CHC Eligibility
Who Qualifies for NHS Continuing Healthcare?
There is no diagnosis that automatically qualifies or disqualifies someone from NHS Continuing Healthcare. Eligibility is determined by a structured assessment of needs across 12 care domains, leading to a single legal question: does the person have a "primary health need"?
The primary health need test
The National Framework for NHS Continuing Healthcare (July 2022) defines the primary health need test through four characteristics. Assessors must weigh needs against each of these to determine whether, taken together, they are primarily a health responsibility.
The four characteristics
Nature — the type of need and what it requires by way of care. A need whose nature is medical or nursing in character carries significant weight.
Complexity — how needs interact with each other, or fluctuate in ways that require professional skill to manage. Co-morbidities that affect each other raise complexity.
Intensity — the extent and severity of need, and the level, continuity, or frequency of care required to meet it.
Unpredictability — the degree to which needs fluctuate and create risks that are difficult to manage. A person whose condition deteriorates rapidly and unpredictably — even if not continuously needy — can qualify on this characteristic alone.
No single characteristic is decisive. The assessor must consider the overall picture.
How domain scores lead to an eligibility decision
The 12-domain assessment produces a score for each domain: No Needs, Low, Moderate, High, Severe, or Priority (not all levels apply to every domain).
The Decision Support Tool (DST) then maps those scores to an eligibility recommendation using three indicators:
- A single Priority score in any domain creates a strong presumption of eligibility.
- Two or more Severe scores across different domains also indicates eligibility is likely.
- A mixed picture below that threshold requires the assessor to apply the four-characteristic test to the whole profile and make a holistic judgement.
The ICB — not the MDT — makes the final funding decision. The MDT's DST is a recommendation, not a binding outcome.
Who carries out the assessment?
A multidisciplinary team (MDT) — typically a registered nurse and a social worker — completes the Decision Support Tool. They should consult the person being assessed (if they have capacity) and people who know them well, including family members and care staff.
You have the right to be present during the assessment, to see the completed DST, and to comment on it before the ICB makes its decision. Many families do not know this.
You can request a CHC assessment from a GP, a hospital discharge team, a social worker, or directly from your ICB. The NHS cannot lawfully refuse to carry out an assessment if there is a reasonable belief the person may be eligible.
What happens if the person is found ineligible?
Refusal is not the end. You have three formal escalation routes:
Local resolution — a meeting with the ICB to discuss the decision. New evidence can be submitted. This must be requested within three months of the decision.
Independent Review Panel (IRP) — if local resolution fails, you can request an independent review. The IRP panel includes an independent chair, an independent clinical advisor, and an ICB representative.
Parliamentary and Health Service Ombudsman (PHSO) — if the IRP process is not followed correctly, a complaint to the PHSO is available. Judicial review is available as a last resort where the ICB has acted unlawfully.
The grounds for refusal are frequently challengeable. Common errors include incorrect domain scoring, failure to consider unpredictability, and applying the primary health need test too narrowly.
Frequently asked questions
Can someone in a residential (non-nursing) home get CHC?
Yes. The type of care home does not determine eligibility. Needs do. A person in a residential home whose health needs meet the primary health need threshold qualifies for CHC, and the NHS should then arrange appropriate care — which may mean moving to a nursing home, or funding a higher level of care in the existing setting.
Does having dementia automatically qualify someone?
No — but dementia that involves significant behavioural disturbance, risk, unpredictability, or serious co-morbidities commonly gives rise to CHC eligibility. The assessment must consider the person's actual presentation, not their diagnosis.
What if the person lacks capacity to consent to an assessment?
Assessment can and should proceed under the Mental Capacity Act 2005. A family member or independent advocate should be involved throughout. The assessor has a duty to consult people who know the person well, and a best-interests decision can be made if the person cannot consent.