‘Optimising’ and NHS Continuing Health Care (CHC)
A recent ombudsman report concerns a shocking (but not untypical) example of how NHS Integrated Care Boards (ICBs) are developing local policies that frustrate the principles and practices detailed in the 2022 National Framework. Policies that objectively prioritise an ICB’s ‘resources and targets ahead of the needs of its service users’ and, indeed, the interests of councils.
What follows is a summary (with comments) of the excellent ombudsman report which, however, deserves reading in full.
The case[1] concerned the discharge from hospital of a disabled person with multiple health conditions. The ‘professionals’ determined at a best interest meeting that he should move to a nursing home. They also agreed, unanimously, that it was unlikely that there be any significant change to his needs after he left hospital – that he would not benefit from rehabilitation or any other form of time-limited input – and that he had a primary health need and was likely to be eligible for CHC funding.
In accordance with the English Hospital Discharge Guidance,[2] the hospital policy had four pathways for discharge planning. Pathways 0 and 1, for patients who could return home, with or without support; Pathway 2, for patients who needed rehabilitation, assessment, care planning or short-term intensive support somewhere other than their own home; and Pathway 3, for people who needed to be discharged to a care home for the first time and for complex discharges. The hospital decided that he should be discharged under Pathway 3.
For the discharge to proceed, the nursing home needed to know who was going to pay its fees. In this case the fees could have been paid by the ICB, the council or the family (alone or in combination). Given that the relevant professionals were of the view that he was likely to be eligible for CHC funding, his family asked that this be assessed while he was still an inpatient – or that the ICB arrange interim NHS funding to cover the cost of the placement until his eligibility for CHC was determined. On the face of it, these seem to have been the most sensible options, but the ICB refused to do either.
The ICB had a local policy that blocked decisions concerning eligibility for standard CHC funding,[3] by refusing to accept CHC Checklists for hospital inpatients, until ‘an onward care package has been arranged for them’ – and neither it nor the council had done this.
The council was in a difficult position. It believed that he was eligible for CHC funding, which (if so) meant that it would be unlawful for it to fund his care. On the one hand, the ICB’s local policy meant that it could not move this process on by completing a Checklist – while on the other hand, if it funded his interim care (in order to facilitate the hospital discharge) it needed to undertake an assessment of need and an assessment of the patient’s finances (for charging purposes) – to which the family objected.
The disabled person was, however, discharged to a nursing home in October 2024 and a month later the ICB accepted that he was eligible for CHC funding. A dispute then arose as to whether the family or the ICB should pay the care home fees that arose prior to the CHC funding decision.
The ombudsman had little difficulty in finding maladministration. The 2022 Framework guidance (para 107(e)) requires that ICBs ensure that a variety of pathways exist for assessing eligibility for CHC, including the completion of Checklists in an ‘acute hospital and a full assessment of eligibility for CHC’ taking place before discharge – as does the Discharge Guidance which notes that ‘there may be rare circumstances where assessments for CHC may take place in an acute hospital environment’ (chapter 8). The ICB’s rigid policy was contrary to this guidance and meant that there was ‘no such provision for people who are deemed to have no potential for improvement’. In addition, it was maladministration for the ICB to have a ‘blanket policy of refusing to accept CHC referrals for them until other organisations have arranged onward care and support for them’.
In relation to the ICB’s justification for having such a policy – namely that ‘without it, its resources would be under undue pressure to complete full CHC assessments in the community within 28 days of receipt of the referral’ the ombudsman observed, that this:
puts the ICB’s resources and targets ahead of the needs of its service users. This policy approach is fault and not in line with the National Framework or the Discharge Guidance. This is because it prevents the Council from fulfilling its responsibility to advise the ICB of patients who are likely to be eligible for CHC as soon as possible. And, it avoidably delays the CHC assessment process for service users.
Perverse ICB policies and practices of this kind are rife. Examples include: gatekeeping barriers that result in Checklist delays/refusals – such as the ICB asserting that a patient’s health has not yet ‘optimised’ but simultaneously refusing to fund their care package until it has optimised; ICBs pre-scoring Decision Support Tools (DSTs) (or rescoring them after a MDT assessment); ICBs imposing ‘no double-scoring’ rules for DST assessments; ICBs arguing that behaviours are not ‘unpredictable’ but ‘predictable/unpredictable’; ICBs asserting that ‘nursing needs’ have to be ‘needs requiring a qualified nurse’; ICBs unilaterally withdrawing funding from patients previously considered to be eligible for CHC; and so on.
The July 2026 Survey of Directors of Adult Social Services (ADASS)[4] referred to the ‘urgent attention’ that was needed in consequence of the ‘ongoing reduction in the number of people receiving CHC’ which it considered ‘flies in the face of our ageing population’. The report noted that three-quarters of Directors referred to ‘an increase in the number people presenting to adult social care who were or would have previously been eligible for CHC’; that the ‘focus on which organisation is responsible for paying distracts from focusing on the person and care they need’; and that ICBs ‘are failing to invest in services vital for supporting people in the community, including CHC’. This echoes concerns in previous surveys, for example its 2025 report[5] spoke of ‘restricted eligibility’ for CHC; that almost three quarters said ‘that more people are having their CHC reviewed and found ineligible’ and that ‘75% of Directors reported an increase in the number people presenting to adult social care who were or would have previously been eligible for CHC’ and that changes to CHC ‘Delivery need to be done in full consultation’ with councils and not ‘imposed’ on them.
2026 research by the Kings Fund[6] noted that its finding concerning the variation in access to CHC between ICBs was ‘a longstanding issue, with eligibility rates for standard CHC ranging from as low as 2% to as high as 35%’ and expressed the view that this was due to ‘inconsistencies in how the national framework is interpreted and applied at a local level, which raises questions about fairness and creates significant uncertainty for families’. The research found that between 2017 and March 2026 the proportion of applicants for Standard CHC assessed as eligible, fell from nearly 1 in 3 to less than 1 in 5 (31.25% to 16.65%). 2025 research by the Nuffield Trust reported similar findings – namely that the number of people eligible for CHC varied significantly across England and that ‘local area characteristics cannot fully explain the variation in eligibility’.[7] The report included the following quote from a care provider:
In [parts of the ICB], trying to get a DST [completed] for some of our clients is very difficult. We get sent a paper to fill in. Then we get told it’s not the right paperwork. Then we get told it’s a different health professional that has to complete it. So we don’t know from which patient that we’re talking about, whether we’re going to get that same service.
Perverse policies and practices of this kind lead to increased discharge delay’s, distress for patients and their families. They shunt costs that ICBs should bear onto councils as well as creating for them, significant and unnecessary administrative burdens and undermining their efforts to develop ‘joint working’ relationships.
Of course, practices of this kind will impact on many more families than the one that brought this flawed policy to the attention of the ombudsman. Many families will be unaware that such a policy is unlawful or – for understandable reasons – decide that it was not worth challenging. In this context it should be noted that although the ombudsman considered this was ‘not a complex complaint to investigate’ it took the ICB from October 2024 until the end of August 2025 to respond (by rejecting the complaint).
The issues considered in this posting cannot be dismissed as a ‘one off’ failure. ICBs are, in my experience, acting in this way routinely – knowing that they are, in essence, unaccountable. NHS England and the Department of Health and Social Care have the power to intervene; the power to issue corrective guidance and directions; the power to hold a tight rein in cases such as this and to ensure that the letter of the Framework Guidance is followed. But this is not happening.
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[1] Local Government and social Care Ombudsman Wirral MBC & NHS Cheshire and Merseyside ICB (25 010 609): 26 May 2026
[2] Department of Health and Social Care Hospital Discharge and Community Support Guidance 2024.
[3] There is no suggestion in the report that the patient might have been eligible for CHC funding via the Fast Track route.
[4] ADASS Spring Survey July 2026
[5] ADASS Spring Survey 2025.
[6] Kings Fund ‘No man’s land’: the experience of patients at the interface between health and social care’ (2 June 2026).
[7] R Hutchings, E Dodsworth et al ‘All or nothing? Access and variation in NHS continuing health care’ Nuffield Trust 2025.
Posted 17 July 2026