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Around 17% of those formally assessed are found eligible, down from roughly 31% in 2017/18. A great many refusals are overturned on review — but only if they are challenged properly, and in time.
The deadline that catches families out
Six months
An appeal against a Continuing Healthcare decision must normally be brought within six months of the decision letter. Miss it and that route can close. You cannot use a retrospective claim to make a late appeal — they are separate processes and only one has a deadline.
You ask the Integrated Care Board to review its own decision. Written representations, usually followed by a Local Resolution meeting. This is where most successful appeals are actually won, and where the evidence work matters most.
Convened by NHS England when local resolution does not settle it. The panel reviews both whether the correct process was followed and whether the eligibility decision itself was right.
Where the panel outcome is still disputed and there are grounds relating to maladministration or service failure.
Available in limited circumstances where a decision is unlawful, irrational or procedurally unfair. Strict time limits apply and it is rarely the first answer.
Weak appeals assert that every domain should be higher. Panels see that constantly and discount it. Strong appeals do something more disciplined: they identify the specific domains where the recorded score does not match the contemporaneous evidence, and they explain how needs interact.
That interaction point is where most cases are genuinely won. A person who cannot safely transfer is one thing. A person who cannot safely transfer and does not recognise that she cannot, and therefore repeatedly tries to stand, is a different order of risk — one that demands constant supervision, two-person assistance and sensor monitoring. That is Complexity and Unpredictability, and it is invisible if you read the domains as twelve separate boxes.
Care records are full of entries saying someone was settled and comfortable. Assessors read those as evidence of low need. They are the opposite.
The National Framework requires needs to be recorded at the level they would be without the care currently in place. The right question is not whether she was settled, but what had to happen for her to be settled: the low bed, the sensor mat, the two carers, the hoist standing by, the medication given on time. A well-managed need is still a need, and this is the most common reason a decision goes the wrong way.
Sometimes the decision is wrong because the process was. Each of these is a ground in its own right:
Care providers are expected, on reasonable request, to produce current resident records within about two weeks and archived records within about four. In practice records arrive late, arrive for the wrong period, or arrive incomplete — blank attachments, a care plan with headings but no narrative, no historic risk assessments.
When that happens, an ICB may propose to determine the appeal anyway. Our position in those circumstances is straightforward: no substantive determination should be made on a knowingly incomplete evidential record while relevant, identifiable records remain reasonably obtainable. The right procedural step is to ask the Board for a category-by-category schedule of what it has received and what is still outstanding, before it decides anything.
That request costs nothing and changes the footing of the appeal.
Eligibility is not determined by diagnosis, by the setting in which care is delivered, or by adding up domain scores. The question is whether the totality of the needs amounts to a primary health need — the boundary drawn by section 22 of the Care Act 2014 between local authority care and support and healthcare that is the NHS's responsibility.
R v North and East Devon Health Authority ex parte Coughlan [2001] QB 213 remains the foundational authority: where the primary need is a health need, responsibility lies with the NHS, and the analysis must address the nature and extent of the services required rather than simply where they are delivered. R (Grogan) v Bexley NHS Care Trust [2006] EWHC 44 (Admin) reinforces that the assessment must lawfully address that boundary — which is why a decision that treats individual domain scores as the end of the inquiry, without considering the totality and interaction of needs, is open to challenge.
Yes. You can request a review from your Integrated Care Board yourself, free of charge, and families do succeed. Specialist help earns its place where records are incomplete or being withheld, where the case is heading to an Independent Review Panel, or where you do not have the capacity to run it alongside caring for someone.
Send us the decision letter. We will tell you free of charge whether there are grounds worth pursuing — and say so plainly if there are not.
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