In order to qualify for NHS Continuing Health Care Funding (CHC) – free NHS-funded care – you need to establish that you have a ‘Primary Health Care Need’ (PHCN).
There is no legal definition of what a PHCN is. But, if the care required is predominately social in nature, for example, your relative needs help with daily activities such as getting dressed, managing personal hygiene, shopping, household tasks, managing money and their personal affairs, the provision of care is likely to be the responsibility of the Local Authority (Social Services Department) under the Care Act 2014.
The care they provide is ‘means-tested’, which means that your financial circumstances will be taken into account.
The Local Authority will not contribute to care unless you have savings or investments below their upper capital threshold of £23,250. They will also take into account any income, for example from pensions. If your means are above the limit, you will have to self-fund your own care. Over the years, there have been numerous articles in the press and radio-chat discussions with frustrated callers, who have told of personal heart-rending stories when selling their parents’ home to pay for their care. No government has yet successfully tackled the social care funding crisis and avoiding the need to sell homes or liquidate assets and savings to pay for care. There has been much talk over the last few years of the government introducing a cap on social care fees (April 2020 and October 2023), but despite two recent attempts to introduce it, the proposed reforms have been delayed yet again, until October 2025 (so far!). Families who fall above the £23,500 current threshold will have to continue to find the funds to pay for care privately.
However, the position is different if you are found to have a PHCN i.e. “the main aspects or majority part of the care they require is focused on addressing or preventing health needs” – in which case, care is outside the remit of what the Local Authority can legally provide and has to be provided by the NHS instead.
If your relative is found to have a PHCN, the NHS will be responsible for providing for ALL of their assessed healthcare and associated social care needs, including accommodation, if that is part of the overall need, regardless of the amount of savings or investments that they have. As the focus is on health needs, personal finances should never be part of the discussion.
So, whether an individual’s needs are found to be social care or healthcare needs, can impact hugely on a their finances – depending on who has to pay for their care.
The common problem is that there is little publicised about CHC Funding and you really have to be ‘in the know’ to access it – or else, you could unwittingly be self-funding for years and quickly erode all your hard-earned savings! For more information around the subject, read these helpful blogs:
To determine whether an individual has a PHCN you have to look at the overall picture and consider the totality of their needs. The assessment process is carried out at a Multi-Disciplinary Team Meeting using the NHS’ Decision Support Tool (DST). The DST gives some useful guidance to help establish whether a PHCN exists.
There are four ‘Priority’ health care needs described within the DST that should automatically give rise to a Primary Health Care need, as follows:
1). Breathing: Unable to breathe independently, requires invasive mechanical ventilation.
2). Behaviour: Challenging’ behaviour of a severity and/or frequency and/or unpredictability that presents an immediate and serious risk to self, others or property. The risks are so serious that they require access to an immediate and skilled response at all times for safe care.
3). Drug Therapies and Medication: Has a drug regime that requires daily monitoring by a registered nurse to ensure effective symptom and pain management associated with a rapidly changing and/or deteriorating condition.
OR Unremitting and overwhelming pain despite all efforts to control pain effectively.
4). Altered states of consciousness: Coma or ASC that occur on most days, do not respond to preventative treatment, and result in a severe risk of harm.
The first of the situations above (Breathing) is the only one where there is no debate to be had. The patient will be on a ventilator with no ability to breathe independently.
The situations at (2) to (4) all have factors that need to be proven, and are therefore open to interpretation. This is where, the guidance and support of someone with the expert knowledge of CHC Funding can be invaluable. Otherwise, families might find themselves struggling to make themselves heard.
Here’s an example of how points (3) and (4) might be applied:
Take ‘James’, a patient on anti-convulsants, rescue medication and oxygen therapy to manage epilepsy. James has daily seizures and needs daily monitoring to decide when/whether to administer rescue medication and oxygen. This case could be argued using point (3) above. The seizures give rise to a ‘rapidly changing condition’ i.e. when the seizures occur a registered nurse needs to ensure effective symptom control by administering oxygen to keep the patient breathing during the seizure and/or to bring the seizure under control with the rescue medication.
In addition, or in the alternative, it could be argued that James meets the criteria at point (4). James’ continued frequent seizures, despite his preventative daily medication/treatment is not controlling the condition (i.e. the epilepsy). James is at severe risk of harm due to the potential for brain damage, cardiac arrest or death. To argue the points under both (3) and (4), a chart, or record, identifying the dates, duration, type of seizures and what remedial action was required, would be helpful to evidence the ongoing care needs.
In addition to the four ‘Priority’ instances noted above, there are many other situations, where a combination of ‘Severe’, ‘High’, ‘Moderate’ or ‘Low’ care needs recorded on the DST may give rise to a PHCN. These situations need to be individually argued based on the four Key Characteristics namely: Nature, Complexity, Intensity and Unpredictability of the individual’s health care needs.
The National Framework for NHS Continuing Healthcare Funding provides definitions for Nature, Complexity, Intensity and Unpredictability as follows:
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.
Intensity: This relates to both the extent (‘quantity’) and severity (degree) of the needs and the support required to meet them, including the need for sustained/on-going care (‘continuity’).
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 interactions 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 when a physical health need results in the individual developing a mental health need.
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 individual’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.
Whilst these descriptions are helpful to a certain extent, there is still a lot to understand and specific ways in which to present the care needs and how they interact with one another in order to establish a PHCN.
The four Key Characteristics will be different for each individual. Each case is fact specific. So it is simply not possible to compare one person’s needs with another, however tempting and obvious it might seem. We often hear people say (possibly quite wrongly) that their parent is ‘worse’ than another person they know who is CHC Funded. Such comparisons are not helpful and do not create a precedent.
This is a complex area to understand, with subjective interpretation of eligibility criteria set out in the DST, needing to be argued in a specific way depending on the case. We can help you to find your way through the process and access professional support to take away the stress and confusion.
Let us assist you in determining whether you or your relative has a Primary Health Care Need. Browse our Care To Be Different website for lots of free information and resources or get in touch if you have a pressing problem and need some help.
If there is a particular topic you would like us to cover, we’d love to hear from you! Just send an email via our “Contact Us” page with the subject “blog request” and we’ll do our best to cover your suggested topic.