How we can help with complaints about continuing healthcare funding

This page explains what you can do if you’re not happy with a decision the NHS has made about continuing healthcare funding, including when and how we can help.

What is NHS continuing health care?

NHS continuing healthcare (CHC) is a package of care, arranged and paid for by the NHS, that you receive in your own home, a care home or another setting that is not a hospital. It is for people whose primary need is for healthcare.

How does it work?

If you think you, or someone you care for, might be eligible for CHC funding, you have the right to ask for an assessment. Here’s how it works:

Stage one: checklist assessment

The first stage is a brief 'checklist' which is done by a health or social care professional. They will use a tool called the Checklist Tool to find out whether you need to have a full assessment.

Sometimes the NHS may choose not to do the checklist stage and move straight onto carrying out a full assessment.

You can find out more about how the checklist assessment works on the NHS.UK website.

If you’re not happy with the checklist decision, you can complain to the NHS about this through the NHS complaints process.

Stage two: full assessment

The second stage is a full assessment. This is where the NHS decides whether or not you are eligible for funding. It is the clinical commissioning group, or another NHS organisation, that makes this decision. If the NHS decides not to give you funding, you or your family can ask NHS England to carry out an Independent Review of this decision.

How we can help

Our role is to make final decisions on complaints about the NHS. You can ask us to look into your complaint about CHC funding if:

  • You are not happy with the NHS’s checklist decision, have made a complaint to the NHS about this and are not happy with its response, or
  • You have had a full assessment by the NHS, have been turned down for funding and have already been through the Independent Review process, or
  • You have been given funding but are not happy with the amount and have made a complaint to the NHS about this.

If you would like to bring a complaint to us, we have an online form that you can use for this. Follow the complaint checker from our website home page.

What we can and can’t do

When we investigate complaints about CHC funding, our role is to decide whether or not the NHS carried out its decision making process in line with established guidelines (the National Framework). These are nationally agreed criteria for making decisions about who is eligible for CHC funding. The National Framework is there to make sure all decisions are consistent.

If we agree to investigate your case, we will look to see whether the NHS followed the National Framework properly. When we investigate we are looking for a specific fault in the way the NHS reached its decision. These decisions are based on clinical judgments and opinions, and the fact that someone else has a different opinion does not mean that there must have been a fault in the decision-making process.

If we do find a specific fault and uphold your complaint, we will usually ask the NHS to take action. For example, we might ask it to explain how it reached its decision, or to look again at its decision. We can’t make the NHS change its decision, and we can’t make our own decision about whether you are eligible for funding, but we will say what we think the NHS needs to do to put things right.

Getting help with making your complaint

If you want to make a complaint through the NHS complaints process or want to ask for an Independent Review, you can represent yourself or you can get help free of charge from a local advocacy service. You can find out more about where to get free help here on our website . You don’t have to pay a solicitor or a claims company to represent you.

If you do decide to use a representative to help you, the NHS will ask them for proof that they are authorised to act on your behalf.

If you’re bringing a complaint to us to look into, we will do our best to make sure that our service is accessible to you. But we can also point you to organisations that can offer free support if you would like help making your complaint.

We know that a large number of recent claims to the NHS have been put through professional representatives, such as solicitors and claims companies, who charge for their services. We rarely find that there has been a need for someone to pay somebody else to bring their complaint to us, or to the NHS. Because of this, it is unusual for us to recommend that the NHS reimburses you for any fees you may have paid to have someone represent you.

Bringing a complaint to us after an Independent Review

If you bring a case to us following an Independent Review, you need to make sure you tell us how you think the Independent Review process was unreasonable or unfair. You will have had the opportunity to raise your concerns about the assessment process with the Independent Review and our investigation will look at how the Independent Review addressed your concerns. We will usually only investigate issues that you have previously raised with the Independent Review.

These are the kind of things you can ask us to investigate

  • Did the Independent Review find any failings in the assessment for funding and have these failings been addressed?
  • Were all the right people involved in the assessment, including family, appropriate clinical staff, representatives from the NHS and local authority?
  • Was all the relevant information considered by the Independent Review, including the evidence put forward by you and/or your family?
  • Was the Independent Review decision explained thoroughly?

Making a claim for past periods of care

You can make a claim for CHC funding after the period of care has elapsed, or for instance, on behalf of someone who has since died.

In 2012 the Department of Health announced final deadlines for any new claim for NHS CHC funding in the period from April 2004 until 31 March 2012. We know that the NHS received about 60,000 new claims following the introduction of these deadlines. We understand that the NHS is currently processing those claims, and it is likely that in many of these cases people will be disappointed with the decision about funding.

If you’re not happy with the decision the NHS has made about your claim, you can challenge this through the NHS complaints and appeals process. After that, if you remain dissatisfied, you can ask us to look into your concerns.

Because the announcement of the final deadlines for claims for past periods of care led to such a large number of requests for assessments, we know that the NHS will take a while to process them. We expect the NHS to prioritise current cases (where the person is still alive and needs ongoing care) over past cases where there is no longer a need for financial help with care needs.

However, we would also expect NHS organisations to keep people informed about the progress of their claim. If your claim is approved, the Department for Health guidance on redress requires interest to be paid for all of the time since the period of care concerned.

Useful information