CHC, put simply.
What Is a Primary Health Need in NHS Continuing Healthcare?
Primary Health Need is the central legal concept in NHS Continuing Healthcare. It determines whether the NHS — rather than the Local Authority — is responsible for arranging and funding a person's care.
Who is responsible for meeting these needs?
This is the question at the heart of NHS Continuing Healthcare.
Local Authority
Social Care Needs
Support with everyday living.
Usually the responsibility of the Local Authority, following a Care Act assessment.
NHS
Health Needs
Complex health and clinical needs.
May indicate a Primary Health Need and NHS Continuing Healthcare eligibility.
A Primary Health Need is not decided by a diagnosis.
It is decided by looking at the whole picture and asking:
Are these needs mainly health needs?
CHC Clarity · CHC, put simply.
What does Primary Health Need mean?
A Primary Health Need means that a person's overall care needs — taken together — are primarily health needs rather than social care needs. When that is the case, the NHS has a legal duty to arrange and fund the person's care in full.
Primary Health Need is considered within the NHS Continuing Healthcare framework by looking at the totality of the person's needs — their Nature, Intensity, Complexity and Unpredictability — and whether those needs go beyond what a Local Authority can lawfully be expected to provide. There is no numerical pass mark, and each person must be considered individually. It cannot be reduced to a diagnosis, a score, or a particular number of high-level domains on a form.
If this is the case:
The NHS is responsible for arranging and funding care.
If not:
The Local Authority may be responsible for meeting eligible social care needs.
The key question
Are this person's needs primarily health needs — or primarily social care needs?
There is NO legal definition of a Primary Health Need.
- No diagnosis that guarantees eligibility.
- No pass mark.
- No automatic score.
- No single domain that automatically qualifies.
Instead: Professionals must look at the whole picture.
Why does Primary Health Need matter for CHC eligibility?
NHS Continuing Healthcare (NHS CHC) is a package of care that is arranged and fully funded by the NHS. Unlike Local Authority social care, it is not means-tested. If a person is found to have a Primary Health Need, the NHS is legally responsible for meeting their care needs — regardless of where that care is provided.
This distinction matters enormously for families. A person receiving care at home or in a nursing home who qualifies for NHS CHC will have the full cost of their care met by the NHS. Where a person is not eligible for NHS CHC, their needs may be met through a combination of Local Authority social care and NHS services, depending on their individual circumstances. People in nursing homes who do not qualify for full NHS CHC may also be eligible for NHS-funded nursing care (FNC), which is a separate NHS contribution towards the nursing element of their care home fees.
Health needs and social care needs: where does responsibility change?
Not all care needs are the same. Some needs are primarily social care needs — support with everyday living that the Local Authority is responsible for providing following a Care Act assessment. Other needs are primarily health needs — complex clinical needs that require nursing skill, medical intervention, or ongoing health monitoring.
The law does not allow Local Authorities to provide services that are more than incidental or ancillary where the person's needs are, in substance, healthcare needs. This is the legal boundary that NHS Continuing Healthcare is designed to address.
In practice, many people have a mix of both types of need. The CHC assessment does not ask whether a person has any health needs — it asks whether their needs, considered as a whole, are primarily health needs.
Nature, Intensity, Complexity and Unpredictability
Professionals apply four key characteristics when considering whether a person has a Primary Health Need. These are often referred to as NICU.
Nature
- What are the needs?
- How serious are they?
- What interventions are needed?
Intensity
- How much care is required?
- How often?
- How much skill or supervision is needed?
Complexity
- How do different needs interact?
- Do they make each other harder to manage?
Unpredictability
- Can needs change suddenly?
- Could there be unexpected deterioration?
- Are there significant risks?
Often called
NICU
Nature · Intensity · Complexity · Unpredictability
These four characteristics are at the centre of every CHC eligibility decision.
How do the four characteristics work together?
Nature, Intensity, Complexity and Unpredictability are not four independent boxes to be ticked. They are four lenses through which professionals consider the same person's needs — and they interact with each other.
A person's needs may be highly unpredictable without being especially complex. Another person's needs may be relatively stable but of such intensity that they require continuous skilled nursing input. A third person may have needs that are individually manageable but interact in ways that create significant complexity.
The question is always whether the overall picture of needs — considered through all four characteristics — amounts to a Primary Health Need. No single characteristic is decisive on its own.
Example
For example: a person with advanced dementia may have needs that are moderate in intensity but highly unpredictable, with significant complexity arising from the interaction of cognitive, nutritional, skin integrity and behavioural needs. The four characteristics must be considered together, not in isolation.
Does a diagnosis determine CHC eligibility?
No. A diagnosis is relevant context — it helps professionals understand the nature of a person's needs — but it does not determine CHC eligibility on its own.
Two people with the same diagnosis can have very different needs. One person with dementia may have relatively stable, predictable needs that are well managed with social care support. Another person with the same diagnosis may have highly complex, unpredictable needs that require continuous skilled nursing input.
Dementia
Does not automatically mean CHC.
Stroke
Does not automatically mean CHC.
Cancer
Does not automatically mean CHC.
Parkinson's
Does not automatically mean CHC.
None of these diagnoses automatically means CHC eligibility — and none automatically rules it out.
CHC eligibility is determined by the nature of the needs, not the label attached to them.
Do you need a Severe or Priority domain to qualify for CHC?
No. There is no combination of domain levels in the Decision Support Tool that automatically results in CHC eligibility or ineligibility.
Many families are told:
"You need a Priority."
"You need two Severes."
This is a misunderstanding of how the CHC framework works.
Families are sometimes told they need a Priority level in one domain, or two Severe levels, to qualify. This is a misunderstanding of how the CHC framework works. The National Framework for NHS Continuing Healthcare is clear that domain scores may indicate a Primary Health Need — but they do not determine it automatically.
The Decision Support Tool is a structured framework to support professional decision-making. It is not a points-based eligibility calculator. Professionals must use it alongside professional judgement to consider whether the person's needs, taken as a whole, amount to a Primary Health Need.
What does a "well-managed need" mean in CHC?
A well-managed need is still a need. This is an important principle in NHS Continuing Healthcare that families often find confusing.
If a person's needs are being effectively managed — for example, through skilled nursing care, medication, or specialist equipment — that management does not remove the underlying need. The question is what the need is, and what is required to meet it, not whether it is currently under control.
Professionals should consider what would happen if the current care and management were removed. If the answer is that the person's health would deteriorate significantly or rapidly, that is evidence of an underlying health need — even if it is currently well managed.
A well-managed need is still a need. The management does not remove the underlying health need — it demonstrates it.
How do the DST and MDT consider Primary Health Need?
The full CHC assessment uses the Decision Support Tool (DST) — a structured framework that looks at a person's needs across 12 care domains, including behaviour, cognition, communication, mobility, nutrition, skin integrity, breathing, drug therapies, psychological needs, continence, altered states of consciousness, and other significant care needs.
The DST is completed by a multidisciplinary team (MDT) — usually including a nurse and a social worker — who consider the evidence and record the level of need in each domain. But the DST is a support tool, not a scoring system. The MDT must then consider whether the overall picture of needs amounts to a Primary Health Need.
The MDT makes a recommendation. The final funding decision is made by the Integrated Care Board (ICB). Families have the right to be present at the MDT meeting and to contribute to the assessment.
What evidence can help demonstrate a Primary Health Need?
Preparing evidence before a CHC assessment can make a significant difference. Professionals can only consider what is in front of them — and families are often best placed to provide a full picture of a person's day-to-day needs.
- A detailed care diary recording daily needs, incidents and interventions
- Medical records, GP letters and hospital discharge summaries
- Nursing notes and care home records
- Specialist reports — for example, from a speech and language therapist, tissue viability nurse or consultant
- A written account from family members describing the person's needs in their own words
- Evidence of incidents, falls, episodes of distress or rapid deterioration
The CHC Clarity DST Preparation Pack is a free resource designed to help families organise their evidence and understand what professionals are looking for in each domain.
Download the free DST Preparation PackWhat happens if the ICB decides there is no Primary Health Need?
If the Integrated Care Board decides that a person does not have a Primary Health Need, they will not be eligible for NHS Continuing Healthcare funding. The person may still be eligible for NHS-funded nursing care (FNC) if they are in a care home, or for Local Authority social care subject to a financial assessment.
Families have the right to request a review of the decision and, if necessary, to appeal. The appeals process involves a Local Resolution stage with the ICB and, if unresolved, an Independent Review Panel.
If you disagree with an eligibility decision, there is a process for challenging it. Understanding the reasons for the decision and gathering relevant evidence can help you present your concerns clearly.
Frequently asked questions about Primary Health Need
CHC Clarity
Ready to understand the full CHC process?
The Primary Health Need is the starting point. The CHC Journey page walks you through every stage — from the initial Checklist to the final funding decision.