What to Include in a CHC Appeal Letter (with Template)

A CHC refusal letter has just landed. The 6-month clock is running. You sit down to write the appeal — and most families default to what feels natural: an emotional account of how much their relative has deteriorated and how unfair the decision is. ICB reviewers receive those letters every week. They do not change scores.

What changes scores is a structured, domain-by-domain rebuttal mapped to the published descriptors in the 2022 National Framework, anchored to the Primary Health Need legal test, and indexed against attached evidence the reviewer can find in under a minute. This guide is the section-by-section anatomy of that letter, with a multi-domain worked example and the free editable template.

Reviewed by legal professionals and social care professionals.

TL;DR: A strong CHC appeal letter has six sections: header, grounds, DST domain-by-domain rebuttal, evidence map, Primary Health Need argument, and IRP escalation notice. About 13% of Local Resolution requests succeed (Nuffield Trust, 2024) — meaningfully higher with the four-line per-domain rebuttal pattern below. Free editable template and worked example linked at the foot of the post.

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When can you appeal a CHC decision?

A CHC eligibility refusal can be appealed locally within six months of the date on the ICB's decision letter, under the 2022 National Framework for NHS Continuing Healthcare. The Framework sets out a two-stage process: Stage 1 Local Resolution by the ICB itself, and Stage 2 Independent Review Panel administered by NHS England.

Two practical points to settle before drafting. First, the deadline is for requesting the review, not for completing it — a written request received by the ICB within six months keeps the appeal alive even if the Local Resolution Meeting happens months later. A short holding letter naming the decision being appealed and asking for a Subject Access Request to the case file is enough to stop the clock; the full grounds and evidence can follow. Second, the clock starts on the date printed on the decision letter, not the date the family received it — for the full mechanics of the deadline, see our CHC appeal time-limit guide.

Most ICBs aim to acknowledge an appeal within five working days and to complete Local Resolution within three months of the request, per Framework guidance. In practice timelines are often longer; for the wider process map, the CHC appeals overview covers the route end to end.

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What are valid grounds for a CHC appeal?

An appeal letter should articulate its grounds in three categories: procedural failings, incorrect domain scoring, and misapplication of the Primary Health Need legal test. The strongest appeals combine at least two; a pure process challenge rarely changes a substantive outcome on its own, and a pure scoring challenge can be dismissed for not engaging the legal framework.

Procedural failings are typically where the assessment was rushed, the multidisciplinary team was not properly constituted (the National Framework expects relevant professionals to attend — district nurses, community mental health teams, social workers), the family was not given adequate notice or opportunity to participate, or key medical records were not before the assessors at the time of the decision.

Domain scoring failings are the bulk of most successful appeals. The Decision Support Tool scores 12 care domains against published Annex C descriptors. A domain marked "Moderate" when the evidence on file supports "High" — or "No Needs" when daily care logs show recorded incidents — is challengeable on the record before the original decision-makers.

Legal failings turn on the underlying Primary Health Need test set by the Court of Appeal in R v North & East Devon HA, ex parte Coughlan [1999] (BAILII). Two specific patterns recur: the "well-managed needs" downscoring (where stable presentation is read as low need, rather than as the result of skilled intervention) — covered in detail in our guide to the well-managed needs principle — and assessments that consider domains in isolation, without addressing how they interact under paragraph 56 of the National Framework.

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The six-part structure of a CHC appeal letter

Every effective Local Resolution appeal letter contains six sections in this order:

1. Header and reference details — your contact details, the ICB CHC team address, a clear subject line with the patient's name and the date of the original decision being appealed
2. Authority to act and grounds for appeal — who you are (the patient themselves, an attorney under a registered Health and Welfare LPA, or a next of kin / primary carer), the legal authority for the request, and a two-to-three sentence statement of grounds
3. DST domain-by-domain rebuttal — the central section; a table or numbered list challenging each disputed domain with a four-line pattern (covered in the next H2)
4. Evidence map — a short indexed list of the records being relied on, with dates and source for each item attached
5. Primary Health Need legal argument — a structured application of the four key characteristics (Nature, Intensity, Complexity, Unpredictability) and the Coughlan test, with explicit reference to the interaction between domains
6. Outcome sought and IRP escalation notice — what you are asking the ICB to do (typically a fresh MDT or specific domain rescoring), and a stated intention to escalate to NHS England's Independent Review Panel within six months if Local Resolution upholds the refusal

The total letter is typically 2–4 pages, plus the evidence pack as enclosures. The longer it gets, the harder it is to read. Reviewers are working through case files in roughly 20-minute windows; a structured letter that signposts to the evidence pack survives that first read, where an unstructured wall of prose does not.

The editable Stage 1 template below is built to this exact six-section structure — colour-coded fill-in placeholders mean families can produce a structurally complete first draft in an evening:

📄 Download: Stage 1 Local Resolution Request — editable DOCX template

Pair with the fully completed worked example (PDF) for a fictional multi-domain case (vascular dementia + Category 3 pressure ulcer + catheter management) showing the level of clinical specificity that wins Local Resolution.

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How to write the DST domain-by-domain rebuttal

This is the section that decides most appeals. The pattern for each disputed domain is four lines, in this order:

1. Recorded score — the level the ICB assigned in the DST
2. Score the evidence supports — the level you are asking the panel to apply
3. Quoted descriptor language — the specific Annex C descriptor for the higher level, in the Framework's own words
4. Evidence references — the specific dated items in your evidence pack that support the higher level

The reason for this format is mechanical: ICB reviewers triage appeals by mapping family arguments back to the DST. A reviewer can change a recorded score if a family points at the descriptor, names the evidence, and ties them together in two or three sentences. A reviewer cannot change a recorded score in response to an emotional paragraph that does not engage the rubric — even if the underlying need is real.

A worked excerpt — Behaviour domain, taken from the completed example linked above:

Domain: Behaviour. ICB recorded score: No Needs. Score the evidence supports: Moderate.

Daily care notes from Elmview Care Home (January–February 2026) record 14 episodes of verbal aggression and physical resistance to personal care during the assessment period. The episode dated 29 January 2026 required two care workers to manage safely. These episodes are not reflected in the DST.

Evidence enclosed: Behaviour log extract; care home incident forms dated 8 and 29 January 2026.

The same pattern, repeated for each disputed domain, is what builds the case. Pick the domains the evidence genuinely supports — usually three to five — rather than disputing all twelve. Picking battles signals to the reviewer that the family has read the file.

Two craft points worth underlining:

• Use the Framework's own descriptor language. "Skin integrity is at serious risk, with complex wounds needing skilled management on a frequent and ongoing basis" is not optional rhetoric — it is the Severe descriptor for Skin/Tissue Viability. Quoting it directly removes the reviewer's room for re-interpretation.
• Flag the four key characteristics by name. "This pattern demonstrates unpredictability, in that incidents cannot be scheduled or anticipated in advance" maps the evidence to the Framework's eligibility test in one line. Our DST evidence builder guide walks through the descriptor language for each of the 12 domains.

For the deeper template-fill mechanics — the colour-coded placeholders, the procedural-concerns wording, the supporting-evidence index format — the full appeal templates guide is the authority reference. This post is the strategic walkthrough; the guide is the line-by-line companion when you are mid-draft.

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How to argue the Primary Health Need test

The Primary Health Need test is the legal question the ICB must answer — and the question most refusal letters fail to address explicitly. A person has a Primary Health Need if, looking at the totality of their needs, the main need is for health care rather than social care. The test was set by the Court of Appeal in Coughlan (1999), and the High Court ruled in R (Grogan) v Bexley NHS Care Trust [2006] (BAILII) that ICBs must apply it with reasons — assertion is not application.

Frame the argument around the four key characteristics the Framework uses to assess severity:

• Nature — the type of intervention required and the skill needed to deliver it. Skilled clinical care (catheter management, wound care, complex medication titration, behavioural de-escalation) sits at the NHS end of the boundary
• Intensity — the quantity and continuity of input the person needs. Continuous monitoring, multiple skilled interventions per day, or two-person hoist transfers are intensity indicators
• Complexity — how needs across different domains interact. A single straightforward condition is rarely complex; multiple interacting conditions producing fluctuating or hard-to-predict needs typically are
• Unpredictability — the risk of needs changing suddenly or without warning. Seizures, falls, hypoglycaemic episodes, unpredictable aggression, and rapidly evolving conditions sit here

The strongest Primary Health Need section in an appeal letter argues domain interaction explicitly, citing paragraph 56 of the National Framework. A case where Cognition is Moderate, Continence is Moderate, Skin/Tissue Viability is Moderate, and Mobility is Moderate — none individually Severe — may still amount to a Primary Health Need when assessed together, because each domain exacerbates the others. The worked example linked above is built around exactly this kind of "cluster" case.

A craft note on case law. Cite Coughlan and Grogan only where the parallel is real. A name-drop with no factual link reads as legalistic padding; a focused reference to the principle the case established ("the test requires the decision-maker to look at the totality of needs, not score them in isolation") is more persuasive than dropping a paragraph number. For the underlying legal analysis, see our deep-dive on the Primary Health Need test and our guide to the 2022 National Framework criteria.

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Evidence to attach to your appeal letter

A strong appeal letter is only as good as the evidence attached to it. Five categories of evidence move domain scores most often, and each maps to specific domains in the DST:

• Care home daily notes and incident logs — Behaviour, Cognition, Continence, Mobility, Other Significant Care Needs. Date-stamped entries are the highest-value evidence the ICB rarely sees in the original assessment
• GP records and specialist letters — Cognition (MMSE/ACE-III scores), Drug Therapies, Skin (tissue viability nurse), Continence (community nursing input), Breathing (respiratory medicine)
• Hospital discharge summaries and consultant letters — Complexity and Unpredictability evidence across multiple domains; particularly material where there have been admissions in the assessment period
• Risk assessments — Falls history, Waterlow pressure-damage scoring, Moving and Handling assessments, MUST nutrition scoring. These map directly to the descriptor language
• A written family statement — the lived presentation between formal assessments. Structured by domain, dated, and cross-referenced to the records — not an emotional plea. Our guide to writing a compelling family statement walks through the structure

How to obtain each: a Subject Access Request to the ICB, GP, hospital, and care home returns most clinical records within one calendar month under the UK GDPR. Care home daily logs are returnable on the same statutory basis. For the SAR letter mechanics, see how to obtain medical records via SAR and download the SAR letter pack.

Pacing note: lodge the appeal request first — a holding letter is fine — then assemble the full evidence pack during the Local Resolution window. The six-month deadline is for filing the request, not for producing every page of evidence.

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Common reasons CHC appeal letters fail

Six recurring failure modes account for most rejected family-written appeals. Each has a specific fix.

1. Emotional plea with no domain mapping. The letter describes how much the family is struggling and how unfair the decision feels, but never names a DST domain, never quotes a descriptor, and never points at evidence. The fix is the four-line domain rebuttal pattern in the section above.
2. No reference to the National Framework. The letter argues the case in general terms, never citing the document the ICB is statutorily required to apply. The fix is to name the Framework explicitly in the grounds paragraph and reference specific paragraphs (56, 91) where they apply.
3. "Well-managed needs" accepted without challenge. The decision letter cites stable presentation as evidence of low need; the appeal letter accepts the framing. The fix is the well-managed needs rebuttal pattern — paragraph 91 requires assessors to score the need at its actual level, not as reduced by skilled care input.
4. Name-dropping case law. Coughlan and Grogan appear without context, used as authority for nothing in particular. The fix is to cite the principle the case established, only when the factual parallel is real.
5. Evidence attached without an index. The reviewer receives a pack of records with no cross-reference to the letter's arguments. The fix is a numbered evidence index in Section 4, with each item tied to the domain it supports.
6. No IRP escalation notice. The letter argues the case but does not signal that the family will escalate if Local Resolution fails. The fix is a single closing line stating the intention to request an Independent Review Panel within the statutory six-month window if needed.

These are the patterns Care to be Different and Beacon CHC commentary describe most often in their published case observations, and they map cleanly to the PHSO findings in Continuing Healthcare: Getting it Right First Time (2020).

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When to escalate to an Independent Review Panel

If the ICB's Local Resolution upholds the original refusal, the next route is the Independent Review Panel (IRP) administered by NHS England. The IRP request must be made within six months of the Local Resolution outcome letter. Submit via NHS England's published referral process; once requested, families have approximately six weeks to lodge all written evidence.

The IRP is not a re-assessment. It reviews three things: whether the ICB followed the process correctly; whether the DST scoring was supported by the evidence; and whether the eligibility decision itself was reasonable on the record before the original decision-makers. It can recommend the ICB reconsider, make findings of process failure, or — in exceptional cases — directly recommend eligibility. The recommendation goes back to the ICB, which is expected to accept it; in rare cases of dispute, the route is then to the Parliamentary and Health Service Ombudsman.

You do not need a solicitor to request an IRP. The same six-part letter structure scales to the IRP submission, with the addition of a brief account of the Local Resolution outcome and where you believe it went wrong. For the wider IRP mechanics — what happens at the hearing, what the panel can and cannot do — see the IRP section of our complete CHC appeal guide.

If you are not sure whether your case has the evidence to support either an appeal letter or an IRP, the lowest-friction first move is a five-day Case Strength Report at £97 — a structured evidence-strength rating against the Framework before committing to the work of a full appeal.

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What this means for your next draft

The single biggest predictor of a successful CHC appeal at Local Resolution is whether the letter is structured around the DST. Reviewers triage by domain; letters that match the structure are read; letters that do not are not. The six-part anatomy in this post — header, grounds, domain rebuttal, evidence map, Primary Health Need argument, outcome and IRP notice — is the format the existing Framework, Annex C descriptors, and case law all reward.

The two highest-leverage moves before you draft a single paragraph:

• Get the records first. A Subject Access Request to the ICB returns the case file in one calendar month. The DST scoring you are challenging only makes sense alongside the underlying records that produced it.
• Triage the evidence strength. If you are not sure the evidence supports the appeal — or which domains are genuinely worth disputing — a £97 Case Strength Report returns a structured view in five working days. Cheaper than the time cost of an unfocused appeal that does not survive Local Resolution.

The free editable template and worked example are the operational companions to this post:

• 📄 Stage 1 Local Resolution Request — editable DOCX template — colour-coded fill-in placeholders, built to the six-section structure above
• 📄 CHC Appeal Letter — Completed Worked Example (PDF) — a fictional multi-domain case showing the clinical specificity that wins Local Resolution

This guide is reviewed by legal professionals and social care professionals. CareAdvocate provides advocacy and evidence preparation, not legal advice. The template and example are provided for information only and do not constitute legal advice; outcome statistics referenced are sector-wide NHS England figures and individual cases vary.