Birmingham and Solihull Integrated Care Board

4. Mrs Q complains that Birmingham and Solihull Integrated Care Board (ICB) did not make an eligibility recommendation after doing a continuing healthcare (CHC) decision support tool (DST) assessment for her mother, Mrs E, on 8 February 2024.

5. She believes her mother may have been entitled to CHC funding and therefore, she may not have received the care she needs. She cannot appeal that the ICB did not put a CHC package in place after February 2024 because there is no eligibility decision from this time.

6. Mrs Q also complains that the ICB did not accept positive checklists that the care home submitted in April and July 2025. She is unhappy the ICB compared her mother’s needs to the discontinued 2024 DST to justify not doing another one in 2025. She says the ICB’s decision not to do a DST in 2025 means her mother did not receive the full assessment she was entitled to.

7. Mrs Q complains that the ICB agreed her mother was eligible for funded nursing care (FNC) in February 2024 and August 2025. But it did not arrange this care until September 2025 and then ‘backdated’ it to April 2025. This means her mother did not receive the nursing care she needed.

8. Mrs Q complains the ICB’s communication throughout this process has been inadequate and inaccurate. She has found this stressful, and it has caused her anxiety. She says the ICB’s actions have made trying to resolve the issues unnecessarily time-consuming.

9. Mrs Q wants the ICB to review its decision not to issue an eligibility recommendation in February 2024 and give her a decision so that she has the option to appeal if necessary. She wants the ICB to complete a full DST following the positive checklists in 2025. She wants the ICB to involve her in the process properly. She also wants a financial remedy recognising the emotional impact she has experienced and the time she has spent trying resolve the issues.

10. CHC is a package of care for people who have a ‘primary health need’. An ICB will decide this by doing a CHC assessment after receiving a positive checklist. A multidisciplinary team (MDT) completes a decision support tool (DST). If that shows the person has a primary health need and is eligible for CHC, the ICB will fund all their health and social care needs.

11. Mrs E was in her late 90s in early 2024 and lived in a care home. She had issues with her mobility, had had a stroke and did not have capacity to represent herself. Her care home completed a checklist for her, which was positive. The ICB arranged an MDT assessment to complete a DST in February 2024.

12. The ICB and local authority disagreed on four of the care domain weightings. The ICB said Mrs E was not medically optimised so it could not make an eligibility recommendation.

13. The ICB held a resolution meeting with the local authority in May 2024. It did not make an eligibility decision.

14. In April and July 2025 the care home sent the ICB three positive checklists. It did not do a new assessment, but it did say Mrs E was eligible for funded nursing care (FNC). An ICB funds FNC for a person who does not have a primary health need but has some nursing needs and is receiving care in a home with nursing provision. It is paid directly to the care home.

15. Mrs E died in early 2026.

19. Mrs Q is extremely frustrated that the ICB never decided whether her mother was eligible for CHC in the two years before she died. She does not feel the ICB has been fair and she is worried her mother did not have the right level of care. She says the whole process has been extremely confusing and has caused her stress, anxiety and extra work. She says it was very difficult to get any information from the ICB about what it was doing.

20. When the ICB stopped the CHC assessment in February 2024 without making an eligibility decision, it said this was because Mrs E was not medically optimised. It said she needed mental health and falls risk assessments. It also said her medical and care providers needed to help resolve various issues before it could complete its assessment.

21. Mrs Q says the ICB’s decision was not in line with Mrs E’s records and care plans. She says the ICB asked carers and medical professionals to do things they could not, such as making sure her mother was compliant with taking her medication. She believes Mrs E was medically optimised. She says the ICB wrongly refused to make a decision in 2024.

22. The National Framework says it is not appropriate to start the CHC assessment process (do a checklist) if the person has ‘short-term health care needs or is recovering from a temporary condition and has not yet reached their optimum potential’. In this situation an assessor would not have a full understanding of the person’s likely long-term needs to make an evidence-based decision. It also says that if a positive checklist is done in hospital, then it may be appropriate for an ICB to delay doing the full CHC assessment until the person’s ongoing needs are known.

23. Neither of these points strictly apply to this case. The CHC assessment process had already started – Mrs E already had a positive checklist – and that checklist was not done in hospital. But the principle of the National Framework applies. That is, an ICB should only decide whether a person has a primary health need when it has full information about their ongoing needs. The ICB felt it did not have full information about Mrs E’s ongoing needs, so we have looked at whether that was justified.

24. The ICB said ‘not medically optimised’ means a person:

• is in an acute or unstable phase • is awaiting treatment or further medical intervention • has fluctuating needs due to recent illness, surgery, or a temporary condition.

25. We asked our adviser about this. They said optimal health in the context of a CHC assessment means the person does not need further interventions for their needs before an ICB can assess them. They said an assessor should consider what interventions have already been tried.

26. Our adviser noted Mrs E was in her late 90s in 2024, with a deteriorating condition of dementia. The records do not show she had short term health needs or was recovering from a temporary condition. Because of her age and what was wrong with her, our adviser said Mrs E’s conditions were not going to improve in the way the ICB appears to have suggested they might.

27. We can see from the records that Mrs E’s carers and medical professionals had already tried various interventions to manage her conditions and associated needs. The community mental health team (CMHT) had discharged her in late 2023 because it said it could not offer anything else that would help her in the future. In February 2024 the CMHT said changing her medication regime to calm her behaviour would increase Mrs E’s risk of falls because she was very mobile but frail.

28. The records also indicate Mrs E was compliant when taking her medication. Mrs E was prescribed paracetamol, senna for constipation and an ointment for her skin. Our adviser said her medication was simple to give her and monitor.

29. We can also see Mrs E had 24 hour 1:1 care but still had falls. It is not clear what extra information the ICB needed about this aspect of her care that it did not already have in February 2024.

30. When we weigh up the evidence, we think Mrs E was as medically optimised as she would ever be in February 2024. Her condition was not going to improve. The things the ICB asked for had already been considered and actioned as far as possible, and nothing was likely to change.

31. We have found the ICB’s rationale for stopping the CHC assessment and not making an eligibility decision in 2024 was not evidence-based. We think it should have made its decision based on Mrs E’s needs at the time.

32. We set out the impact of this later in the report. We next look at what the ICB did after this point.

33. Mrs Q says the ICB did not go back to complete a CHC assessment for her mother before she died. She highlights that the ICB did not accept new positive checklists from the manager of Mrs E’s care home in April and July 2025. Mrs Q says the lack of a completed CHC assessment before Mrs E died means she may not have had the care package she needed during that time.

34. There are a couple of sections of the National Framework that are relevant here. It says an MDT must make a recommendation to an ICB as to whether the person is eligible for CHC. This is supported by NHS England, who told us ICBs must make sure DSTs are not left incomplete.

35. The National Framework sets out the type of health and social care professionals who can complete a checklist. This includes registered nurses, GPs, clinicians or local authority staff including care managers. It says it is for the ICB and local authority to identify who can do this locally, but it should be someone involved in assessing or reviewing the person’s care as part of their day-to-day work.

36. The ICB told care homes in early April 2025 it was changing its policy about who it would accept checklists from. This was a health or social care practitioner trained in their use, which it defined as a patient’s GP, social worker or district nurse. It says the checklists the care home manager sent in April and July 2025 were not in line with this policy.

37. The ICB also gave other reasons for not accepting the checklists. It said the care home manager had not submitted the April 2025 checklist correctly. It said the checklist could be resubmitted via the online portal. It also asked the care home to give more information in various sections of the checklist. The care home manager sent a second checklist in late April with more information in it, by email. The ICB did not accept this because it was not sent via its portal. It reminded the care home to use the portal. The care home manager submitted another positive checklist, via the portal, in July. The ICB still did not think Mrs E was medically optimised enough for a full CHC decision. But it says it decided Mrs E was eligible for FNC.

38. We can see the ICB gave three different reasons for not accepting the positive checklists in April 2025: who it got them from, how they were sent and whether there was all the relevant information in them. We look at each of those reasons.

39. Our ‘Principles of Good Administration’ say public bodies should have policies and procedure that are clear, accurate, complete and understandable. And they should follow their own policy and procedural guidance. Our principles say public bodies should behave helpfully, dealing with people promptly. And they say public bodies should treat people with sensitivity, bearing in mind their individual needs, and respond flexibly to the circumstances of the case.

40. The ICB said it would no longer accept checklists from care homes. And it flagged this when the care home manager sent the first April checklist. But the ICB continued to invite the care home manager to submit further checklists. Its policy was not clear or accurate. This does not ultimately appear to have been the reason the ICB did not do a full CHC assessment, but it added confusion to an already confusing situation.

41. After the care home manager submitted a checklist with the additional information the ICB had said was missing from the first, the ICB declined the second April checklist on the grounds that it had not been submitted via the portal. This was merely an administrative point. We do not think it was good reason, as there was a person who may have needed CHC waiting in the background. The ICB did not deal with the matter promptly, did not bear Mrs E’s needs in mind, and did not respond flexibly to the situation.

42. In June 2025 Mrs E wrote to the ICB to complain. In July 2025, the care home sent a further positive checklist. The ICB declined this on the basis that Mrs E was still not medically optimised. Our adviser said there is no indication from the information in the checklist that her needs had become less since February 2024. So for the same reasons we set out earlier, we do not think this was an evidence-based decision.

43. When we weigh up the evidence, we think the ICB had grounds to ask for more information when it got the first April 2025 checklist. But the evidence indicates the ICB’s reasons for rejecting the second April and the July checklist were not justified.

44. When it rejected the July checklist, the ICB decided Mrs E was eligible for FNC. The records show it began sending FNC payments to the care home in late July 2025. It told Mrs E’s family its decision in August. In November 2025 the ICB wrote to Mrs Q and said it would backdate the funding of Mrs E’s nursing care to April 2025, when it received the first checklist that year from the care home.

45. FNC is paid directly to care homes. It is for an additional level of care in specific care areas that an ICB has identified needs to be provided by a registered nurse. The National Framework says an ICB cannot decide a person is eligible for FNC without first having decided if they are eligible for CHC. This is because the ICB must decide first if the person has a primary health need.

46. NHS England told us it would consider any payment in such circumstances as not actually FNC but a ‘without prejudice’ payment.

47. In line with the National Framework, an ICB can decide a person has nursing needs and is eligible for FNC on the basis of a checklist or a DST. If a checklist is negative or a DST does not indicate CHC eligibility, either could still show a person has some nursing needs. But we do not think this applied in Mrs E’s case. We would expect a clear audit trail of the ICB’s decision making, to show it had acted in line with the National Framework and its policy and guidance, as our principles say. But there is no evidence of this from the records we have seen.

48. The ICB should not have made a decision about FNC in July because it had not yet made a decision about CHC. It later decided to ‘backdate’ the FNC to April 2025, based on this being when the care home sent the first two checklists of that year. But it had rejected those checklists, so it should not have made any decisions based on them.

49. The ICB felt its backdating of ‘FNC payments’ was a goodwill gesture. We would theoretically agree on the basis that FNC cannot be backdated, because a care home cannot retrospectively provide an additional level of care. But the ICB also told us Mrs E was in a home which provided nursing care, and she required the involvement, supervision, and oversight of a registered nurse due to the complexity of her assessed needs. It said the home was giving Mrs E this additional care from April 2025. The ICB paid the backdated FNC to the care home, so it did not give Mrs E anything as a goodwill gesture.

50. Although the care home did not specify this in the first April 2025 checklist, in line with the National Framework, a change in the care in a person’s needs is a prompt to do a new CHC checklist. So it would follow that the care home did this in response to an increase in the level of care Mrs E needed.

51. Although the ICB’s decision making about FNC was flawed, it had evidence Mrs E had some nursing needs three months before it started paying this. It if was going to make a decision about FNC in the absence of a decision about CHC, it is unclear why it could not do this as soon as it had the evidence. The evidence we have seen indicates the backdated payment was more than a goodwill gesture, it was for nursing care Mrs E needed and had got But either way, paying FNC is not an adequate replacement for a full and thorough CHC assessment and decision.

52. When we weigh up the evidence, we have found the ICB did not act in line with the National Framework or our ‘Principles of Good Administration’ when it received the second April and July checklists and in how it made its decisions about paying FNC. We set out the impact of this later in this report.

53. Lastly, we looked at Mrs Q’s concerns about the ICB’s communication. She says she did not know what was happening about her mother’s eligibility decisions. She says the ICB did not explain the CHC process to her or send a copy of the incomplete DST before its local resolution meeting in 2024. She says this meant she could not support her mother or properly challenge what the ICB was doing.

54. We have looked at what the ICB said in its response to her complaint. It acknowledged it did not contact her about the original meeting to complete the DST, so she could not be there to put forward her views. It acknowledged it did not explain to her what had happened after the meeting. It also acknowledged that it did not provide her with all the details she needed before the local resolution meeting in 2024 and failed to keep her properly informed of decisions in 2025.

55. Our ‘Principles of Good Administration’ say organisations should communicate with people clearly in a way which is appropriate to their circumstances. From the ICB’s own response, it is clear it did not act in line with our principles in how it communicated with Mrs Q.

Summary and impact

56. On the basis of the evidence we have seen we have found the ICB:

• should have made a CHC decision for Mrs E after it got the February 2024 checklist • wrongly rejected the second April and the July 2025 checklists • made decisions about FNC before making a CHC decision and three months after it had evidence of her nursing needs • communicated poorly with Mrs Q.

57. We have found that what the ICB got wrong:

• denied Mrs E a decision about whether she was eligible for CHC in her lifetime • denied Mrs E, or Mrs Q on her behalf, the opportunity to challenge or appeal a CHC decision in line with the NF because there was no decision • has caused confusion, frustration, stress and extra work for Mrs Q throughout the process, and caused her to lose faith in the ICB, which it compounded by its poor communication • has significantly drawn out the process for Mrs Q since early 2024.

58. We cannot say if the ICB would have found Mrs E eligible for CHC in 2024 or 2025 if it had made eligibility decisions then. But there remains the possibility that Mrs E did not get the level of care she needed and that she may have wrongly had to pay for her care.

1. We have found the ICB got something wrong when it did not complete a full continuing healthcare (CHC) assessment for Mrs E in February 2024. We have found it wrongly rejected two CHC checklists in April and July 2025. We think it should have decided whether Mrs E was eligible for CHC before it paid funded nursing care (FNC) from July 2025. Given the reason it did pay FNC, we the evidence shows it should have done so three months earlier. We think its communication with Mrs Q throughout was poor.

2. We have found the ICB denied Mrs E a full CHC assessment in her lifetime, and Mrs Q the chance to appeal. It caused Mrs Q frustration, stress and anxiety and has also made the process much longer than it should have been for her. We do not think the ICB has done enough to put things right. We are upholding the complaint overall.

3. We are recommending the ICB apologises and pays Mrs Q £750 to recognise the upset and frustration its mistakes caused her. We are recommending it assesses whether Mrs E should have been eligible for CHC. And it should explain how it will improve its service.

59. We make recommendations in line with our Principles for Remedy which are reflected in the ‘NHS Complaint Standards’. These say organisations should identify instances where things have gone wrong, take responsibility for these and find ways to put things right for those involved. They should learn from complaints to improve services.

60. The ICB did not recognise it should have made a CHC eligibility decision for Mrs E. We can see it apologised for not communicating with Mrs Q as it should have done. It set out that it would learn from the communication issues, which is in line with the NHS Complaint Standards. But we do not think this is enough, in the context of what we have found the ICB got wrong.

Recommendation 1

61. We recommend the ICB writes to Mrs Q within a month of this report to acknowledge what it got wrong in its management of the CHC process for Mrs E in 2024 and 2025. It should apologise for the frustration, stress, anxiety and loss of faith this caused Mrs Q.

Recommendation 2

62. We expect organisations to compensate people appropriately if they cannot return them to the position they would have been in if the poor service had not occurred. In some cases, this means a financial remedy. To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale.

63. We recommend that within one month of the date of our final report the ICB pays Mrs Q £750 to recognise the emotional impact of its mistakes on her.

Recommendation 3

64. No action the ICB takes now can change the care Mrs E had while she was alive. But there is provision within guidance that sits alongside the National Framework for ICBs to consider if a person was eligible for CHC during a past period. This is called a previously unassessed period of care (PUPoC) assessment. If a person is found eligible for CHC retrospectively, the ICB can reimburse them (or their estate if they have died) their contribution to the costs of their care.

65. We recommend that the ICB does a PUPoC assessment of Mrs E’s needs, taking into account the positive checklists between February 2024 and July 2025. For completeness, we suggest the ICB considers the period from February 2024 to when Mrs E died in 2026.

66. This will determine whether Mrs E should have been eligible for CHC during that period, and if not will allow Mrs Q to challenge the decision via the appeals process.

67. We are aware of the CHC pressures on ICBs and that assessments can take a long time, particularly as they must prioritise assessments for individuals who may need care now. We recommend that within one month of the date of our final report, the ICB sets out a realistic timetable for the PUPoC assessment and gives Mrs Q the details, taking into account that a full CHC assessment for Mrs E has already been delayed since 2024.

Recommendation 4

68. We recommend that within three months of the date of our final report, the ICB should create an action plan to address what we think it got wrong. This should include the reason for the failings (where possible), any relevant changes the ICB has already made or actions it will take now to address the issues in this complaint, who is responsible for each action, the timescale for completion, and how it will be monitored. It should share this with Mrs Q.

69. The ICB should send us evidence it has completed all the recommendations we make in the final report.