How long do I have to appeal?

Under the British NHS Continuing Healthcare National Framework 2022, the family has 6 months from the date of the eligibility decision to appeal. The 6-month clock starts on the date the ICB communicates the decision in writing. Late appeals may be accepted at the ICB's discretion but there is no right to such acceptance. Appeals should be lodged as early as possible — the appellant has the burden of progressing the case through Local Resolution → IRP → PHSO and the British escalation pathway can take 12-24 months overall.

How long does the appeal take?

British CHC Local Resolution typically takes 60-90 days from the appeal lodgement to written outcome. If unfavourable, IRP convening takes a further 3-6 months. The IRP hearing itself is typically a half-day session. The IRP decision is communicated within 4-6 weeks of the hearing. If PHSO escalation is then required, PHSO investigation takes 6-18 months. The overall pathway from initial appeal to PHSO outcome can therefore take 12-24+ months. Most successful UK CHC appeals resolve at Local Resolution or IRP.

What evidence do I need?

Critical British CHC appeal evidence includes: (a) the Decision Support Tool (DST) forms completed by the care team — these are the original assessment documents; (b) the MDT Eligibility Decision Report; (c) GP letter with overall clinical view; (d) Specialist consultant's letter (geriatrician, neurologist, psychiatrist depending on conditions); (e) care home daily logs showing actual needs and interventions; (f) medication regime; (g) behavioural support plan if applicable; (h) family witness statements on the cumulative impact of needs; (i) care needs assessment from social services. Strong British appeals combine clinical evidence with care-team daily-record evidence.

Can I claim retrospective fees?

Yes — Expert mode in the template includes the retrospective claim framework. Where the patient privately paid care fees during a period when the eligibility threshold was met (but the ICB did not determine eligibility), the British family can seek a retrospective CHC determination from the date the threshold was first met, with refund of the privately paid fees. Typical UK retrospective claims range from £15,000 to £100,000+. The claim period is usually limited to 6 years (Limitation Act 1980 s.5) but the ICB has discretion to consider longer periods.

Will I need to attend a hearing?

At Local Resolution stage, no hearing — the British ICB review is on the papers. At IRP stage, the family can elect a personal hearing or a paper review. Personal hearings are strongly recommended — the IRP can ask questions of the family directly and the family can address questions of clinical interpretation. The IRP hearing is typically a half-day session at NHS England Regional Team offices. The family can bring an advocate / solicitor / specialist consultant. At PHSO stage, the investigation is on the papers but the ombudsman can interview parties if needed.

Do I need a solicitor?

Not strictly — many British CHC appeals are progressed by family members in person. The Framework is designed to be accessible. However, for complex cases (catastrophic injury, multiple comorbidities, large retrospective claims over £30,000), instructing a UK CHC specialist (solicitor with CHC experience or specialist consultant) materially improves outcomes. Specialist consultants typically charge £1,500-£5,000 for full appeal handling; solicitors £150-£250 per hour. NO Legal Aid is available under LASPO 2012 Schedule 1 for CHC claims — the family bears the cost. Some firms work on contingency / success fees.

What happens if PHSO rejects?

If the British Parliamentary and Health Service Ombudsman declines to investigate or rejects the complaint, judicial review remains theoretically available (within 3 months of the IRP decision under CPR Part 54). Judicial review challenges procedural error or unreasonableness in the eligibility determination process, not the substantive eligibility decision itself. JR is rarely successful and is expensive (typical cost £15,000-£50,000+ without Legal Aid). Most British families do not pursue JR. The realistic position is that PHSO is the final practical stage of the CHC appeal pathway.

PersonalUnited Kingdom

UK NHS Continuing Healthcare Appeal Template (CHC)

Draft a UK NHS Continuing Healthcare (CHC) Appeal Statement of Case for submission to the patient's Integrated Care Board (ICB) under the NHS Continuing Healthcare National Framework 2022 (England). The template covers the statutory framework (NHS Act 2006 s.3 + National Framework 2022 + Care Act 2014 s.18), the 4 key indicators (Nature, Intensity, Complexity, Unpredictability), the 12 care domains, the Coughlan and Pointon boundary case-law, retrospective CHC claims with refund of privately paid care fees, and the full escalation pathway (Local Resolution → Independent Review Panel → PHSO). British families facing CHC eligibility refusals — affecting potentially £40,000-£80,000+ per year of care costs — use this template to mount a structured appeal.

Create Your NHS Continuing Healthcare Appeal — Statement of Case

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NHS Continuing Healthcare Appeal — Statement of Case

In Respect Of Mr Geoffrey Charles Whitaker · DOB 1938-04-22 · NHS No. 847 924 3185

TO: NHS Surrey Heartlands Integrated Care Board — Continuing Healthcare Team
Dukes Court, Duke Street, Woking GU21 5BH

FROM: Margaret Anne Whitaker (acting as family member / LPA-appointed attorney) of 47 Cherry Tree Lane, Guildford GU2 4PR
Contact: m.whitaker@protonmail.com · 07832 419872

IN RESPECT OF: Patient Mr Geoffrey Charles Whitaker, Oakfield Care Home, 28 Manor Road, Guildford GU1 3AB
CHC DECISION DATE: 2026-03-14
DECISION REFERENCE: CHC-2026-SR-04829
APPEAL DATE: 2026-06-03

NHS CHC APPEAL — STATEMENT OF CASE

Mr Geoffrey Charles Whitaker · Local Resolution

PATIENT, APPELLANT AND ICB DECISION

1.1 The patient is Mr Geoffrey Charles Whitaker (DOB 1938-04-22). 1.2 The Appellant is Margaret Anne Whitaker, acting as family member / LPA-appointed attorney. 1.3 The Integrated Care Board (NHS Surrey Heartlands Integrated Care Board — Continuing Healthcare Team) made a CHC eligibility decision on 2026-03-14 (reference CHC-2026-SR-04829) determining the patient ineligible for NHS Continuing Healthcare funding. The Appellant appeals.

STATUTORY FRAMEWORK

2.1 NHS Continuing Healthcare ("CHC") is funded under section 3 of the National Health Service Act 2006, governed by the NHS Continuing Healthcare National Framework 2022 (the "Framework") and the NHS Continuing Healthcare and Funded Nursing Care Regulations 2018. 2.2 Eligibility is determined by reference to the patient's primary need being a health need rather than a social need. The boundary is governed by R v North and East Devon HA, ex p Coughlan [2000] 2 WLR 622 (Court of Appeal) and refined in Pointon v Secretary of State for Health [2010] EWHC 1392 (Admin). 2.3 The eligibility assessment requires consideration of the patient's needs across 4 indicators (Nature, Intensity, Complexity, Unpredictability) and 12 care domains (Behaviour, Cognition, Communication, Psychological and Emotional, Mobility, Nutrition, Continence, Skin, Breathing, Drug Therapies, Altered States of Consciousness, Other). 2.4 The Care Act 2014 s.18 governs the boundary between NHS-funded and local-authority-funded care.

GROUNDS OF APPEAL

3.1 The Appellant submits that the ICB's decision was wrong because of multiple combined grounds — misapplied 4 indicators, underrated 12 domains, and Coughlan boundary. 3.2 The detailed grounds are as follows:
The Appellant submits the ICB's decision is wrong on three combined grounds: (1) misapplication of the 4 key indicators — the ICB rated Intensity as "moderate" but the patient requires 24/7 supervision with bed-bound nursing care; Unpredictability was rated "low" but the patient has variable cognitive state with frequent episodes of agitation requiring specialist response; (2) underrating of the 12 domains — Behaviour, Cognition, Continence, Mobility and Drug Therapies all underrated; specific rating revisions are detailed below; (3) misapplication of the Coughlan boundary — the patient's needs are primarily health (dementia, cardiac, complex medication regime, behavioural management) rather than social (assistance with daily living alone). The cumulative profile meets the CHC eligibility threshold per the National Framework 2022.

12-DOMAIN ANALYSIS

4.1 The Appellant's domain-by-domain analysis of the patient's needs:
Domain 1 (Behaviour) — ICB rated "Moderate"; Appellant submits "High" — frequent agitation, resistance to personal care, occasional verbal aggression requiring specialist nursing response.
Domain 2 (Cognition) — ICB rated "Moderate"; Appellant submits "Severe" — disorientation to time/place/person, declining decision-making capacity, unable to recognise close family.
Domain 4 (Psychological and Emotional) — ICB rated "Low"; Appellant submits "High" — frequent emotional distress, depression episodes.
Domain 5 (Mobility) — ICB rated "Moderate"; Appellant submits "Severe" — bed-bound from January 2026 except for hoist transfer to chair.
Domain 7 (Continence) — ICB rated "Moderate"; Appellant submits "High" — doubly incontinent, requires 6-hourly care intervention.
Domain 10 (Drug Therapies) — ICB rated "Moderate"; Appellant submits "High" — complex medication regime (12 medications, anti-psychotic + cardiac + analgesia) requiring nursing administration and observation.

COUGHLAN AND POINTON ANALYSIS

5.1 The Coughlan test — the patient's primary need must be a health need rather than a social need — is applied as follows:
Coughlan establishes that NHS-funded care is appropriate where the primary need is a health need. Pointon refined the analysis with focus on the totality of needs. The patient's needs are: dementia (Cognition + Psychological); cardiac (Breathing + Drug Therapies); mobility (bed-bound, hoist-dependent); incontinence (Continence + Skin); complex medication. These are primarily health needs requiring trained nursing intervention — not social needs for assistance with daily living. The Coughlan boundary places the patient on the NHS side.

RETROSPECTIVE CLAIM

6.1 The Appellant also seeks a retrospective CHC determination from the period Period: 22 February 2025 (date of cardiac event and step-change in needs) to 13 March 2026 (day before ICB decision). Privately paid care fees during this period: approximately £62,400 (£1,200/week × 52 weeks). The Appellant submits that the patient's needs met the CHC threshold from 22 February 2025 onwards and a retrospective CHC determination is sought. on the basis that the patient's needs at the relevant historic times met the CHC eligibility threshold and care home / domiciliary care fees were privately paid that should have been NHS-funded.
Period: 22 February 2025 (date of cardiac event and step-change in needs) to 13 March 2026 (day before ICB decision). Privately paid care fees during this period: approximately £62,400 (£1,200/week × 52 weeks). The Appellant submits that the patient's needs met the CHC threshold from 22 February 2025 onwards and a retrospective CHC determination is sought.

INDEPENDENT REVIEW PANEL (IRP) PATHWAY

7.1 Where Local Resolution does not produce a satisfactory outcome, the Appellant will request escalation to the Independent Review Panel (IRP) under the National Framework 2022 Annex E. The IRP is convened by NHS England with an independent chair and clinical advisor.
If Local Resolution does not result in an eligibility reversal within 60 days, the Appellant will request IRP escalation under Annex E of the National Framework 2022. The IRP will be convened by NHS England Regional Team South East with an independent chair and clinical advisor. The Appellant will request a personal hearing at the IRP.

PHSO ESCALATION

8.1 If the IRP outcome remains unfavourable, the Appellant will refer the complaint to the Parliamentary and Health Service Ombudsman (PHSO) under the Health Service Commissioners Act 1993, in particular for maladministration in the eligibility determination process.
If the IRP outcome remains unfavourable, the Appellant will refer the complaint to the PHSO under the Health Service Commissioners Act 1993 on grounds of (a) maladministration in the application of the 4 indicators; (b) failure to provide adequate written reasons; (c) failure to consider the cumulative effect of multiple domain needs. Possible PHSO remedies include compensation for service failure and recommendations to NHS England for systemic improvement.

EVIDENCE SCHEDULE

9.1 The Appellant relies on the following evidence:
Annex 1 — DST forms completed by Oakfield Care Home Team (May 2025); Annex 2 — MDT Eligibility Decision Report 14 March 2026; Annex 3 — GP letter Dr Margaret Foster 22 February 2026; Annex 4 — Consultant Geriatrician letter Prof Howard Pemberton, Royal Surrey County Hospital 18 January 2026; Annex 5 — Care home daily logs (Jan-May 2026); Annex 6 — Family witness statements (Margaret Whitaker, Charlotte Whitaker); Annex 7 — Medication regime schedule; Annex 8 — Behavioural support plan.

10.

DETERMINATION SOUGHT AND GOVERNING LAW

10.1 The Appellant requests the ICB to: (a) overturn the eligibility decision; (b) determine the patient eligible for NHS Continuing Healthcare with effect from the date of decision (or the relevant historic date for retrospective claims); (c) refund any privately paid care fees attributable to the period of incorrect eligibility classification; and (d) provide written reasons within 28 days. 10.2 This appeal is conducted under the law of England and the NHS Continuing Healthcare National Framework 2022.

11.

DECLARATION

I, Margaret Anne Whitaker, declare that the contents of this Statement are true to the best of my knowledge and belief.

APPELLANT

Margaret Anne Whitaker

On behalf of Mr Geoffrey Charles Whitaker

Date: ____________________

Available as a print-ready PDF or an editable Microsoft Word (.docx) file.

What Is a UK NHS Continuing Healthcare Appeal?

NHS Continuing Healthcare (CHC) is a package of NHS-funded care available to British adults whose primary need is a health need rather than a social-care need. Where eligible, the NHS funds the full cost of the patient's care — typically £40,000-£80,000+ per year for care home placement or extensive home care. CHC is governed by the NHS Continuing Healthcare National Framework 2022 (England) issued by NHS England, supplemented by the NHS Continuing Healthcare and Funded Nursing Care Regulations 2018. Eligibility is determined by the patient's Integrated Care Board (ICB) — the body that replaced Clinical Commissioning Groups under the Health and Care Act 2022.

A CHC eligibility appeal can be brought where the ICB has determined the patient ineligible for CHC funding. The appeal pathway under the National Framework 2022 has three stages: (1) Local Resolution — initial review by the ICB itself, typically within 60 days; (2) Independent Review Panel (IRP) — convened by NHS England Regional Team with an independent chair and clinical advisor where Local Resolution fails; (3) Parliamentary and Health Service Ombudsman (PHSO) — investigation of maladministration where IRP outcome remains unfavourable. The British family typically has 6 months from the eligibility decision to appeal under the Framework.

The eligibility analysis turns on two structures. First, the 4 key indicators — Nature, Intensity, Complexity, Unpredictability — assessed across the patient's needs profile. Second, the 12 care domains — Behaviour, Cognition, Communication, Psychological & Emotional Needs, Mobility, Nutrition, Continence, Skin, Breathing, Drug Therapies, Altered States of Consciousness, Other — each rated on a 6-level scale (No needs / Low / Moderate / High / Severe / Priority). The Coughlan boundary case-law (R v North & East Devon HA, ex p Coughlan [2000] 2 WLR 622) provides the doctrinal framework distinguishing health needs (NHS-funded) from social-care needs (LA-funded under Care Act 2014). Pointon v Secretary of State for Health [2010] EWHC 1392 (Admin) refined the totality-of-needs analysis.

What's Covered in This UK Template

Our UK template produces a structured Statement of Case for ICB Local Resolution and onwards through IRP / PHSO.

Appellant + Patient + ICB Identification

Appellant in person / family attorney / solicitor / IMCA advocate (Mental Capacity Act 2005). Patient identification (name, DOB, NHS Number, care address). ICB name, address, decision date and reference.

National Framework 2022 Citation

NHS Act 2006 s.3 + NHS Continuing Healthcare National Framework 2022 + Care Act 2014 s.18 + NHS CHC and Funded Nursing Care Regulations 2018 — the British statutory framework correctly cited.

4 Key Indicators Framework

Nature, Intensity, Complexity, Unpredictability — the 4 key indicators assessed across the patient's needs profile. Misapplication of any indicator is a primary appeal ground.

12 Care Domains Framework

Behaviour, Cognition, Communication, Psychological & Emotional, Mobility, Nutrition, Continence, Skin, Breathing, Drug Therapies, Altered States of Consciousness, Other — each on 6-level scale.

Coughlan + Pointon Boundary

R v North & East Devon HA ex p Coughlan [2000] 2 WLR 622 and Pointon v Secretary of State for Health [2010] EWHC 1392 — the case-law boundary between health (NHS) and social (LA) needs.

Primary Ground Selection

Pick misapplied 4 indicators / underrated 12 domains / Coughlan boundary misapplied / multiple combined — drives the appellant's narrative structure.

Evidence Schedule

Structured evidence schedule — DST forms, MDT report, care home records, GP letter, consultant's letter, care needs assessment, family witness statements.

12-Domain Detailed Analysis

Expert mode adds the structured domain-by-domain analysis — severity rating with supporting evidence per domain, ICB rating vs Appellant's submitted rating, supporting clinical observations.

Coughlan / Pointon Detailed Analysis

Expert mode adds the structured Coughlan / Pointon boundary application — primary health need vs social need analysis with reference to the patient's specific clinical profile.

Retrospective Claim

Expert mode adds the retrospective CHC claim framework — recovery of privately paid care fees during a period of incorrect eligibility classification. Typical UK retrospective claims £15,000-£100,000+.

IRP Pathway (NHS England)

Expert mode adds the IRP (Independent Review Panel) escalation pathway under National Framework 2022 Annex E — NHS England Regional Team, independent chair, clinical advisor, personal hearing option.

PHSO Escalation

Expert mode adds the Parliamentary and Health Service Ombudsman (PHSO) escalation framework under the Health Service Commissioners Act 1993 — maladministration investigation where IRP outcome unfavourable.

How to Create a UK NHS CHC Appeal

Follow these steps to draft a structured CHC eligibility appeal Statement of Case.

1
Enter Appellant + Patient + ICB
Enter the British appellant's name, address, optional contact; the patient's name, DOB, NHS Number, care address. Pick appellant capacity — in person, family / LPA-appointed attorney, solicitor, or IMCA advocate under the Mental Capacity Act 2005. Enter the ICB name, complaints address, decision date and reference.
2
Pick Primary Ground + Write Grounds Narrative
Pick the primary ground — misapplied 4 indicators / underrated 12 domains / Coughlan boundary misapplied / multiple combined (recommended). Write the detailed grounds narrative — specific 4-indicator analysis, specific domain analysis, Coughlan boundary application. Specificity wins at CHC appeal — generic submissions carry little weight.
3
Build Evidence Schedule
List the evidence — Decision Support Tool (DST) forms completed by the care team; Multi-Disciplinary Team (MDT) Eligibility Decision Report; GP letter; Consultant's letter (especially specialist — geriatrician, neurologist, psychiatrist); care home daily logs; medication regime; behavioural support plan; family witness statements; care needs assessment. Annexes should be numbered and cross-referenced.
4
Unlock Expert: 12-Domain + Coughlan + Retrospective
In Expert mode, add the structured 12-domain analysis (severity rating with supporting evidence per domain — Behaviour, Cognition, Communication, Psychological, Mobility, Nutrition, Continence, Skin, Breathing, Drug Therapies, ASC, Other). Add the Coughlan / Pointon boundary analysis. Add the retrospective claim (privately paid care fees during incorrect eligibility classification period — typically refund of £15,000-£100,000+).
5
Add IRP + PHSO Pathway and Submit
In Expert mode, add the IRP escalation pathway (Independent Review Panel under National Framework 2022 Annex E — NHS England Regional Team, independent chair) and the PHSO escalation framework (Parliamentary and Health Service Ombudsman maladministration investigation). Download as PDF and submit to the ICB CHC Team within the 6-month appeal window. Track Local Resolution → IRP → PHSO escalation sequentially.

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Legal Considerations

CHC eligibility is a fact-sensitive determination — preparation and evidence determine outcomes.

This template is for informational purposes only and does not constitute legal advice. For complex CHC appeals (catastrophic injury, multiple comorbidities, retrospective claims over £30,000), instruct a UK CHC solicitor or specialist consultant. Care home families do NOT receive free Legal Aid for CHC claims under LASPO 2012 Schedule 1.

Reviewed for England NHS CHC practice (June 2026)

National Framework 2022 + Eligibility Test

NHS Continuing Healthcare is governed by the NHS Continuing Healthcare National Framework 2022 (England) issued by NHS England, supplemented by the NHS Continuing Healthcare and Funded Nursing Care Regulations 2018. Eligibility is determined by reference to the patient's primary need being a health need rather than a social need. The assessment uses the Decision Support Tool (DST) which scores the patient across the 12 care domains; the Multi-Disciplinary Team (MDT) then makes the eligibility decision having regard to the 4 indicators. The British Integrated Care Board (ICB) ratifies the MDT decision. The whole process is documented and the family is entitled to see the DST forms and MDT report.

The 4 Indicators in Practice

Nature: the type of need (cognitive, physical, behavioural, complex medication) — does the patient have characteristics requiring NHS-funded intervention? Intensity: the level and frequency — how often and how intense is the need? Complexity: the interaction between needs — does the patient have multiple interacting conditions requiring specialist coordination? Unpredictability: the variation requiring expert response — how reliably can the patient's needs be anticipated? The British ICB must consider each indicator. Where any indicator points to NHS-funded care, the overall picture may meet the eligibility threshold even if individual domains do not.

Coughlan + Pointon Case-Law

R v North & East Devon Health Authority, ex parte Coughlan [2000] 2 WLR 622 (Court of Appeal) is the foundational British authority establishing the health-needs/social-needs boundary. The court held that where a patient's nursing care needs are more than incidental or ancillary to social care, the NHS is responsible. Pointon v Secretary of State for Health [2010] EWHC 1392 (Admin) refined the analysis with focus on the totality of needs rather than the predominant single condition. The British ICB must apply the Coughlan boundary correctly — misapplication is a primary appeal ground. Where the patient has multiple interacting conditions (typical in dementia + cardiac + mobility cases), the totality analysis from Pointon typically places the patient on the NHS side.

Local Resolution → IRP → PHSO Pathway

The appeal pathway under the National Framework 2022 has three stages. Stage 1 — Local Resolution: the British ICB itself reviews the decision, typically within 60 days. Most successful appeals resolve at this stage. Stage 2 — Independent Review Panel (IRP): convened by NHS England Regional Team with an independent chair and clinical advisor, where Local Resolution fails. The IRP can hold a personal hearing where the family attends. Stage 3 — PHSO: where the IRP outcome remains unfavourable, the family can refer the complaint to the Parliamentary and Health Service Ombudsman under the Health Service Commissioners Act 1993 for investigation of maladministration. The PHSO can recommend compensation and systemic change. Judicial review of any stage is available but rarely successful absent serious procedural error.

Frequently Asked Questions

Draft Your UK NHS CHC Appeal Now

Use our free NHS Continuing Healthcare National Framework 2022 + Coughlan / Pointon template to draft a structured Statement of Case for CHC eligibility appeal. Expert mode unlocks the 12-domain analysis, Coughlan / Pointon boundary application, retrospective claim framework, IRP escalation pathway and PHSO maladministration framework — the complete UK CHC appeal toolkit.

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