Analysis Reveals Unfair “Luck Of The Draw” In Access To NHS Funded Care Packages

NHS Continuing Healthcare (CHC) – a package of free health and social care provided outside of hospital which the NHS pays for – is failing to reach some of the most unwell patients in England in their time of need. CHC is also reinforcing deep regional inequalities, with varied eligibility rates and less being spent per person on care in deprived areas and the North of England.

That’s according to new research by the Nuffield Trust, part funded by the Nuffield Foundation, which is a deep exploration of data on CHC eligibility, assessments and spending, alongside the views of people working in health and social care. The report highlights the paradox that, despite overall demand for health and care services being on the rise and spending on CHC increasing by around 17% between 2017 and 2023, the total number of people found eligible has fallen over time (by 9% between June 2017 and December 2024) and varies significantly across the country.

CHC funding can be a lifeline for people with significant ongoing care needs, such as from an accident or disability, including at the end of life. But if someone is found ineligible they can be faced with potentially catastrophic costs, or local authorities can be required to foot the care bill. The authors say that the current ‘all or nothing’ approach to deciding who gets this free care is dysfunctional and does not reflect the nature of need.

A lack of awareness and understanding of CHC among the public and health and care professionals and a complex and often gruelling application process are key reasons for poor access. Despite a National Framework setting standards to improve consistency, there are concerns that decisions about who gets funding are arbitrary and subjective, leaving people potentially missing out on vital support.

Key findings include:

• There is an almost five-fold difference between the Integrated Care Boards (ICBs) with the highest and lowest rates of CHC eligibility. Some of this variation could be explained by differences in population need. Areas with older and more deprived populations were more likely to have higher CHC eligibility rates. But this does not explain the extent of the variation.
• Spending on CHC is not distributed equally and is lower per eligible recipient in the north of England, even after adjusting for geographical differences. In 2022/23 (latest data), a person found eligible for Standard CHC in the North West had on average £22,432 less spent on their care that year compared to the England average which is £65,012 per eligible recipient.
• In 2022/23, the average (median) amount spent per eligible recipient of Standard CHC was £47,300 in the most deprived fifth of local areas compared to £95,085 in the least deprived fifth of areas.
• The research raises concerns about a “postcode lottery” and unfair and inconsistent practice. Variable relationships between NHS organisations and local authorities and financial pressures are affecting the numbers of people being referred, assessed and found eligible for CHC.
• The average cost per eligible recipient has increased for both Standard and Fast-track care packages, which may reflect a growing number of complex cases requiring more intensive or prolonged care.

In the short term, the authors say NHS and Department of Health and Social Care leaders urgently need to improve consistency and fairness in how CHC operates, through better training, sharing good practice and ensuring assessments are conducted in line with national standards. The funding package is intended to help people live in their communities while dealing with health issues, so ensuring fairness is crucial to the government’s aim to shift more care from hospital to community.

The research also raises questions about the very existence of CHC and whether it perpetuates an in-built unfairness where some people’s needs are supported but other people’s needs are not. With the flawed and cash-strapped social care sector making it even more difficult for people to get support when they’re rejected by CHC, the Nuffield Trust says The Casey Commission into adult social care offers a key opportunity to create a resilient and fair care system which can work alongside the NHS.

Nuffield Trust Fellow, Rachel Hutchings said:“For people grappling with the bewildering CHC process, the stakes couldn’t be higher. Being eligible can be the difference between having all of your health and social care funded or being faced with catastrophic care costs, often during times of crisis. But our research suggests that access to this vital funding is unfair and inconsistent.

“Not only is the assessment process itself challenging, but the toll it takes on families is long-lasting, part of an ongoing struggle to access good-quality, timely care for their loved ones. CHC is a window into the stark divide in our system between care that is funded by the NHS and care that isn’t, and it exposes yet more flaws with our wider social care system.”

In an accompanying Q&A, Sharon Allen, who has experience of CHC both through her professional role as Chief Executive of the Arthur Rank Hospice Charity and in her personal life, following the recent application for her mother to receive CHC funding, said:

“On both a personal and a professional level, my overall experience with CHC has been very negative.

“It seems to me that the system is designed to say no and that you have to fight extremely hard to get anywhere with it… Nobody knows my mum better than me and my sister and my dad, but we’re not listened to. And I know we are not alone. I speak to many people going through the same thing and it’s heartbreaking.”