Casey Commission and CHC: What Reform Means for Families

The biggest review of adult social care in a generation is under way. Baroness Louise Casey is chairing an independent commission tasked with designing a National Care Service for England, with Phase 1 recommendations expected in 2026. And buried inside its terms of reference is a sentence that every family navigating NHS Continuing Healthcare should know about.

The Commission must examine "the boundary between social care and the NHS, where we know public money is not always being used to best effect." That's a direct reference to CHC — the £5bn+ funding system that determines whether the NHS pays for your relative's care in full. With eligibility rates having fallen from 31% in 2017/18 to 17% in 2025/26, and a near five-fold variation in who qualifies depending on where they live, CHC sits squarely at the centre of this review (GOV.UK, 2025). For an introduction to how the existing system works, see our main NHS Continuing Healthcare guide.

TL;DR: The Casey Commission is examining the NHS/social care boundary and CHC is explicitly in its scope. Eligibility has fallen sharply over eight years, regional variation is extreme, and local authorities are running record deficits partly because of CHC tightening. Reform is coming — but it could go in any direction. Families shouldn't wait: the rules in force today are what determine your relative's care costs right now (Nuffield Trust, September 2025).

What Is the Casey Commission?

The government announced in May 2025 that Baroness Louise Casey would chair an independent commission on adult social care, with a mandate to produce a roadmap toward a National Care Service (Community Care, May 2025). Phase 1 recommendations are due in 2026. The Commission is not a parliamentary committee — it's an independent body reporting to ministers, with significant scope to recommend structural change.

The Commission's terms of reference are broader than previous social care reviews. Unlike the Dilnot Commission (2011), which focused narrowly on the care cost cap, Casey's brief covers the whole system: workforce, funding, the NHS interface, and long-term sustainability. That breadth is precisely why CHC cannot escape its attention.

A parliamentary committee report preceding the Commission described CHC as a major but neglected pillar of the social care system and called for its own review. The Casey Commission was effectively handed that brief as part of its wider work. This is the most direct scrutiny CHC has received from an official body in years.

Why CHC Is Central to the Commission's Remit

The Commission's terms of reference require it to examine the NHS/social care boundary and assess whether public money is being used effectively — and CHC eligibility rates have declined from 31% in 2017/18 to 17% in 2025/26, a 14 percentage-point fall affecting tens of thousands of families (Nuffield Trust, September 2025). That's not a marginal shift. It's a systemic tightening of who the NHS accepts responsibility for.

CHC is where the NHS/social care boundary becomes concrete. When the NHS decides someone doesn't qualify, the local council must fund their care — often through means-testing that depletes family assets. When the NHS does fund, families pay nothing. The stakes at this boundary are enormous, and it's drawn differently in every part of England — for the detail on regional variation, see our CHC postcode lottery analysis, and for the ICBs actively cutting eligibility right now, our ICB CHC eligibility cuts breakdown.

Citation capsule: NHS Continuing Healthcare eligibility in England fell from 31% of people assessed in 2017/18 to 17% in 2025/26 — a 14 percentage-point decline over eight years. Over the same period, CHC spending rose 17% while recipient numbers fell 9%, meaning the remaining budget is concentrated on a smaller, higher-acuity group. There is a near five-fold variation in eligibility rates between local NHS areas (Nuffield Trust, "All or Nothing", September 2025).

What Problems Will the Commission Have to Confront?

The Nuffield Trust's September 2025 report described CHC as "consigned to the too difficult box" — a system that is "dysfunctional" and "all or nothing", where a single legal test determines whether the NHS covers everything or nothing (Nuffield Trust, 2025). That binary structure produces profound unfairness and perverse incentives for NHS commissioners.

Three specific failures stand out.

Eligibility Has Tightened Without Transparency

No minister announced that CHC would become harder to qualify for. No regulations changed the eligibility criteria. The decline from 31% to 17% happened through a combination of administrative tightening, changed assessment practices, and ICB-level budget pressure. Families applying today face a much harder standard than families in 2017, without any public acknowledgement of that shift — the May 2026 NHS CHC data transparency announcement is the first official step toward fixing this.

Regional Variation Is Indefensible

A near five-fold difference in eligibility rates between NHS areas means the same person, with the same needs, is eligible for free NHS care in one county and self-funding in another. This isn't a minor inconsistency — it's a structural failure of the National Framework that's supposed to standardise decisions. The Commission will have to confront it directly.

The Costs Are Being Pushed Onto Councils

The Association of Directors of Adult Social Services (ADASS) reported a record £774m local authority social care overspend in 2024-25, with 73% of council directors citing CHC tightening as a contributing factor (ADASS, 2025). When the NHS declines to fund someone under CHC, the cost doesn't disappear. It shifts to local councils — and ultimately to families through means-testing. The boundary isn't saving the public money overall. It's moving the debt. Our analysis of CHC council cost-shifting covers what that means at the family level.

We've seen this pattern repeatedly in the cases that reach us. Families are told their relative "doesn't quite" meet the CHC threshold, the council funds care on a means-tested basis, and within two years the family home has been depleted to cover costs the NHS arguably should have funded. The Commission has the chance to address this — but it will take political courage to act. The Healthwatch England testimony collated in our families' experience analysis is exactly the kind of evidence the Commission needs to weigh.

What Could Reform Actually Look Like?

The Commission hasn't published recommendations, so any projection involves genuine uncertainty. But three directions have been discussed by researchers and policy analysts working on this issue.

Option 1: Simplify and Standardise the Boundary

The most technically straightforward reform would tighten the National Framework to reduce regional variation — essentially forcing ICBs to apply the legal test more consistently. This would help families in lower-eligibility areas but wouldn't change the fundamental "all or nothing" structure.

Option 2: Create an Intermediate Funding Tier

The Nuffield Trust and others have proposed a "care continuum" model that replaces the binary CHC/non-CHC divide with graduated funding based on assessed need. Under this model, someone not qualifying for full CHC might still receive significant NHS contributions rather than the current £267.68/week NHS funded nursing care rate or nothing at all. This approach is appealing in theory but expensive and politically complex.

Option 3: Restrict CHC Further and Expand Social Care

A less family-friendly direction — but plausible given fiscal pressures — would formally narrow CHC to the most acute cases and invest the savings in a better-funded social care system. Families in the middle ground would receive improved means-tested care, but not free at the point of use. This would represent a significant shift in the implicit promise CHC makes.

The 4.4% uplift to the Better Care Fund NHS minimum contribution for 2026-27 (GOV.UK, February 2026) is a small indicator of direction: incremental investment in the joint health/care budget, not structural reform. The Commission may push for something bolder, but it will be operating within tight public spending constraints.

What Should Families Do Right Now?

Don't wait for the Commission. Phase 1 recommendations in 2026 will be followed by consultation, legislation, and a multi-year transition period. Meaningful change, if it comes at all, is years away. Your relative's care costs are being decided under the current rules — today.

If your relative has complex health needs, a CHC assessment is worth pursuing now, under the framework as it stands. The legal test — whether someone has a "primary health need" for which the NHS bears responsibility — hasn't changed, even if practice has tightened. An evidence-based application, prepared properly, can still succeed. Our free CHC eligibility screener gives you a structured read on whether the current threshold is likely to be met before you contact the ICB.

A few practical steps:

Request a CHC checklist in writing. If your relative is in a care home or has had an NHS care package, the ICB is obliged to screen for CHC eligibility. Ask your relative's GP, hospital discharge team, or the care home itself to initiate a checklist assessment. Put the request in writing.

Document everything before the assessment. The CHC system is evidence-heavy. Nursing notes, care plans, GP records, and family observations all feed into the Decision Support Tool. Don't assume professionals will have what they need — compile it yourself, or get support to do so.

Understand that the system isn't passive. ICBs have budget pressures that create an incentive to decline. Well-evidenced cases, submitted by families who understand the framework, have better outcomes than uncontested assessments. The gap between the 17% average eligibility rate and what families who prepare properly achieve tells part of this story.

Use the CHC eligibility screener to get a read on your relative's position. It takes about ten minutes and gives you a structured view of the domains that will matter at assessment.

The Casey Commission may yet produce the reform CHC needs. But whatever it recommends, it won't be retroactive. The families who act now — under the current rules — are the ones who won't spend the next two years depleting a relative's savings waiting for a system that might change.

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This article draws on the Casey Commission terms of reference (May 2025), the Nuffield Trust's "All or Nothing" report (September 2025), ADASS local authority financial data (2025), and the GOV.UK Better Care Fund Framework 2026-27 (February 2026). It does not constitute legal advice. Content was last reviewed in May 2026 and has been reviewed by legal professionals and social care professionals.