Author and Publication
Author: Ben Slater, Registered Social Worker, Founder and Managing Director of Nellie Supports
Reviewed by: Kerry Slater, Director of Operations
Last reviewed: 20 July 2026
Citation
1. Department of Health and Social Care (2022) National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care. Available at: https://www.gov.uk/government/publications/national-framework-for-nhs-continuing-healthcare-and-nhs-funded-nursing-care
2. R (Grogan) v Bexley NHS Care Trust and others [2006] EWHC 44 (Admin).
3. Parliamentary and Health Service Ombudsman. Making a complaint about the NHS in England. Available at: https://www.ombudsman.org.uk
4. R v North and East Devon Health Authority, ex parte Coughlan [2000] 2 WLR 622.
Copywright
Copyright © 2026 Nellie Supports Ltd. All rights reserved.
This article is made available for general information, education and professional reference. It may be downloaded, printed and shared for non-commercial purposes, provided that it is reproduced in full, is not altered in any way, and is properly cited as the work of Nellie Supports Ltd. This material must not be edited, adapted, sold, republished, incorporated into commercial products, or used for commercial training, assessment, report-writing or advisory services without prior written permission from Nellie Supports Ltd.
This article does not constitute legal advice, clinical advice or a substitute for a decision-specific professional assessment. Where legislation, government guidance, court forms or external professional materials are referred to, those materials remain subject to their own copyright, licensing and re-use terms.
Abstract
This guide identifies the errors that make an NHS Continuing Healthcare decision open to challenge. It distinguishes reasoning errors from procedural failures, covers the most common defects including disregard of well-managed needs, attribution by setting, missing characteristics analysis, unevidenced domain levels and departure from the multidisciplinary team recommendation, and explains how to frame each in a review request.
What makes an NHS Continuing Healthcare decision flawed
A decision you disagree with is not the same as a decision that is flawed. Challenges succeed most often when they identify a specific defect in the reasoning or the process, rather than expressing disagreement with the outcome. This guide sets out what those defects look like.
Reasoning errors and procedural failures
The two are worth separating. A reasoning error means the test was applied wrongly, for example by disregarding well-managed needs or by treating a diagnosis as decisive. A procedural failure means the process was not followed, for example an improperly constituted team or a decision issued without reasons. Both are grounds for challenge, they call for different responses, and raising them separately is more effective than merging them.
Disregarding well-managed needs
This is the most common defect. The National Framework is clear that a need which is successfully managed remains a need, and the assessment must record it as it would be without the intervention. Where domain levels reflect the person's stable presentation rather than the underlying need, the assessment has not applied the principle. Behaviour, medication, skin and nutrition are where this occurs most often.
Attributing needs by setting or provider
A need does not become a social care need because it is met in a care home, because a care assistant rather than a nurse delivers it, or because the local authority has been funding it. The Framework excludes setting, provider and funding source as decision factors. Wording in a decision letter that relies on any of them is a clear and identifiable defect.
Deciding on diagnosis
No condition qualifies automatically and none is excluded. A decision that turns on the condition rather than on assessed needs has not applied the primary health need test. Phrases suggesting that a particular condition is a social care condition, or that dementia is not a health need, indicate this error directly.
Missing characteristics analysis
Domain levels are evidence, not the decision. The assessment must analyse the needs through nature, intensity, complexity and unpredictability, and explain how that analysis supports the conclusion. A recommendation that moves straight from a set of levels to an outcome has missed a required step, and that gap is one of the more straightforward defects to identify.
Levels not supported by the narrative
Read each domain level against the narrative recorded beneath it. It is common to find a narrative describing significant, skilled and frequent intervention alongside a moderate or low level. Where the two do not match, the level rather than the narrative is usually the error, and pointing to the inconsistency within the Board's own document is powerful.
Departing from the recommendation
Where the Integrated Care Board has not accepted the multidisciplinary team recommendation, the Framework expects that to be exceptional and reasoned. A departure without identified defects in the assessment, or one that appears to substitute the Board's view for a properly reasoned professional judgement, is a strong procedural point.
Gaps, blanks and absent voices
Blank or thinly evidenced domains, no contribution from anyone who knows the person day to day, no record of the family's account, and no consideration of night time or fluctuating needs are all defects. A blank domain is a gap in the assessment rather than a finding of no need, and it should be described that way.
Key takeaway
Identify the defect and name it. Well-managed needs disregarded, needs attributed by setting, decisions made on diagnosis, no characteristics analysis, levels contradicted by the narrative, or an unexplained departure from the recommendation. Specific defects supported by dated evidence succeed far more often than general disagreement.
Frequently asked questions
Is disagreeing with a domain level enough?
On its own, rarely. Name the domain, quote the descriptor you say applies and provide dated evidence supporting it. A disagreement anchored to the tool's own wording is far stronger than an assertion that the level is too low.
What is the single most common defect?
Disregarding well-managed needs. The assessment records the person as they present under an effective care package rather than recording the underlying need and the intervention required to control it.
Does a procedural failure win an appeal on its own?
Not usually on eligibility, but it can require the decision to be retaken properly. Raise procedural and reasoning points separately, since each calls for a different response from the reviewer.
Related NHS Continuing Healthcare pages
These links take you to the most relevant Nellie Supports service page and to the supporting guides that explain the surrounding process.
Speak to an independent CHC specialist
Nellie Supports prepares independent needs evidence for NHS Continuing Healthcare assessments, reviews and appeals across England and Wales. Our reports are written by registered social workers on a permanent employed team, with internal peer review before release. Call 0333 987 5118 or send an enquiry and we will talk through where you are in the process.