Two families. Both have a parent with advanced dementia, profound cognitive decline, and daily nursing needs. One family lives in a high-eligibility ICB area. Their parent gets full NHS CHC funding — care home fees paid entirely by the NHS. The other family lives 50 miles away. Their parent is refused. They pay £1,200 a week from savings. Same health needs. Opposite outcomes.
This is not an edge case. A landmark Nuffield Trust study published in September 2025 found a nearly five-fold variation in CHC eligibility rates across NHS Integrated Care Boards — ranging from 3.4% to 57.9% of those assessed. The research is titled "All or Nothing", and that title captures it precisely.
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TL;DR: A Nuffield Trust study (September 2025) found CHC eligibility rates vary nearly five-fold between NHS areas — from 3.4% to 57.9% of those assessed. Nationally, the eligibility rate has fallen from 31% in 2017/18 to 17% in 2025/26 (Healthwatch England, October 2025). Geography is driving outcomes. But your legal rights don't change based on your postcode — and appeals still work.
Note: your ICB itself may have just changed. On 1 April 2026, twelve ICBs were abolished and six new ICBs took their place. If your area was affected, see our guide to what the ICB mergers and NHS England abolition mean for your CHC claim.
Key Facts
- Nearly five-fold variation in CHC eligibility rates across ICBs — 3.4% to 57.9% (Nuffield Trust, September 2025)
- National eligibility rate fell from 31% in 2017/18 to 17% in 2025/26 — a 14-point drop in eight years (Healthwatch England, 2025)
- CHC recipients declined 8.8% over four years, while spending rose 17% (Nuffield Trust, 2025)
- Spending per recipient ranges from £32,558 to £133,201 depending on your ICB
- Most deprived areas receive just £47,300/year per recipient vs £95,085 in least deprived areas
- North West England recipients receive £22,432 less annually than the England average of £65,012
- 51,154 adults eligible for NHS CHC as of Q3 2025/26 (NHS Digital, February 2026)
What Does the Five-Fold Variation Actually Look Like?
The Nuffield Trust's "All or Nothing" report, published on 26 September 2025, found eligibility rates ranging from 3.4% to 57.9% of those assessed, depending on ICB. Measured in terms of recipients per 50,000 population, the gap runs from 20 to 95 people. That means in some areas, five times as many people with comparable health needs receive CHC funding as in others.
Think about what that number means in practice. If you live in a high-eligibility area, roughly one in two people assessed are found eligible. In a low-eligibility area, fewer than one in 25 are approved. The clinical criteria are the same. The National Framework is the same. The variation comes from how each ICB interprets and applies those criteria.
The NHS Confederation acknowledged the problem in its response to the research: the system is "failing to reach some of those who need it most." That's a striking admission from the body that represents NHS trusts and ICBs.
How Has the National Eligibility Rate Changed Over Time?
According to Healthwatch England (October 2025), the national CHC eligibility rate was 17% in 2025/26, down from 31% in 2017/18. That's a 14 percentage-point decline over eight years. The Nuffield Trust's data adds another dimension: CHC recipients fell 8.8% over four years even as total CHC spending rose 17% from 2017 to 2023.
The chart below shows the trajectory of that decline.
The money hasn't disappeared. Spending per recipient has risen. In 2023, the NHS spent 17% more on CHC than in 2017 — but it spread that money across 9% fewer people. Resources are concentrating at the most complex end of need, and the threshold for qualifying is rising as a result.
What does that mean for families? More people are being refused who might have been approved five years ago. The decline isn't gradual. It's structural.
Read about ICB-level eligibility cuts
Why Does Eligibility Vary So Much Between ICBs?
The Nuffield Trust's report identifies several drivers of ICB variation, and Community Care's coverage of the findings (29 September 2025) describes the system as "unfair and inconsistent." There are three factors worth understanding.
Budget pressure translates into higher thresholds. ICBs under financial strain have a direct incentive to reduce CHC eligibility. CHC is funded from the NHS budget. Every person found eligible costs the ICB. There is no ring-fenced CHC budget. When an ICB runs a deficit, CHC refusal rates tend to rise. The National Framework doesn't change, but how vigorously assessors apply the benefit-of-the-doubt provisions does.
"Primary health need" is a judgement, not a measurement. The Decision Support Tool produces domain scores, but converting those scores into a funding decision involves clinical interpretation. Different ICBs train their assessors differently, use different weighting approaches, and operate different decision panels. Two DSTs with identical scores can produce opposite outcomes depending on which ICB panel reviews them.
Panel composition shapes outcomes. Some ICBs use panels weighted toward clinical staff who apply stricter thresholds. Others use multidisciplinary panels that weigh family evidence more heavily. The National Framework doesn't specify panel composition in a way that eliminates this discretion.
Does Deprivation Make It Worse?
The Nuffield Trust's data shows a deeply uncomfortable pattern. The most deprived areas — where need is typically highest and self-funding is least likely — receive the least per CHC recipient. Their analysis found most deprived areas receive £47,300 per recipient per year on average, compared with £95,085 in the least deprived areas (Nuffield Trust, September 2025).
That's a gap of nearly £48,000 per person per year, between the areas that arguably need the most support and the areas that need it least.
Regional inequality compounds the picture. The Local Government Lawyer (1 October 2025) reported that North West England recipients receive £22,432 less annually than the England average of £65,012. That's not a rounding error. It's a structural funding gap that directly affects care quality.
What Does This Mean If You're in a Low-Eligibility Area?
Being in a low-eligibility ICB does not reduce your legal entitlements. The National Framework for NHS Continuing Healthcare (2022) applies uniformly across England. Your relative's right to a CHC assessment, and the legal standard that assessment must meet, doesn't change depending on ICB geography.
What it does mean is that you need to prepare more carefully, challenge more assertively, and know your rights more thoroughly than families in higher-eligibility areas. Not sure which ICB covers your area? Find your local ICB and see its eligibility data.
Postcode search
Enter your postcode to jump straight to your local ICB page.
Your postcode is only used to look up your ICB — it is not stored.
Document Everything
Low-eligibility ICBs tend to approve cases with the strongest paper trails at the CHC Checklist stage. Clinical records, nursing notes, care home daily logs, and GP letters all feed into the domain scoring. Gaps in documentation — particularly around behaviour, cognition, and skin integrity — give assessors room to downgrade scores. Don't leave documentation to chance.
Check your relative's eligibility
Attend the Assessment
You have the right to attend the DST assessment. Families in our experience consistently find that in-person advocacy changes domain scores. Assessors hear what clinical records don't capture: the 3am falls, the refusal to eat, the distress that requires two carers. You can and should challenge scores in the room if they don't reflect day-to-day reality.
Appeal Low-Quality Refusals
Healthwatch England's research found that most families only discover CHC through social media or word-of-mouth, and describe the process as "a full-time job." We've pulled out the most actionable findings in our Healthwatch CHC families analysis — the rights families can use today, drawn directly from the testimony. Low-eligibility ICBs can and do overturn refusals at appeal when families provide systematic domain-by-domain challenges backed by evidence. A bare refusal letter is not the end of the process — our CHC appeal guide explains the formal steps.
In our casework, families who appeal with domain-specific evidence — attaching nursing records, GP letters, and a written family statement per domain — consistently achieve different outcomes than those who appeal with a single covering letter. The format of the challenge matters as much as the content.
Know the Current Snapshot
NHS Digital's Q3 2025/26 data (published February 2026) shows 51,154 adults currently eligible for CHC — 34,140 standard and 17,014 fast-track. Just 76.0% of referrals were completed within the 28-day target in September 2025. If your ICB is missing the target, that's a documented failure you can reference in your correspondence.
What Should the Government Do?
The Nuffield Trust called for CHC to be treated as a priority rather than "consigned to the too-difficult box." The NHS Confederation's response acknowledged the system is failing people who need it. Neither organisation produced a specific reform timetable.
That's not satisfying, but it's honest. The variation is structural, budget-driven, and deeply embedded in how ICBs operate. Families shouldn't wait for reform. They should use the rights they have now, with the evidence the system requires.
The data doesn't just describe an unfair system. It gives families negotiating leverage: if your ICB has a significantly lower eligibility rate than comparable areas, that's a fact you can cite when challenging a refusal. If your relative's needs are comparable to those being approved 50 miles away, that inconsistency matters.
Frequently Asked Questions
What is the CHC postcode lottery? The CHC postcode lottery refers to the near five-fold variation in NHS Continuing Healthcare eligibility rates between NHS Integrated Care Boards. A Nuffield Trust study published in September 2025 found eligibility rates ranging from 3.4% to 57.9% of those assessed, depending on which ICB covers your area. This means two people with clinically identical needs can receive opposite outcomes based solely on geography.
Which areas have the lowest CHC eligibility rates? The Nuffield Trust study (September 2025) found that recipients per 50,000 population range from 20 in the lowest areas to 95 in the highest. North West England recipients receive £22,432 less annually than the England average of £65,012 (Local Government Lawyer, October 2025).
Has the national CHC eligibility rate changed? Yes, significantly. Healthwatch England data shows the eligibility rate fell from 31% in 2017/18 to 17% in 2025/26 — a 14 percentage-point decline over eight years. The Nuffield Trust found total CHC recipients declined 8.8% over four years while CHC spending rose 17% from 2017 to 2023.
Does deprivation affect CHC outcomes? Yes. The Nuffield Trust found spending per CHC recipient in the most deprived areas averages £47,300/year vs £95,085 in the least deprived. Spending per recipient ranges from £32,558 to £133,201 depending on ICB, regardless of relative need levels.
What can I do if I'm in a low-eligibility area? Being in a low-eligibility ICB doesn't change your legal rights. The National Framework (2022) applies uniformly. If your relative has been refused, request the full written DST scoring, challenge specific domain decisions, and appeal with domain-specific evidence. Evidence quality makes a measurable difference to outcomes, even in restrictive ICBs.
Use our free eligibility screener to check where you stand
Sources: Nuffield Trust, "All or Nothing", 26 September 2025; Healthwatch England, 13 October 2025; NHS Digital, Q3 2025/26, 12 February 2026; Local Government Lawyer, 1 October 2025; Community Care, 29 September 2025; NHS Confederation response.