Challenges to the rationality of care provision decisions

R (WND by his litigation friend WSA) v NHS West and North London Integrated Care Board (London Borough of Haringey, Interested Party) [2026] EWHC 2356 (Admin)

Integrated Care Boards (“ICBs”) make evaluative judgements about clinical and care needs and the resources required to meet it. Challenges to the rationality of those judgements rarely succeed: the range of reasonable decisions is broad, and the court disclaims any substitutionary role.

WND is notable as a successful challenge to the rationality of an ICB decision. David Pittaway KC, sitting as a Deputy High Court Judge, held that the decision was outside the range of reasonable responses (outcome rationality), and that the reasoning involved an error of logic and disregarded an obviously relevant consideration (process rationality). The decision was quashed.

The element of the reasoning of most interest is the court’s analysis of a report from the care provider’s clinical lead, which (contrary to the Defendant’s submissions) the judge read to recommend 24/7 care.

Factual background

WND is 13 years old [5]. He has a rare genetic disorder causing seizures, fluctuating muscle tone, learning disability, and communication and mobility impairments. His seizures are intermittent but the risk is highest at night, and he is at high risk of sudden unexpected death in epilepsy (SUDEP). He lives at home with his parents [6]. His parents provided night-time care, which on their case was unsustainable.

The ICB has provided continuing care since June 2015. Since 2023 this has comprised 63 hours per week at a 2:1 ratio (126 staffing hours), with no provision for 24/7 care [2]. Whether one of the two staff should be a registered nurse was left open in an ICB decision of September 2025 [29], [34].

The ICB made an updated assessment of WND’s needs and reviewed the appropriate staffing for his package of care [9]. In line with its policy, a Decision Support Tool (“DST”) was drafted by a senior nurse, peer-reviewed, and submitted to the ICB for its consideration [31]. The DST recommendation was that WND was not eligible for continuing care at all.

Ms Hassall was the clinical lead manager for the agency providing care to WND [24]. She provided a clinical report dated 23 January 2026. It included an assessment that “[WND] clearly always requires two-to-one support… The presence of a registered nurse is a clinical necessity rather than an enhancement” [27].

In a decision on 28 January 2026, the ICB rejected the DST recommendation and determined that “WND’s needs should be met by one Registered Nurse and one Healthcare Assistant and that WND’s Continuing Care package of 63 hours per week at a 2:1 ratio (126 hours) [should continue] …” [9] Its stated rationale was that:

“North Central London Integrated Care Board (NCL ICB) used the National Children and Young People’s Continuing Care Framework (2016), decision support tool and the Continuing Care Health Assessment tool (CCHAT) to guide decision making at Panel.

The Panel also took into consideration the complexity, intensity, and risk of WND’s holistic clinical needs, along with supporting clinical evidence to guide decision making.”

The Claimant challenged that decision. He contended that the only lawful conclusion was that he must have 24/7 care [22]-[24].

The parties disagreed about the nature of Ms Hassall’s opinion, both as contained in her report and as reported by her. Ms Hassall provided no witness statement for either party. The ICB’s evidence was that she had confirmed by email on 24 April 2026 that she had not meant to recommend 24/7 nursing. WND’s mother’s witness statement set out that “Ms Hassall has told me clearly and unequivocally that her professional view is in fact that he does require nurse led healthcare every day, day and night” [25].

The law

The judgment refers to the standard of review of ICB decisions as summarised by Fordham J in four propositions at [15] of R (Simpson) v NHS Mid and South Essex ICB [2024] EWHC 3063 [38]. In summary: (i) the ICB makes evaluative judgments and the court does not substitute its own; (ii) the court asks whether the outcome is beyond the range of reasonable responses, whether the reasoning involves a recognised error of approach (such as an error of logic or disregard of an obviously relevant consideration), and whether there was an insufficiency of reasonable inquiry; (iii) decision documents are not to be examined in an overzealous or legalistic way; and (iv) a balance must be struck between the intensity of review and respect for the functional distance between decision-maker and the court.

The court also set out at [40]-[42] Chamberlain J’s analysis of outcome and process rationality in R (KP) v Secretary of State for Foreign and Commonwealth Affairs [2025] EWHC 370 (Admin) at [56]-[57] and [77]. Process rationality requires that the reasoning contain no logical error or critical gap, which includes asking whether the conclusion follows from the evidence or whether there is an unexplained gap or leap in reasoning. Under a heightened standard of review, more is required by way of justification, and the range of reasonable decisions may narrow, potentially down to just one reasonable outcome [42]. Although ‘need’ is a relative concept better assessed by experienced professionals than by courts (R (Wahid) v Tower Hamlets LBC [2002] EWCA Civ 287, cited at [43].

Decision

The decision not to provide for 24/7 care fell into “a very small number of cases” in which it was outside the range of reasonable responses, and the reasoning involved an error of logic and the disregard of an obviously relevant consideration (which was Ms Hassall’s report) [45]. Despite the Defendant having a multidisciplinary, experienced and well-informed panel [45], [47], the outcome and process were irrational [47].

The court rejected the Defendant’s narrow interpretation of Ms Hassall’s report and her email of 24 April 2026 that she had not meant 24/7 nursing [46]. The court found that “it does not withstand […] analysis that Ms Hassall was only referring to the period when commissioned care was being provided”. It was significant that there was no witness statement from Ms Hassall to support the Defendant’s interpretation of her report.

The judge accepted the Claimant’s contention that the DST “proved to be an inappropriate basis” for the decision [46]. Respectfully, the court does not fully explain this finding given that the Defendant in fact rejected the DST’s recommendation. The judge did not expressly hold that the DST’s conclusions were irrational and in any case, the DST’s recommendation is not prescriptive. While not explicit, it may be the case that the judge’s view was that the DST’s analysis formed the evidence base for the package proposed by the ICB [20].

The court made a quashing order [51] but declined to be prescriptive about how the Defendant should carry out its future statutory responsibilities.

Comment

Given that the Defendant will now make a new decision, it may be a pyrrhic victory for the Claimant. It may be open to the panel to make a new decision which (a) rejects the findings of Ms Hassall’s report and (b) engages with its rejection of the DST recommendation without any error of rationality.

WND is a useful reminder that clinical reports must be read for what they say, not for what the decision-maker would prefer them to say. After-the-event clarification, unsupported by a witness statement from the report’s author, will carry little weight against the document’s text. For ICBs, the practical lessons are that it is necessary to explain expressly why it disagrees with a clinical recommendation, and to obtain direct evidence from its author where its meaning is contested.

Leo Kirby is a barrister at 1 Crown Office Row. This article first appeared in the set’s Quarterly Medical Law Review.