The Postcode Lottery
Your postcode should not determine your NHS funding
Whether NHS Continuing Healthcare is granted varies almost five-fold between England’s 42 Integrated Care Boards. The same patient. The same condition. A different outcome depending on where they live.
Last reviewed June 2026 · Based on the National Framework for NHS Continuing Healthcare (revised 2022).
What is the CHC postcode lottery?
NHS Continuing Healthcare is meant to be a national entitlement: if your health needs meet the eligibility threshold, the NHS must fund your care — regardless of where you live. That is the law. In practice, it does not work that way.
In September 2025 the Nuffield Trust found an almost five-fold difference between the Integrated Care Boards (ICBs) with the highest and lowest rates of CHC eligibility — the regional bodies responsible for commissioning CHC assessments and making eligibility decisions. The Trust described access as an unfair “luck of the draw.”
This is not a difference in the health needs of local populations. It is a difference in how strictly each ICB applies the eligibility criteria. Some ICBs interpret “primary health need” generously. Others apply the threshold so narrowly that only the most severe presentations qualify. Both approaches are applied to the same National Framework — the same set of rules.
The result is a postcode lottery with real financial consequences. Families in low-approval ICBs who would qualify in a neighbouring area are paying privately for care that should be NHS-funded. At £67,600 per year on average for a nursing home, the difference can be financially catastrophic.
How ICBs make eligibility decisions
Under the National Framework for NHS Continuing Healthcare (July 2022), eligibility is determined by completing a Decision Support Tool (DST) — a structured assessment across 12 care domains. Each domain is scored from No Need to Priority. A Priority score in any domain, or a pattern of Severe scores across multiple domains, should indicate eligibility.
The Framework does not set a numerical cut-off. It requires a multidisciplinary team (MDT) to make a holistic judgement. That discretion is where regional variation enters. ICBs can influence outcomes through:
- The composition and training of MDT panels
- Local guidance on how to interpret borderline domain scores
- Whether the ICB actively challenges MDT recommendations
- The degree to which they treat the National Framework as a ceiling rather than a floor
Some ICBs have faced legal challenge for setting unlawful eligibility thresholds — in particular, for using financial considerations (i.e. the cost of care packages) as a factor in eligibility decisions. This was explicitly ruled unlawful in R (Grogan) v Bexley NHS Care Trust [2006].
What this means for your family
If your loved one has been assessed and found ineligible, the ICB in which they live may have applied a stricter threshold than the National Framework requires. This is not a theoretical risk — it is a documented, widespread practice.
If your ICB has a historically low approval rate, you should:
- Request a copy of the completed DST and all assessment documentation
- Check whether all 12 domains were properly scored and evidenced
- Consider requesting an Independent Review if you believe the decision was wrong
- Take advice from a specialist CHC solicitor before accepting the outcome
An appeal submitted with proper legal or professional support has a meaningfully higher chance of success than an unsupported challenge.
Can you choose your ICB?
ICB responsibility follows the patient’s registered GP practice. You cannot simply choose to be assessed by a more favourable ICB. However, if your loved one moves into a care home in a different area, responsibility transfers to the new ICB — and a fresh assessment may be triggered.
This is not a practical solution for most families, but it illustrates the arbitrary nature of the current system: geography, not health need, determines the outcome.
Frequently asked questions
Can you choose which ICB assesses your loved one?
No. ICB responsibility is determined by the patient’s registered GP practice address. If your loved one moves into a care home in a different ICB area, responsibility transfers to the new ICB — but this is not a practical route to securing a fairer assessment. The better approach is to challenge the decision through the Independent Review process.
What should you do if your ICB has a low approval rate?
First, do not accept a negative outcome without scrutiny. Request a copy of the completed Decision Support Tool and all assessment documentation. Check that all 12 care domains were properly scored and evidenced, and that no irrelevant factors (such as cost) influenced the decision. Consider instructing a CHC solicitor before submitting an appeal — professionally supported challenges have a meaningfully higher success rate.
Can you appeal on the grounds that your ICB applied an unlawful threshold?
Yes. If you can demonstrate that the ICB applied eligibility criteria that are inconsistent with the National Framework — for instance, by using cost as a factor, or by setting a local threshold higher than the Framework requires — you have grounds for both an NHS Independent Review and, ultimately, judicial review. R (Grogan) v Bexley NHS Care Trust [2006] established that financial considerations cannot lawfully influence CHC eligibility decisions. A specialist solicitor can advise on the strength of any such challenge.