NHS England

4. Mr F complains on behalf of his mother. He complains NHS England’s independent review panel (IRP) upheld the local integrated care board’s (ICB) decision his mother, Mrs K, was not eligible for continuing healthcare funding (CHC) in September 2023.

5. Mr F disagrees with how the IRP considered the nutrition and psychological and emotional needs domains. He also disagrees with how the IRP considered the four key characteristics of his mother’s needs.

6. Mr F says his mother should have been eligible for CHC funding to meet the cost of her care and she has been financially disadvantaged as she has had to pay for her own care fees.

7. Mr F would like NHSE to reconsider its IRP decision.

8. CHC is a package of health and social care that is funded by the NHS for people who have a primary health need. ICBs manage CHC and decide if a person has a primary health need by doing a CHC assessment. If an ICB decides the person does not and is therefore not eligible for CHC, the person or their representative can appeal this decision. This is first to the ICB and then to NHS England, which may decide to arrange an independent review panel (IRP) to consider the ICB’s decision.

9. Mrs K was diagnosed with Alzheimer’s disease in 2016. In 2022 she was moved from a residential care home to a nursing home, as they were no longer able to meet her increasing care needs. From then, she received funded nursing care (FNC).

10. The ICB did a CHC assessment for Mrs K in September. The ICB gave its decision in November. It did not find Mrs K eligible for CHC but said she was eligible for funded nursing care FNC. This is awarded to people who do not have a primary health need, but who have some nursing needs and are living in a nursing home. It is paid directly to the home. Mrs K’s sons appealed this decision in January 2024.

11. In February the ICB held a local resolution meeting. It upheld its original decision and gave this decision a year later in March 2025. Mr F requested an independent review and NHSE arranged an IRP for September 2025. NHSE sent the outcome letter in October, upholding the ICB’s decision that Mrs K was not eligible for CHC.

14. Before we decide if we should do a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong.  We do this by comparing what should have happened with what did happen.  We have done this and have not found any indications that something has gone wrong. We explain why below.

15. It is our role to decide whether NHS England’s IRP acted in line with the National Framework when it considered whether Mrs K was eligible for CHC in September 2023. The National Framework sets out the principles and processes ICBs and NHS England should follow when considering if someone is eligible for CHC.

16. We cannot consider the discretionary decisions the IRP made when it decided on eligibility. This includes the decisions it makes based on clinical judgement and clinician’s opinions. We can only consider if the IRP has followed the National Framework. This means we can only uphold a complaint about a CHC eligibility decision if we find the IRP did not follow the National Framework when it made its decision.

17. The IRP reviews if the ICB should have found the person to have a primary health need, and therefore be eligible for CHC. It also reviews the ICB’s procedures when it made its eligibility decision, to make sure it was acting in line with the National Framework. If the IRP does find the ICB made a mistake, it can:

• recommend the ICB reconsiders if the patient had a primary health need, and • recommend the ICB addresses any procedural faults the IRP identified.

18. When we look at a complaint about an IRP, we consider if it took into account all the relevant information when it made its eligibility decision.

19. The National Framework says ICBs and NHS England should use the decision support tool (DST) to determine a person’s CHC eligibility. The DST looks at a person’s care needs in 12 care areas. These are what we refer to as the domains. Each domain is broken down into levels of need (weightings), which range from ‘no needs’ to ‘priority’, depending on the domain. It also describes each weighting to guide clinicians. We call these descriptors. Mr F has specifically complained about how the IRP considered the nutrition and psychological and emotional needs domains. We look at these first.

Nutrition

20. Mr F told the IRP he felt his mother’s needs in the nutrition domain were high. The ICB weighted this domain as moderate and the IRP agreed with it.

21. Mr F told the IRP he felt his mother was at nutritional risk and suffers from dysphagia (swallowing problems), which required intervention from the speech and language therapy (SALT) team and monitoring to minimise the risk of harm. He told the IRP his mother needed prompting and encouragement with her nutritional intake. She has issues with the texture of food and was prescribed a level 4 soft pureed diet and level 0 thin fluids. He told the IRP she lost 7.2% of her weight from November 2022 to January 2023. She is unable to use cutlery or hold a cup. She is also prescribed a high calorie diet and takes a long time to eat due to refusing to open her mouth.

22. The IRP found Mrs K’s needs were moderate. The DST describes a moderate need in this domain as:

‘Needs feeding to ensure adequate intake of food and takes a long time (half an hour or more), including liquidised feed.

OR Unable to take any food and drink by mouth, but all nutritional requirements are being adequately maintained by artificial means, for example via a non-problematic PEG.’

23. For the IRP to have scored high in this domain, it would have needed to see that at the time of the assessment (the IRP looked at the evidence from the few months leading up to it), Mrs K had dysphagia requiring skilled intervention to ensure adequate nutrition/hydration and minimise the risk of choking and aspiration to maintain airway, that she was nutritionally at risk due which may be associated with unintended, significant weight loss. Or it would have needed to see she had fluids managed by trained carers, weight loss or gain due to identified eating disorder or problems relating to a feeding device (such as a PEG).

24. We can see the IRP considered Mrs K’s nutritional risk and risk of choking in detail, as these were the key elements of the descriptor the family felt showed Mrs K’s needs were high. The IRP considered the evidence and found no evidence of aspiration, choking or swallowing difficulties in the records. It found no evidence she had any active involvement from the SALT service for this. It accepted it took a long time for Mrs K to eat and that her weight had changed.

25. For the timeframe the IRP was considering, Mrs K’s nutritional score was 0. Whilst she had previously been nutritionally a medium risk, she was no longer considered to be and her appetite had improved. We can see the evidence provided to the IRP by the family’s representative mostly related to dates significantly before the period being considered. We reviewed the records and can see for example in June 2023, ‘diet and fluids taken well’. In July, ‘accepted diet and fluids. In August ‘assisted with supper and fluids’ and ‘good intake of diet and fluids’. In September ‘diet, fluid, medication accepted with assistance’ and ‘diet and fluids taken well’. There is no indication there were any difficulties with Mrs K’s eating at that time for the IRP to consider.

26. The IRP appropriately took into account the family’s views and evidence. We would not expect the IRP to reach a decision based on records from a long time before the assessment, which were referenced by the representative. The IRP properly weighed up the descriptors to reach a view on Mrs K’s needs at the time of the assessment. We think the IRP was correct with how it considered Mrs K’s needs for this domain and it followed the DST guidance.

Psychological and emotional needs

27. Mr F feels his mother’s needs were moderate in this domain. The ICB weighted this domain as low and the IRP agreed with it.

28. Mr F told the IRP he felt his mother’s needs were moderate on the basis that at the time of her assessment she suffered mood disturbance anxiety and distress which impacted her health and wellbeing and did not readily respond to reassurance. Also she was prescribed an antidepressant medication, to help her disturbed sleep routine. Mr F told the IRP he had seen his mother cry and that her mood could be up and down.

29. The DST defines a low need as:

‘Mood disturbance, hallucinations or anxiety symptoms, or periods of distress, which are having an impact on their health and/or well-being but respond to prompts, distraction and/or reassurance.

OR Requires prompts to motivate self towards activity and to engage them in care planning, support, and/or daily activities.’

30. For this to have been a moderate need, the IRP would have needed to see Mrs K did not readily respond to prompts, distraction and/or reassurance and this had an increasing impact on her health and/or well-being. Or that she had withdrawn from attempts to engage in support and/or daily activities.

31. The IRP report includes a detailed consideration of this domain, including the records, family’s comments and their representative’s submission. The extracts from the records noted by the family’s representative again significantly pre-date this assessment, so the IRP has correctly referenced records from the lead up to, and time of, the assessment. The IRP saw that Mrs K was noted to have settled days, and that she was ‘contented’, ‘bright’ and ‘laughing at times’. It also noted she was ‘responding to interaction’.

32. We have reviewed the records which, as the IRP identified, do not indicate Mrs K would not respond to distraction or reassurance. Despite sometimes being vocal at those times there is no indication this impacted her health and wellbeing. There is also no indication she had withdrawn from support and daily activities. Examples in the records state ‘currently sat in the lounge’, ‘had a settled day in the lounge’, ‘assisted with all care needs’ and ‘settled and comfortable’. She was noted to be eating, drinking and her hygiene and care needs were being met. When Mrs K was distressed, she responded well to reassurance and would become settled. The records described Mrs K to be sleeping well. There is no indication there were symptoms of hallucinations, anxiety or distress that were having an increasing impact on Mrs K’s health and wellbeing. The IRP recognised this and weighted her needs in line with the low descriptor.

33. We can see the IRP appropriately weighed up Mrs K’s needs taking into consideration all the evidence and descriptors for this domain in line with the DST guidance.

Key characteristics

34. The IRP also applies an eligibility test to help it make a decision about a person’s CHC eligibility. The National Framework separates this test into four key characteristics: nature, intensity, complexity and unpredictability. This test is used to establish if the quantity or type of a person’s care needs are more than what the local authority can provide. This indicates they have a primary health need, which in turn indicates they are eligible for CHC.

35. The National Framework sets out questions for the IRP to consider to help establish a person’s level of need. They are outlined in ‘Practice Guidance 3, When identifying a primary health need, how should the four key characteristics be approached?’ (PG3). The National Framework is clear the questions it provides are not meant to be strictly applied and are there to guide the IRP’s considerations. We use these questions when we are looking at whether the IRP considered the four key characteristics of Mrs K’s needs.

36. Mr F has told us he disagrees with the IRP’s consideration of each of the four key characteristics.

Nature

37. The National Framework says this characteristic should ‘describe the particular characteristics of an individual’s needs (which can include physical, mental health or psychological needs) and the overall effect of those needs on the individual, including the type (‘quality’) of interventions required to manage them.’

38. Mr F has provided details about the nature of Mrs K’s needs. He says her cognitive impairment required staff with prior knowledge of her condition to support her with all elements of her daily life, to protect her from harm and deterioration. He says she needed staff with sufficient knowledge to anticipate her needs across several care domains. He also says she needed interventions across her needs such as nutrition, mobility, medication, continence and skin.

39. The IRP presented a clear picture of Mrs K’s needs. It described the nature of her condition and consideration of the types of care Mrs K needed across each of the care domains. It described the interventions she needed and how often, for example encouragement and assistance with nutrition, help throughout the day for personal care continence needs, application of barrier cream and carers for all mobilising and transfer needs. The IRP concluded the quality of Mrs K’s needs were not over and above what a local authority could provide with the assistance of other NHS services and FNC contribution. We can see the IRP included consideration of the information provided by Mr F and his representative, when it reached its conclusion.

40. We do not doubt Mrs K’s carers needed to be skilled and dedicated to keep her safe and well and our decision on this complaint should not take away from this. When we have looked at Mrs K’s care plans, we cannot see her carers needed any specialist skills above what they would be expected to provide. Mrs K did need the oversight of a registered nurse and this was provided through her FNC.

41. We think the IRP acted in line with the guidance set out in PG3 of the National Framework when it considered the nature of Mrs K’s needs. It had regard for the questions PG3 provides, we do not think it made a mistake here.

Intensity

42. The National Framework says this characteristic ‘relates to both the extent (‘quantity’) and severity (‘degree’) of the needs and to the support required to meet them, including the need for sustained/ongoing care (‘continuity’)’.

43. Mr F submits his mother’s needs were of the intensity of a primary health need. He says this is because she needed consistent prompting for nutritional intake and the frequency of prompting required along with the severity of the failure to meet the need evidences the intensity of it. He also says Mrs K’s mobility needs were intense as she needed two carers for transfers and repositioning regularly. He also says she needed two members of staff for all continence and skin care, and without this there would be a significant impact on her skin. He says she needed several interventions a day.

44. The report shows how the IRP considered the intensity of Mrs K’s needs in detail, and whether these were evidence of a primary health need. It considered how severe her needs were and looked in detail at how often her interventions were required, how long they took and how many carers were involved, particularly as Mr F’s submission was that these things indicated her needs were intense. The IRP found whilst she required two members of staff for moving and handling this was routine and good practice. There was no evidence to suggest it took a long time to complete those interventions.

45. The IRP concluded whilst Mrs K was unable to initiate or carry out her own care independently, the amount of care needed, frequency of interventions and length of time taken were all within the level of care the local authority could provide. It did not find Mrs K’s needs were of a level demonstrating a primary health need. We have considered the information in its report, and in Mr F’s submission, and we cannot see it made a mistake here. We think it followed the National Framework.

Complexity

46. The National Framework says complexity ‘is concerned with how the needs present and interact to increase the skill required to monitor the symptoms, treat the condition(s) and/or manage the care.

47. Mr F has said his mother’s cognitive impairment, inability to communicate, and her needs resulting from that impact on each other. He told the IRP they are interrelated, complex and difficult to manage.

48. The IRP accepted there was interrelation in Mrs K’s needs but not that this added a high degree of complexity to her care as Mr F thought. It agreed her cognitive impairment impacted her needs in other domains. It went through these interactions but said they did not add to a complexity of need. It did not think these needs were difficult to manage as the records indicated they were successfully completed on a day-to-day basis. For example her prompting and supervision at mealtimes, skin care and monitoring, continence care and medication.

49. It said the carers needed to be aware of the totality of her needs and any risks, but the interventions were not complex. The submission did not indicate there were difficulties with managing her needs, it was problematic to alleviate her needs, or that skilled carers/ knowledge was needed to address her needs. There was no indication she made it more difficult for staff to provide the support. The IRP explained the records indicated her needs were well managed. We think this is supported by Mrs K’s records. We think the IRP made its decision here in line with the National Framework.

Unpredictability

50. The final key characteristic of a person’s level of need is unpredictability. The National Framework defines it as ‘the degree to which needs fluctuate and thereby create challenges in managing them. It also relates to the level of risk to the person’s health if adequate and timely care is not provided. An individual with an unpredictable healthcare need is likely to have either a fluctuating, unstable or rapidly deteriorating condition.’

51. Mr F’s submission says Mrs K’s needs were unpredictable. He says she requires continuous monitoring and review across her care, and her needs within the domains could change at very short notice. He said this means the possible requirement for an increased level of support suddenly. He said the nature of Mrs K’s Alzheimer’s dementia is unpredictable. Mrs K has epilepsy medication and Mr F said she could suffer a seizure at any time regardless of whether her medication is managed correctly. He also says her continence needs do not follow a set pattern, and she is unable to tell carers about any incontinence. He says that exacerbates her skin needs and presents a risk to her health and wellbeing.

52. The IRP concluded that whilst Mrs K’s Alzheimer’s deteriorated, there was little change in her needs at the time of being reviewed and no evidence staff had to deviate from her planned care. Staff were able to anticipate her needs and support them. The IRP did not find evidence Mrs K’s risk of seizures was unpredictable, as they are managed with routine medication which was successfully preventing them. There was no indication any additional care or monitoring was required for this. The IRP also explained why her continence issues were not unpredictable, because they were always managed in the same way by changing her continence products and monitoring and treating her skin as required.

53. If a person has unpredictable needs, we would expect to see their care plans needed amending frequently, or evidence that carers often needed to act outside existing care plans to meet the person’s needs. There is no indication this was the case for Mrs K. Her care plans were stable and carer could meet her needs using those care plans. We think the IRP’s report explains what the National Framework expects it to cover in this characteristic. We do not think it made a mistake when it said Mrs K’s needs were not unpredictable.

54. We appreciate Mrs K was entirely dependent on the care she received, and we do not with to undermine this or any challenges faced in meeting her needs. We understand why Mr F therefore feels his mother’s needs are significant. We do not wish to take away from this with our decision. We are satisfied there are no failings in how the IRP considered Mrs K’s needs across the domains we looked at, and how it applied the primary health need test.

1. We have carefully considered the complaint Mr F brought us on behalf of his mother, Mrs K, about how NHS England reviewed the local ICB’s decision Mrs K was not eligible for continuing healthcare funding (CHC). We have seen no indication NHS England did anything wrong when it considered this.

2. We are sorry to read Mr F’s account, through his representative, of his mother’s health and we can clearly see the impact her Alzheimer’s disease has had on her. We acknowledge this is a difficult process for Mr F and his family.

3. We have reviewed all the relevant evidence, and we are satisfied NHS England acted in line with the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care.