NHS Continuing Healthcare (CHC) ~ Ombudsman report

The Health Service Ombudsman has published an important CHC report concerning the failure of an NHS Clinical Commissioning Group (CCG) – now known as an Integrated Care Board (ICB).  The Ombudsman’s Press Release has the heading ‘Carer underpaid by £250K after CCG failed to provide correct care funding’.

The report[1] – which can be accessed by clicking here – followed a complaint by the son of an elderly disabled person (known as Mr Q) who was eligible for CHC funding.  Q lived at home and was assessed as needing 24/7 care, equating to 168 hours per week, with his night time care requiring the support of two carers. Mr Q was given a Personal Health Budget (PHB) which was paid in two distinct ways: a notional budget, managed by the CCG, to pay agency staff and a direct payment, managed by Q’s son, to pay for the costs of live-in care.

The CCG seriously mismanaged the arrangement and in consequence a complaint was made which eventually reached the Health Service Ombudsman.  The CCG’s failures included, for example, the fact that (page 7):

[the] live-in carer worked alone during the nights when two carers were needed. The live-in carer worked, or was expected to work, much more than ten hours per day for many years. The CCG did not provide enough funding for additional staffing to support the live-in carer. …. While there is clear evidence that the live-in carer provided an exceptionally high level of care, he had to do so for unacceptable periods of time and for an unacceptable length of time.


Disturbing as this is – it is not an isolated example.  Many CCG’s had, it seems, a cavalier attitude towards their care planning and funding obligations for community living placements.  In 2020 the Health Service Ombudsman highlighted this in a composite report Continuing Healthcare: Getting it right first time[2] – the forward to which states:

We have found not only significant failings in care and support planning but also failings in reviews of previously unassessed periods of care. The impact of these mistakes on people cannot be understated. They constitute an abrogation of basic rights. They have led to people unnecessarily paying out large sums to cover care, or going without care because of incorrect or delayed decisions. Many have faced years of uncertainty about their future finances and experienced stress, anxiety and ill-health as a result. The NHS should be supporting people in their care needs, not needlessly adding to emotional and financial burdens.  The report, among other things recommended that frontline assessing / care planning practitioners have regular CHC competency training. 

The report referred to cases of unacceptable practice that included:

  • A CCG arbitrarily removing a person’s overnight care from a 24-hour CHC-funded care package – which forced the family to pay £33,000 for this care until the ombudsman intervened;
  • A CCG that failed to produce an adequate care plan, forcing an individual to self-fund some 85% of his care – in total paying approximately £250,000 that should have been paid for by the NHS; and
  • A CCG that failed to produce a plan to support a woman to live at home, and then placed an arbitrary cap on CHC funding – which meant that the family paid £187,000 for private care and themselves provided care worth a further £90,000.

The report notes that in these cases the families managed to fund/ provide care themselves – but that these failings ‘could have much more devastating consequences for people who do not have funds to draw on’.

These complaints suggest that many NHS bodies have a mechanistic / managerial approach to care planning: where the individual is simply the object of an impersonal, under-resourced one-size-fits all programme.  In 2018 this was a problem that promoted the Local Government and Social Care Ombudsman to emphasise that:[3]

Any assessment and decision making by a CCG concerning individual need must be ‘person-centred: … placing the individual, their perception of their needs and preferred models of support at the heart’ of the assessment and care-planning process). 


The 2022 Framework Guidance[4] makes extensive reference to the importance of ‘person-centred’ practice – see for example paras 185 – 200 and in PG 4 page 117.  Para 186 for example stresses that:

ICBs should operate a person-centred approach to all aspects of NHS Continuing Healthcare, using models that maximise personalisation and individual control and that reflect the individual’s preferences, as far as possible, including when delivering NHS Continuing Healthcare through a Personal Health Budget, where this is appropriate (refer to paragraphs 320-324)


Key ‘take-away’ points in the most recent Health Service Ombudsman report[5] include:

Contingency arrangements

The crucial importance of care plans anticipating problems and including ‘plan B’ arrangements to address them –– such as what will be happen when a carer is unavailable or a provider terminates its contract: as the report states:

No appropriate contingency plan was put in place for Mr Q. This resulted in further distress and frustration for [his son], who was concerned that there could be a sudden and serious deficiency in his father’s care at any time. A purported facility to directly access contracted emergency agency provision was not available in practice when tested, raising serious safety concerns (page 7).

The need for care plans to anticipate difficulties of this kind by providing for contingency arrangements has also been stressed by the Local Government and Social Care Ombudsman, including the fact that authorities are not absolved from this responsibility simply because these may be difficult to predetermine in certain cases.[6]

Hospital admissions

One contingency that should have been anticipated concerned the payment arrangements for Mr Qs carer if / when Mr Q was hospitalised, for any reason.  The CCG however had no written policy for this which was maladministration.  The report concludes that the ‘CCG should have paid 80% of the live-in carer’s salary … into the PHB account for the time he was in hospital’.

Annual uprating

That health bodies (ie ICBs) should automatically make annual uplifts in the sums paid to PHB holders to cover factors such inflation and rising costs of their employees / Personal Assistants (page 21).


The report emphasises the importance of health bodies complying with their duty to undertake reviews every 12 months, in line with the Framework guidance.  The 2022 Framework Guidance[7] emphasises that

These reviews should primarily focus on whether the care plan or arrangements remain appropriate to meet the individual’s needs. It is expected that in the majority of cases there will be no need to reassess for eligibility.


Although decisions of the Health Service Ombudsman do not have the same status as a court judgment they are highly persuasive and a CCG/ICB would have to have cogent reasons / convincing arguments if they chose to act in a way that conflicted with the one of his findings (the current Health Service Ombudsman is held by Rob Behrens, CBE).


[1] Parliamentary and Health Service Ombudsman Continuing Healthcare: an investigation into Hounslow Clinical Commissioning Group 25 October 2022.
[2] Parliamentary and Health Service Ombudsman Continuing Healthcare: Getting it right first time HC 872 House of Commons (2020).
[3] Complaint no 16 018 767 against South Tyneside MBC, 8 January 2018 and see also PG 4 2022 Department of Health and Social Care National Framework for NHS Continuing Healthcare and NHS funded Nursing Care (2022) page 117.
[4] Department of Health and Social Care National Framework for NHS Continuing Healthcare and NHS funded Nursing Care (2022).
[5] Parliamentary and Health Service Ombudsman Continuing Healthcare: an investigation into Hounslow Clinical Commissioning Group 25 October 2022.
[6] See for example complaint no 15 019 443, against Kent CC, 20 October 2016 and complaint no  16 010 036 against Sheffield City Council 3 April 2018.
[7] Department of Health and Social Care National Framework for NHS Continuing Healthcare and NHS funded Nursing Care (2022) para 203.  The previous (2018) Framework at page 3, explained that one of the purposes for its revision was to clarify ‘that the main purpose of three and 12 month reviews is to review the appropriateness of the care package, rather than reassess eligibility. This should reduce unnecessary re-assessments. 

Posted 6 November 2022