Into Perspective: Is NHS Continuing Healthcare (CHC) currently fit for purpose?

NHS Continuing Healthcare is free health and social care for some adults with long-term complex health needs, which is arranged and funded solely by the NHS and provided outside of the hospital environment. The national framework was introduced in 2007 and most recently updated in 2022. However, a recent report by Age UK titled Continuing to care? Older people let down by NHS Continuing Healthcare has highlighted how the NHS CHC funding regime is leading to older people and their families missing out on funding.

The report states, ‘The current CHC funding regime is an extreme postcode lottery, which risks deepening inequalities and causes older people and their families enormous additional stress. Older people with ongoing chronic health problems, and associated high levels of social care need, are unfairly losing out. The CHC funding regime desperately needs to be reformed as a part of a review and restoration of our social care system.’

The NHS advises that, in order to receive NHS CHC funding, individuals must be assessed by integrated care boards (ICBs) according to a legally prescribed decision-making process. This process is used to determine whether the individual has a primary health need that requires a package of care, the costs of which are met by the NHS. The Age UK report states, ‘In theory, eligibility decisions should be independent of budgetary constraints and finance officers should not be part of a decision-making process. However, in practice, NHS bodies have been under pressure to make savings from their CHC budgets for at least the last seven years.’

There are two pathways to CHC – standard and fast track. In quarter four of 2023/24, 24% fewer people were assessed for standard CHC when compared to quarter two of 2017/18, while there was an 18% increase in the number of people assessed for fast-track CHC. Based on this data, the Nuffield Trust has questioned, ‘whether people are receiving support at the right time, and not only when their condition has deteriorated significantly’. It points out that, by early 2024, just one in five people undergoing assessment were deemed eligible for a standard CHC package.

The assessment looks at the patient’s needs in relation to four key characteristics. These are: nature (the characteristics and type of needs and the overall effect these needs have); intensity (the extent and severity of the person’s needs and the support required to meet them); complexity (how a person’s needs present and the skill required to monitor symptoms, treat conditions and manage the care); and unpredictability (the degree to which a person’s needs fluctuate, including the risks to health if care is not provided).

Concerns have also been raised about the waiting times for referrals. The CHC assessment process states that a decision on eligibility should be made within 28 days of receiving a completed checklist, which is done by a healthcare professional such as a nurse, GP or social worker. However, the Nuffield Trust’s data reports that, as of 31st March 2024, 1,730 referrals were incomplete and had been delayed by more than 28 days. Within this figure, 40 people had had their decision delayed by over 26 weeks.

Care packages are reviewed after three months, the focus of which should be on whether the care plan is still appropriately meeting the patient’s needs, and thereafter every 12 months. If a person is not eligible for CHC, they are potentially liable to pay all of their social care costs, in what is clearly a challenging time for patients and their families.

Inadequate and inconsistent delivery

In our recent report on NHS Continuing Healthcare (CHC), we concluded by imagining an ideal world in which social care was sufficiently funded, supported and fully integrated with the NHS. In such a world, there may not be a need for CHC. Government announcements at the beginning of 2025 suggest that such a world is a very long way from being realised, if at all. If the current, incredibly unambitious, timetable is pursued, we see some minor tinkering by the end of the decade and substantial change by the middle of the next. And only then if a variety of political and economic stars align.

This speaks to the core of this question – what is the purpose of CHC? By the letter, it is to provide a package of ongoing care, funded by the NHS, where someone has been assessed and found to have a ‘primary health need’. Once someone has passed the often many hurdles required to be found eligible, this is mostly what it delivers, and for those people, it can be transformative. Were this process entirely in line with the rest of the National Framework and not beset with the wide variation we identified in our report, then perhaps the answer to the question: ‘Is CHC fit for purpose?’ may be ‘yes’.

CHC is not unique in health and care services for being inconsistently delivered and subject to postcode lottery, though it may be one of the starker examples. However, there is a question at the core of CHC about the role it arguably plays as a stopgap. In its original form, to answer the question, what level of health-related care can a local authority reasonably expect to be delivered? And more recently, given the growth of fast-track funding, in providing support for people nearing the end of life? The future for CHC includes tackling not only the inadequacies of delivery now but also the wider system, making sure those gaps do not exist at all.

Tom Gentry, Joint Head of Health Influencing, Age UK X: @age_uk Email: [email protected]

We have seen enough insufficient CHC packages

Tension between national discharge to assess (D2A) guidance, the national framework for NHS CHC and the Care Act needs to be examined to address the central legal problem – who is doing what when a person is discharged using a pathway 3 bedded setting, without being ‘checklisted’, when the fee comes out of a pooled budget? D2A is Government-imposed deferral of the Care Act duty to assess on the mere appearance of care and support needs.

Since the 2022 redraft of the national framework, reasons for not ‘needing’ to checklist patients have multiplied. A swathe of Ombudsman’s reports has found conflicting use of non-time limited NHS ‘interim/stepdown’ beds and four-week D2A ‘settling’ beds, or long-term NHS rehab versus council-funded ‘reablement’ beds. Always, the question is, ‘Free, thank you, but for how long? Nobody told me!’

How could it ever be a rules-based system when nurse co-ordinators are required to ‘manage demand’? The cost-shunt is damaging social services, particularly for working age adults. If someone is ineligible, the council must pay the shortfall between their means-tested charges contribution and the package’s full cost (unless its NHS partners have adopted a forward-thinking approach to shared care), because the person is far less likely to have amassed assessable housing wealth.

A flow of Administrative Court case law has been prevented by asserting that the criteria are true to the 1999 Coughlan decision. The ‘remedy’ is layers of internal and surreal ‘due process’ via complaints and a panel system in an NHS hierarchy that knows little of public law or governance – each layer making the disputed eligibility decision a little less judicially reviewable.

CHC care planning is amenable to legal challenge, however. Several children’s cases have recently been won against ICBs. There will be a successful judicial review of care planning by an ICB for a qualified adult patient soon. We have seen enough irrationally insufficient CHC commissioned packages to think it is high time that public law rode to the rescue.

Belinda Schwehr, Director, Centre for Adults’ Social Care – Analysis, Information and Dispute Resolution (CASCAIDr CIC) X: @cascaidr Email: [email protected]

CASCAIDr CIC would appreciate attention to a public consultation poll in support of the first phase work of the Casey Commission.