Case Note Friday: Retrospective Continuing Healthcare Review

What Is Retrospective Continuing Healthcare?

Retrospective Continuing Healthcare (CHC) funding reviews often arise when families believe NHS support should have been in place during a previous period of care, typically in a residential or nursing home. These cases can be complex and emotionally charged, particularly when the individual had high levels of need.

But eligibility isn’t about volume of care alone. It hinges on whether the person had a Primary Health Need, based on a legal test outlined in the National Framework for NHS Continuing Healthcare.

Reviewing the Evidence: A Real-World Scenario

In one recent CHC assessment, our expert was asked to review a ten-month period in which the person required 24-hour care. Their needs included support for advanced dementia, double incontinence, pressure care, mobility assistance, and nutritional monitoring via a soft diet and thickened fluids.

Family members felt strongly that this level of dependency should have qualified for CHC funding.

The decision had already been appealed, and a fresh clinical review was requested.

Key Factors in Retrospective NHS Continuing Healthcare Funding Decisions

Although several care domains, such as cognition, nutrition, and mobility, were assessed as “High,” the overall picture during most of the review period was one of stable and managed care. The person’s needs, while significant, were predictable and met through routine support from care home staff and general practitioners.

It was only in the final weeks when needs escalated in intensity and became more difficult to manage, that eligibility for NHS Continuing Healthcare was confirmed.

What the National Framework Really Requires

To qualify for CHC funding, care must demonstrate one or more of the following:

• Nature: The type and range of needs

• Intensity: How frequent or severe the needs are

• Complexity: Whether multiple needs interact to make management more difficult

• Unpredictability: Whether care needs fluctuate or require rapid intervention

  
  

In this instance, while the person needed continuous support, the interventions themselves did not meet the threshold required for NHS responsibility until much later in the period.

Key Takeaways for Solicitors, Families, and Advocates

This case highlights a common misconception: that the presence of high needs automatically qualifies someone for CHC. In reality, the National Framework looks at how those needs are managed and whether they truly fall outside the remit of local authority-funded care.

When reviewing a period of care retrospectively, it’s essential to assess not just the volume of need, but the clinical characteristics and interaction of those needs over time.

How Apex Experts Can Help

At Apex Experts, we provide clear, evidence-based reports to support retrospective CHC reviews and appeals. Our experienced nurse consultants are trained to interpret complex care records, identify missed funding opportunities, and offer robust expert witness input in line with the National Framework.

Need expert input on a Continuing Healthcare review or appeal? Get in touch with our team