The CHC eligibility criteria, explained

What is the primary health need test?

NHS Continuing Healthcare is the NHS funding for adults whose main need for care is a health need, and our guide to what NHS Continuing Healthcare is covers the basics. This page covers the test itself: what the criteria are, where they are written down, and how assessors are told to apply them.

The whole eligibility decision rests on one question. Does the person have a primary health need? The National Framework, the official rulebook Integrated Care Boards (ICBs) work to, defines it like this:

"An individual has a primary health need if, having taken account of all their needs (following completion of the Decision Support Tool), it can be said that the main aspects or majority part of the care they require is focused on addressing and/or preventing health needs. Having a primary health need is not about the reason why an individual requires care or support, nor is it based on their diagnosis; it is about the level and type of their overall actual day-to-day care needs taken in their totality."

National Framework, page 22, paragraphs 55 to 67

Read that definition slowly, because it does a lot of work. The test looks at all of the person's needs together, in their totality. It asks whether the main part of the care is about health, rather than everyday help with living. And it says, in plain terms, that the reason for the care and the diagnosis behind it are not the test. Two people with the same condition can get different answers, because the test measures needs, not labels.

Nobody applies this test by instinct. The multidisciplinary team works through the Decision Support Tool first, then asks the primary health need question against everything the tool has recorded. That is why the criteria below matter so much: they are the lens the Framework tells assessors to use.

What are the 4 criteria for CHC funding?

The four criteria for CHC funding are the four characteristics of need: nature, intensity, complexity and unpredictability (National Framework, pages 23 to 24, paragraph 60). Assessors use them to decide whether the person's needs, taken together, add up to a primary health need. Each one has a verbatim definition in the Framework, and each is worth knowing word for word before any assessment or appeal.

1. Nature

"Nature: This describes the particular characteristics of an individual's needs (which can include physical, mental health or psychological needs) and the type of those needs. This also describes the overall effect of those needs on the individual, including the type ('quality') of interventions required to manage them."

National Framework, pages 23 to 24, paragraph 60

In plain words: what kind of needs are they, and what kind of care do they demand? A need that calls for clinical skill, such as managing a feeding tube or responding to seizures, has a different nature from help with shopping or washing.

2. Intensity

"Intensity: This relates both to the extent ('quantity') and severity ('degree') of the needs and to the support required to meet them, including the need for sustained/ongoing care ('continuity')."

National Framework, pages 23 to 24, paragraph 60

In plain words: how much care, how severe the needs, and how constant the support. Care needed many times a day, or through the night, or without a break, speaks to intensity.

3. Complexity

"Complexity: This is concerned with how the needs present and interact to increase the skill required to monitor the symptoms, treat the condition(s) and/or manage the care. This may arise with a single condition, or it could include the presence of multiple conditions or the interaction between two or more conditions. It may also include situations where an individual's response to their own condition has an impact on their overall needs, such as where a physical health need results in the individual developing a mental health need."

National Framework, pages 23 to 24, paragraph 60

In plain words: do the needs tangle together, so that meeting one makes another harder? Diabetes on its own may be routine. Diabetes plus dementia plus swallowing problems can be complex, because each condition changes how the others must be managed.

4. Unpredictability

"Unpredictability: This describes the degree to which needs fluctuate and thereby create challenges in managing them. It also relates to the level of risk to the person's health if adequate and timely care is not provided. An individual with an unpredictable healthcare need is likely to have either a fluctuating, unstable or rapidly deteriorating condition."

National Framework, pages 23 to 24, paragraph 60

In plain words: can anyone say what tomorrow looks like? Falls that come without warning, behaviour that changes by the hour, or a condition that is getting worse quickly all point to unpredictability, and to the risk if the right care is not there in time.

One more line from the Framework matters here, because families often assume they must show all four. They do not:

"Each of these characteristics may, alone or in combination, demonstrate a primary health need, because of the quality and/or quantity of care that is required to meet the individual's needs."

National Framework, page 24

So a case can rest on intensity alone, or on unpredictability alone. The characteristics are lenses on the same picture of need, not four hurdles to clear one by one.

What scores indicate eligibility?

The criteria above are applied through two scored stages, and each stage has its own thresholds.

The first stage is the Checklist, a screening tool that scores 11 domains of need at level A, B or C. A full assessment is required with two or more A scores, five or more B scores, one A and four Bs, or a single A in one of the four domains that carry a priority level: Breathing, Behaviour, Drug therapies and medication, and Altered states of consciousness (Checklist guidance, paragraph 19). Our guide to the CHC Checklist walks through all 11 domains and the scoring in detail. The threshold "has intentionally been set low" (National Framework, page 40), so passing it starts a full assessment rather than settling anything.

The second stage is the Decision Support Tool (DST), completed by a multidisciplinary team. It covers 12 domains, each rated on a scale that runs from no needs up through low, moderate and high. Not every domain reaches every level: some cap at high, others reach severe, and four can reach priority (DST guidance, paragraphs 23 to 24). The DST guidance then names the score patterns that point to eligibility:

"A clear recommendation (and decision) of eligibility for NHS Continuing Healthcare would be expected in each of the following cases: A level of priority needs in any one of the four domains that carry this level. A total of two or more incidences of identified severe needs across all care domains."

DST guidance, paragraph 35, page 10

Below those two patterns, the guidance keeps the door open. A severe level combined with needs in a number of other domains, or a number of domains with high or moderate needs, "may also, depending on the combination of needs, indicate a primary health need" (DST guidance, paragraphs 36 to 37). And the Framework warns against treating any of this as arithmetic: the indicative guidelines "are not to be viewed prescriptively" (National Framework, page 51). The recommendation must come back to the four characteristics and the primary health need question, not to a tally of levels.

What does NOT decide eligibility?

Families are regularly told things that the Framework flatly rules out. Four factors have no place in the eligibility decision, and each exclusion is written down:

The setting rule cuts both ways and is worth quoting in full, because families are often told CHC is only for nursing homes:

"NHS Continuing Healthcare may be provided in any setting (including, but not limited to, a care home, hospice or the person's own home). Eligibility for NHS Continuing Healthcare is, therefore, not determined or influenced either by the setting where the care is provided or by the characteristics of the person who delivers the care."

National Framework, page 24

The money rule matters just as much. CHC has no means test. If anyone suggests that a house, a pension or savings affect the answer, the Framework says otherwise: "Financial issues should not be considered as part of the decision on an individual's eligibility for NHS Continuing Healthcare" (National Framework, page 24). A family caring at home, a self-funder in a care home and a council-funded resident all face exactly the same test of need.

How do I know if my relative might qualify?

Start with the shape of the care, because that is what the test measures. Ask what would happen if the current support stopped for a day. If the honest answer involves risk to health, needs that flare without warning, care that runs through the night, or several conditions that have to be managed around each other, the four characteristics may be in play and a Checklist screening is worth requesting.

Watch for well-managed needs. The Framework says "well-managed needs are still needs" (National Framework, page 51, paragraphs 162 to 166), so a person whose risks look small because good care contains them should still be scored on the underlying need.

If you want a picture of where the case stands before asking for a formal screening, our free screener asks 18 plain-English questions about the same areas of daily care and shows whether a full assessment looks due. It takes about three minutes, and nothing about it commits you to anything with the ICB.

Whatever the starting point, put the case in the Framework's own terms. Describe the needs through nature, intensity, complexity and unpredictability, evidence each one with dated examples, and ask for the reasons behind every score in writing. This page is legal information, not legal advice.