Successfully Retaining NHS Continuing Healthcare Funding
A recent case shines a light on the difficulties that sometimes arise around retaining NHS Continuing Healthcare Funding.
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"A person's healthcare needs do not disappear simply because skilled professionals are managing them effectively. In J's case, successful care was not evidence of reduced need, and the NHS ultimately agreed."
The Situation
E contacted Winston Solicitors after NHS Continuing Healthcare (CHC) funding for her mother, J, came under threat following an annual review.
J had previously been found eligible for CHC due to the complexity, intensity and unpredictability of her healthcare needs, including severe cognitive impairment and complex diabetes requiring skilled nursing management. Previous NHS reviews had confirmed that eligibility should continue.
However, following a later annual review, the Integrated Care Board (ICB) sought to progress a further eligibility assessment. E was understandably concerned that J's long-standing CHC funding could be withdrawn despite there appearing to be little evidence that J's underlying needs had reduced.
Our Concerns
After obtaining and reviewing the available documentation, we identified what appeared to be a significant inconsistency.
The review documentation indicated that many of the key needs underpinning J's CHC eligibility remained substantially unchanged. Despite this, a fresh assessment of eligibility was proposed.
In our view, the evidence suggested that J continued to have significant healthcare needs which required ongoing monitoring, supervision and skilled intervention. The fact that those needs were being managed successfully by care home staff did not mean that the needs themselves had disappeared.
This distinction is often crucial in NHS Continuing Healthcare cases. Effective care can reduce the visible consequences of a condition without reducing the underlying need for skilled care and oversight.
How We Helped
We began by challenging the review process through the NHS complaints procedure.
On E's behalf, we obtained disclosure of the relevant documentation, analysed the review evidence and submitted detailed representations to the ICB. We argued that there appeared to be no clear evidential basis for a reassessment of eligibility and highlighted concerns regarding the review process that had been followed. As a result, the ICB investigated the concerns and agreed that the review should be set aside and repeated.
Importantly, the matter did not end there.
Having secured a replacement review, we worked closely with E to prepare for the new assessment. This included obtaining and analysing care records, reviewing the historical evidence surrounding J's eligibility and preparing detailed written representations for consideration by the ICB.
A key part of our case was demonstrating that the evidence did not show a genuine reduction in J's underlying healthcare needs. Instead, it showed that those needs continued to exist but were being managed effectively by skilled nursing staff. We argued that successful management of a condition should not be confused with an improvement in the condition itself.
As part of our specialist CHC service, we also attended the review meeting as E's advocate.
Advocacy at CHC reviews and assessments can be invaluable. By attending the meeting, we were able to ensure that J's needs were properly discussed, that relevant evidence was considered, and that E's concerns and observations were fully represented throughout the process.
The Outcome
Following the replacement review meeting, the ICB confirmed that J remained eligible for NHS Continuing Healthcare funding.
The outcome meant that J's package of NHS-funded care remained in place and avoided the potentially significant financial implications that can arise following the withdrawal of CHC funding.
Most importantly, the final decision reflected what E had believed throughout the process: that J's underlying needs had not reduced and continued to justify NHS Continuing Healthcare funding.
Why This Case Matters
Many families assume that there is little they can do once an NHS Continuing Healthcare review recommends further assessment.
In reality, the review stage itself can be one of the most important points in the entire process.
The National Framework anticipates that, in most cases, reviews should focus on whether existing care arrangements remain appropriate. A full reassessment should only follow where there is clear evidence of a material change in needs. Where a review has failed to properly apply that principle, early intervention may prevent an unnecessary reassessment from taking place in the first place.
Once a case progresses to a full Decision Support Tool (DST) assessment, families can find themselves in a much more difficult position. They may be trying to persuade assessors that eligibility should continue when concerns have already been raised about whether the individual's needs still justify NHS Continuing Healthcare funding.
In E and J's case, the focus was about challenging the review process at an early stage, ensuring the evidence was properly considered and preventing inappropriate conclusions being drawn from the fact that J's needs were being managed effectively by skilled professionals.
By obtaining specialist advice early, E was able to challenge the proposed course of action before any change was made to J's funding arrangements. Through evidence gathering, written representations and advocacy at the review meeting itself, we helped secure a fair reassessment of the position and ultimately preserve J's entitlement to NHS Continuing Healthcare funding.
This case demonstrates that timely specialist support can sometimes make the difference between retaining NHS Continuing Healthcare Funding and becoming involved in a lengthy and costly dispute about restoring funding after it has already been lost.
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*All names changed for anonymity
