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. Department of Health and Social Care (2022) NHS Continuing Healthcare Checklist.
3. Department of Health and Social Care (2022) NHS Continuing Healthcare Decision Support Tool.
4. Care Act 2014, c. 23. Available at: https://www.legislation.gov.uk/ukpga/2014/23/contents
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 explains the relationship between the multidisciplinary team recommendation and the Integrated Care Board decision in NHS Continuing Healthcare. It covers why the two are separate, the exceptional circumstances in which a Board may depart from a recommendation, what reasons must be given, how often divergence occurs in practice, and what to do where a recommendation of eligibility has been overturned.
The MDT recommendation and who makes the final CHC decision
One of the most distressing moments in the NHS Continuing Healthcare process is being told at the assessment that the team is recommending eligibility, and then receiving a letter refusing funding. This guide explains how that can happen, when it is legitimate and what to do about it.
Two separate steps
The multidisciplinary team assesses and recommends. The Integrated Care Board decides. These are genuinely separate steps performed by different bodies with different responsibilities. The team brings professional knowledge of the person's needs. The Board holds accountability as the responsible commissioner and must satisfy itself that the recommendation is properly evidenced and that the primary health need test has been correctly applied.
Why the separation exists
The separation provides a check on consistency. Assessments are carried out by many different teams across an area, and without a decision-making step at Board level there would be no mechanism for ensuring the test is applied in the same way. The separation is therefore legitimate in principle. The difficulty arises when it is used as a budgetary filter rather than a consistency check, which is not what the Framework provides for.
When a recommendation can be departed from
The Framework treats departure as exceptional. Legitimate reasons include a Decision Support Tool that is incomplete, domain levels not supported by the narrative recorded, an error in applying the primary health need test, or reasoning that does not follow from the evidence. Departing because the Board disagrees with a properly reasoned professional judgement, or because of cost, is not a sound basis, and a decision resting on either is open to challenge.
What reasons must be given
Where a Board does not accept a recommendation, the reasons should be recorded and communicated in writing to the person and their representative. A letter stating only that the person is not eligible, without engaging with the recommendation, does not meet that expectation. Requesting the reasons specifically, and referring to the recommendation by date, tends to produce a more useful response than a general request for information.
How often it happens
Departure from a recommendation is uncommon relative to the total number of assessments, but it is a recurring feature of disputed cases and it accounts for a meaningful share of appeals. It is more likely where the recommendation is finely balanced, where the Decision Support Tool contains internal inconsistencies, or where the narrative does not clearly support the levels recorded. A well evidenced and internally consistent tool is the best protection against it.
What to do if it happens to you
Request the completed Decision Support Tool, the multidisciplinary team recommendation and the Board's written reasons for departing from it. Read the three together. The question is whether the Board has identified a genuine defect in the assessment or has simply substituted its own view. Where it is the latter, that is the point to make in local resolution, and it is a considerably stronger point than a general disagreement with the outcome.
The verbal indication problem
Families are frequently given a verbal indication of the likely outcome at the end of an assessment. That indication is not a decision and should not be relied on. It is reasonable to ask the team to confirm in writing what recommendation it is making, and to note the date, so that any later divergence is visible rather than a matter of recollection.
Where this fits in an appeal
A departure from a recommendation is a procedural point as well as a substantive one. It goes to whether the decision was properly made, not only whether it was correct. Raising both, separately and clearly, is more effective than merging them, because local resolution and the Independent Review Panel can each address the process as well as the eligibility conclusion.
Key takeaway
The team recommends and the Board decides. Departure should be exceptional and reasoned. If a recommendation of eligibility has been overturned, get the tool, the recommendation and the written reasons, and test whether a real defect was identified or a view was simply substituted.
Frequently asked questions
Is the team's recommendation binding on the Board?
No, but the Framework expects it to be accepted other than in exceptional circumstances. A Board departing from it should identify a genuine defect in the assessment and give written reasons rather than simply reaching a different view.
Can cost be a reason to refuse?
No. Eligibility rests on the primary health need test applied to assessed needs. A decision influenced by cost is not a lawful application of the Framework and is a specific point to raise in local resolution.
What paperwork should I ask for?
The completed Decision Support Tool, the multidisciplinary team recommendation and the Board's written reasons for its decision. Reading the three together shows whether a defect was identified or a view substituted.
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.