The funding is not tied to a specific location and can be used to cover care in a hospice, care home, or at the individual's own home. View Fast Track CHC services by SG67 Health consultancy. Talk to an expert to learn more.

Yes, you can. There are three stages to a CHC appeal: 1. ICB Local Resolution: The first stage (a formal review by the ICB). This should be requested in writing, with supporting evidence addressing the specific reasons for refusal. 2. NHS England Review: If local resolution does not produce a satisfactory outcome, the case can be escalated to NHS England for an independent review. 3. Independent Review Panel (IRP): The final stage (an independent panel convened by NHS England). The panel's recommendation is not legally binding but carries significant weight and is rarely disregarded. SG67 manages the full CHC appeals process (from the initial challenge through to the Independent Review Panel). We prepare all written submissions, attend hearings, and keep you informed at every stage.

Yes. CHC funding is not restricted to care homes. If a person qualifies, the NHS will fund their care wherever it is delivered (including at home with community nurses, carers, and specialist support). The type of care funded depends on what is needed, not where the person lives. Many families are unaware that CHC-funded care at home is possible.

Funded Nursing Care (often shortened to FNC) is a lower level of NHS funding for people living in nursing homes who do not meet the full CHC criteria but do require registered nursing input as part of their care. The key differences are: NHS Continuing Healthcare (CHC): - Covers the full cost of care - Requires a primary health need to be established - Available at home or in a care home - Person pays nothing Funded Nursing Care (FNC): - Covers nursing element only (approximately £235/week, subject to change) - Does not require a primary health need - Nursing homes only - Person still pays remaining care home fees

No. CHC is not means-tested. A person's savings, property, income, or pension are completely irrelevant to CHC eligibility and to the amount of funding awarded. This is the most important distinction between CHC and local authority social care. If a person qualifies, the NHS funds their care in full (regardless of how much money they have).

Timelines vary significantly depending on the ICB and individual circumstances. In general: - The Checklist should be completed within 28 days of referral - The full DST assessment can take a further four to eight weeks from the Checklist outcome - The ICB's funding decision follows the MDT meeting In urgent situations (where a person is rapidly deteriorating) the Fast Track CHC pathway can bypass the standard assessment entirely and secure funding within days. Speak to an expert to know more.

The CHC assessment is a two-stage process. Most families are surprised to learn how structured (and how challengeable) it is. Understanding the process is the first step to navigating it effectively. Stage 1: The CHC Checklist (Tool 11) The Checklist (formally known as Tool 11) is a screening tool. A healthcare or social care professional completes it, looking at 11 areas of need: breathing, nutrition, continence, skin, mobility, communication, behaviour, cognition, psychological and emotional needs, altered states of consciousness, and symptom control. If the person scores above the threshold, they proceed to a full assessment. If not, CHC is declined at this stage (without any further assessment). Many families are incorrectly screened out at the Checklist stage because domains are under-scored or needs are not fully described. An experienced nurse advocate attending this meeting can make a significant difference to the outcome. Stage 2: The Decision Support Tool (DST) If the person progresses past the Checklist, they move to a full multidisciplinary assessment using the Decision Support Tool (known as the DST). This is where eligibility is decided. The DST is a 12-domain assessment framework, reviewed by a multidisciplinary team (MDT) that typically includes nurses, social workers, and other health professionals. The 12 domains are: behaviour, cognition, psychological and emotional needs, communication, mobility, nutrition, continence, skin, breathing, symptom control, medication, and altered states of consciousness. Each domain is scored (None, Low, Moderate, High, or Severe) based on the person's needs. The overall picture determines whether a primary health need exists. The Integrated Care Board (ICB) (the NHS body responsible for CHC in your area) then makes the final funding decision based on the DST outcome.

To qualify for CHC, a person must be found to have a 'primary health need' - this is the legal test set out in the NHS National Framework for Continuing Healthcare. A primary health need exists when the care a person requires is primarily driven by their health condition - not just social or personal care needs. The assessment looks at four key factors: Nature What type of care is needed, and does it require clinical oversight — such as medication management, wound care, or clinical monitoring? Intensity How often does care need to be provided? How much care is needed at any given time? Is it continuous or episodic? Complexity How difficult is it to manage the person's care needs? Do they interact or make each other harder to manage? Unpredictability How difficult is it to predict when or how care will be needed? Do needs change rapidly and require immediate skilled response? A person does not need to score highly on all four factors. If any one of these characteristics is sufficiently severe or if the combination across several creates a picture of primarily health-related need — CHC eligibility may be established. Important: CHC is not just for people at end of life. Many families assume CHC only applies when someone is dying. This is incorrect. CHC can apply to any adult over 18 with ongoing, complex health needs (and it can be funded for months or years).