NHS England

3. Mr U complains about NHS England’s decision to uphold NHS Cheshire and Merseyside Integrated Care Board’s (the ICB) decision his wife, Mrs U, was not eligible for NHS CHC, following an Independent Review Panel (IRP) in June 2025.

4. Mr U disagrees with how the IRP considered: • the domains of Skin, Mobility, Psychological and Emotional Needs, Behaviour, and Drug Therapies and Medication • the four key characteristics • his wife’s eligibility, given the domain weightings it agreed with.

5. Mr U says as a result, his wife had to pay for care costs which the NHS should have covered.

6. As an outcome, Mr U wants NHSE to reconsider its decision.

7. Mrs U’s medical history includes a diagnosis of mixed dementia, and she moved to a residential home in October 2021.

8. Mrs U’s needs increased following a hospital stay in 2023, and she moved to the care home where she currently still resides in October that year.

9. In November 2023 a positive checklist triggered a full DST assessment, which a multidisciplinary team (MDT) completed the same month. The outcome of the DST was that Mrs U was not eligible for NHS CHC, and a social worker informed Mr U of this on 7 December.

10. Following an internal ratification process, Mr U appealed the ICB’s decision on 19 February 2024. A local resolution meeting (LRM) took place on 2 October, which upheld the original decision.

11. Mr U applied for an independent review of the decision through NHSE’s IRP process. NHSE held an IRP meeting in June 2025. It is this process which we are considering in this complaint.

14. Before we discuss our decision, we would like to explain some information about how an IRP reaches its decision, and what this means for how we look at it.

15. The National Framework sets out that an individual, or their representative, may ask NHSE to arrange an IRP to review a ICB’s decision to decline NHS CHC.

16. The purpose of the IRP is to review the procedure followed by the ICB in reaching its decision about an individual’s eligibility for NHS CHC.

17. It is our role to decide whether the IRP made the decision that Mrs U was not eligible for NHS CHC in line with the National Framework. We cannot question discretionary decisions when these have been made without maladministration (fault). This includes decisions about eligibility for NHS CHC, where the decisions are based on clinical judgements. The fact that someone else has a different opinion does not mean there must have been a fault in the decision-making process.

18. The National Framework sets out that the diagnosis of a particular disease or condition does not in itself determine eligibility for NHS CHC eligibility, and this decision should be made based on the individual’s assessed needs.

19. The IRP can also reach a view as to whether the individual should or should not be considered to have a primary health need. If it is established the individual has a primary health need, they will be eligible for NHS CHC.

20. When we consider a complaint about an IRP, we look at whether it took account of all the relevant information provided to it in reaching its decision about whether this was the case.

Skin

21. Mr U complains about how the IRP considered the domain of Skin, and says his wife met the criteria for a High level of need in this domain.

22. Mr U says staff treat his wife with Mepilex Border Heel dressings, which are specialist dressings.

23. The IRP agreed with the ICB in its assessment of a Moderate level of need in this domain.

24. The DST defines High needs in this domain as, ‘Pressure damage or open wound(s), pressure ulcer(s) with ‘partial thickness skin loss involving epidermis and/or dermis’, which is not responding to treatment.’ or ‘Pressure damage or open wound(s), pressure ulcer(s) with ‘full thickness skin loss involving damage or necrosis to subcutaneous tissue, but not extending to underlying bone, tendon or joint capsule’, which is/are responding to treatment.’ or ‘Specialist dressing regime in place; responding to treatment.’

25. The DST defines Moderate needs in this domain as, ‘Risk of skin breakdown which requires preventative intervention several times each day without which skin integrity would break down.’ or ‘Pressure damage or open wound(s), pressure ulcer(s) with ‘partial thickness skin loss involving epidermis and/or dermis’, which is responding to treatment.’ or ‘An identified skin condition that requires a minimum of daily treatment, or daily monitoring/reassessment to ensure that it is responding to treatment.’

26. The IRP documented its consideration of whether Mrs U’s dressings, including the Mepilex Border Heel dressings, are specialist. The IRP concluded they are not, based on the information provided by the ICB representative, who is a nurse. We recognise Mrs U disagrees with this conclusion, but as set out above, we cannot question decisions which are based on clinical judgements.

27. We have seen the IRP considered the domain in line with the National Framework. We have not identified any indications of failings in the IRP’s consideration of Mrs U’s needs as they relate to Skin. We therefore will not consider this aspect of the complaint any further.

Mobility

28. Mr U complains about how the IRP considered the domain of Mobility, and says his wife met the criteria for a Severe level of need in this domain.

29. Mr U says: • his wife is completely immobile and cannot bend at her neck, waist, knees or ankles • carers must lift his wife by a hoist, and her positioning in this is critical.

30. The IRP agreed with the ICB in its assessment of a High level of need in this domain.

31. The DST defines Severe needs in this domain as, ‘Completely immobile and/or clinical condition such that, in either case, on movement or transfer there is a high risk of serious physical harm and where the positioning is critical.’

32. The DST defines High needs in this domain as, ‘Completely unable to weight bear and is unable to assist or cooperate with transfers and/or repositioning.’ or ‘Due to risk of physical harm or loss of muscle tone or pain on movement needs careful positioning and is unable to cooperate.’ or ‘At a high risk of falls (as evidenced in a falls history and risk assessment).’ or ‘Involuntary spasms or contractures placing the individual or others at risk.’

33. We recognise that the wording of the Severe descriptor for this domain is not as clear as it could be. Mrs U being completely immobile, and her positioning in a hoist being critical on moving, do not satisfy this descriptor by themselves. To meet the descriptor, a person needs to be at high risk of serious physical harm on movement or transfer (because of being completely immobile and/or having a clinical condition). The IRP sets out why this was not the case for Mrs U, and Mr U has not suggested his wife was at high risk of serious harm in his complaint to us.

34. We understand how challenging it is to see a loved one’s health deteriorate. We have not identified any indications of failings in the IRP’s consideration of Mrs U’s needs as they relate to Mobility. The IRP considered this in line with the National Framework. We therefore will not consider this aspect of the complaint any further.

Psychological and Emotional Needs

35. Mr U complains about how the IRP considered the domain of Psychological and Emotional Needs, and says his wife met the criteria for a High level of need in this domain.

36. Mr U says his wife has withdrawn from any attempts to engage in care planning, support and/or daily activities due to her psychological illnesses (epilepsy, bipolar, vascular dementia, and Alzheimer’s).

37. The IRP agreed with the ICB in its assessment of No Needs in this domain.

38. The DST defines High needs in this domain as, ‘Mood disturbance, hallucinations or anxiety symptoms, or periods of distress, that have a severe impact on the individual’s health and/or well-being.’ or ‘Due to their psychological or emotional state the individual has withdrawn from any attempts to engage them in care planning, support and/or daily activities.’

39. The DST defines No Needs in this domain as, ‘Psychological and emotional needs are not having an impact on their health and well-being.’

40. As the IRP sets out, this domain is concerned with the needs arising from a person’s psychological and emotional state. Mrs U’s withdrawal from attempts to engage her were because of her severe needs arising from her cognition, rather than her psychological or emotional state. We recognise Mrs U has psychological illnesses, and that these have a profound effect on her. The IRP concluded it had not seen any evidence her health or wellbeing was being affected by her psychological or emotional state, and we have not seen anything which clearly demonstrates this isn’t the case.

41. We have not identified any indications of failings in the IRP’s consideration of Mrs U’s needs as they relate to Psychological and Emotional Needs. The IRP considered this in line with the National Framework. We therefore will not consider this aspect of the complaint any further.

Behaviour

42. Mr U complains about how the IRP considered the domain of Behaviour, and says his wife met the criteria for a Severe level of need in this domain.

43. Mr U says his wife did show challenging behaviour, but does not any more due to her advancing dementia, and use of medication to manage this.

44. The IRP agreed with the ICB in its assessment of No Needs in this domain.

45. The DST defines Severe needs in this domain as, ‘‘Challenging’ behaviour of severity and/or frequency that poses a significant risk to self, others or property. The risk assessment identifies that the behaviour(s) require(s) a prompt and skilled response that might be outside the range of planned interventions.’

46. The DST defines No Needs in this domain as, ‘No evidence of ‘challenging’ behaviour.’

47. We recognise the National Framework says a need should not be marginalised just because it is well managed. As the IRP explains, the National Framework also says management of the need can have a bearing on eligibility when the successful management of it has permanently reduced or removed an ongoing need, such that the active management of this need is reduced or no longer required. The IRP sets out that this is the case for Mrs U, and Mr U has not disagreed with this.

48. We recognise how upsetting it can be to witness changed in behaviour. We have not identified any indications of failings in the IRP’s consideration of Mrs U’s needs as they relate to Behaviour. The IRP considered this in line with the National Framework. We therefore will not consider this aspect of the complaint any further.

Drug Therapies and Medication

49. Mr U complains about how the IRP considered the domain of Drug Therapies and Medication, and says his wife met the criteria for a High level of need in this domain.

50. Mr U says his wife takes a lot of medications, including several which have serious side effects, and one where the dosing is extremely important.

51. The IRP agreed with the ICB in its assessment of a Moderate level of need in this domain.

52. The DST defines High needs in this domain as, ‘Requires administration and monitoring of medication regime by a registered nurse, carer or care worker specifically trained for the task because there are risks associated with the potential fluctuation of the medical condition or mental state, or risks regarding the effectiveness of the medication or the potential nature or severity of side-effects. However, with such monitoring the condition is usually non problematic to manage.’ or ‘Moderate pain or other symptoms which is/are having a significant effect on other domains or on the provision of care.’

53. The DST defines Moderate needs in this domain as, ‘Requires the administration of medication (by a registered nurse, carer or care worker) due to: non-compliance, or type of medication (for example insulin), or route of medication (for example PEG).’ or ‘Moderate pain which follows a predictable pattern; or other symptoms which are having a moderate effect on other domains or on the provision of care.’

54. We recognise that Mrs U is taking a lot of medications and that these require monitoring. However, all people receiving care in a formal setting would have their medication monitored. To meet the descriptor for a High level of need, a person would need to have their medication regime monitored specifically for the reasons given. The IRP set out its consideration of whether there was any evidence of a potential fluctuation of Mrs U’s medical condition, mental state, or potential severity of side effects, and concluded there was not. Mr U has not provided us with any evidence of the contrary.

55. We have not identified any indications of failings in the IRP’s consideration of Mrs U’s needs as they relate to Drug Therapies and Medication. The IRP considered this in line with the National Framework. We therefore will not consider this aspect of the complaint any further.

Nature

56. Mr U complains about how the IRP considered the nature of his wife’s needs.

57. Mr U says: • the nature of his wife’s needs is wide-ranging • his wife’s needs are not incidental and ancillary to the provision of accommodation, as they are health care needs.

58. The National Framework says, ‘Nature: This describes the particular characteristics of an individual’s needs (which can include physical, mental health or psychological needs) and the type of those needs. This also describes the overall effect of those needs on the individual, including the type (‘quality’) of interventions required to manage them.’

59. We recognise that Mrs U has a wide range of needs and that many of these are health care needs. The IRP does not state otherwise, just that it considers the health needs she does have are not incidental and ancillary to the provision of accommodation, and do not indicate a primary health need. Mr U has not provided us with any specific concerns with the IRP’s consideration, other than the fact he disagrees with the conclusion it came to.

60. We have not identified any indications of failings in the IRP’s consideration of the nature of Mrs U’s needs. We therefore will not consider this aspect of the complaint any further.

Intensity

61. Mr U complains about how the IRP considered the intensity of his wife’s needs.

62. Mr U says: • his wife had a large quantity and degree of need, and her need for continuity of care is clear • his wife’s assessed needs were towards the higher end of intensity in the diagram from the National Framework

63. The National Framework says, ‘Intensity: This relates both to 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’).’

64. Mr U has not provided us with any specific concerns with the IRP’s consideration, other than the fact he disagrees with the conclusion it came to. There is also no specific threshold for what combination of domain weightings would indicate an intensity of needs to indicate a primary health need.

65. We have not identified any indications of failings in the IRP’s consideration of the intensity of Mrs U’s needs. We therefore will not consider this aspect of the complaint any further.

Complexity

66. Mr U complains about how the IRP considered the complexity of his wife’s needs.

67. Mr U says: • his wife’s inability to communicate made her other needs much more complex • the IRP mentioned his wife not needing specialist services, when the National Framework is clear a decision on eligibility should not be based on this • funded nursing care is mentioned despite this not having anything to do with eligibility.

68. The National Framework says, ‘Complexity: This 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. This may arise with a single condition, or it could include the presence of multiple conditions or the interaction between two or more conditions. It may also include situations where an individual’s response to their own condition has an impact on their overall needs, such as where a physical health need results in the individual developing a mental health need.’

69. We recognise that Mrs U’s inability to communicate made her other needs more complex. The IRP also recognises this, but sets out its consideration that this is not to a level which indicates a primary health need. Mr U has not provided us with any specific concerns with the IRP’s consideration here, other than the fact he disagrees with the conclusion it came to.

70. The consideration of whether or not a person’s needs require specialist staff or services is an important one across the domains and other considerations. We are not sure what Mr U has read in the National Framework which makes him believe otherwise. The IRP mentioned funding nursing care as this is what Mrs U is in receipt of, in the absence of NHS CHC.

71. We have not identified any indications of failings in the IRP’s consideration of the intensity of Mrs U’s needs. We therefore will not consider this aspect of the complaint any further.

Unpredictability

72. Mr U complains about how the IRP considered the unpredictability of his wife’s needs.

73. Mr U says his wife’s assessed needs were towards the higher end of unpredictability in the diagram from the National Framework

74. The National Framework says, ‘Unpredictability: This describes 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.’

75. Mr U has not provided us with any specific concerns with the IRP’s consideration, other than the fact he disagrees with the conclusion it came to. There is also no specific threshold for what combination of domain weightings would indicate an unpredictability of needs to indicate a primary health need.

76. We have not identified any indications of failings in the IRP’s consideration of the unpredictability of Mrs U’s needs. We therefore will not consider this aspect of the complaint any further.

Eligibility decision

77. Mr U complains about how the IRP considered his wife’s eligibility, given the domain weightings it agreed with.

78. The National Framework says, ‘Although the tool supports the process of determining eligibility and ensures consistent and comprehensive consideration of an individual’s needs, it cannot directly determine eligibility. Indicative guidelines as to threshold are set out in the tool (for example, if one area of need is at Priority level, then this demonstrates a primary health need), but these are not to be viewed prescriptively. Professional judgement should be exercised in all cases to ensure that the individual’s overall level of need is correctly determined. The tool is to aid decision-making in terms of whether the nature, complexity, intensity or unpredictability of a person’s needs are such that the individual has a primary health need.’

79. The IRP set out its consideration of whether it believed Mrs U had a primary health need, given the domain weightings, the four key characteristics, and the incidental and ancillary test, and concluded she did not. We have not identified any indications of failings in the IRP’s consideration of Mrs U’s eligibility. We therefore will not consider this aspect of the complaint any further.

Conclusion

80. We understand how strongly Mr U feels about his wife’s eligibility. We recognise how difficult it is to see a loved one require care and do not want to take away from his experience. As we have seen the IRP considered Mrs U’s needs in line with the National Framework, we will not consider his complaint any further.

1. We have carefully considered Mr U’s complaint about NHS England (NHSE). We were very sorry to learn about how unwell Mr U’s wife is. We recognise that the NHS Continuing Healthcare (CHC) process can be difficult, time consuming, and emotional.

2. We have decided not to consider Mr U’s complaint any further. This is because we have not found any indications of failings in NHSE’s consideration of Mr U’s appeal.