PART 1 – Looking At The 4 Key Indicators: Unlocking the Basics

PART 1 – Looking At The 4 Key Indicators: Unlocking the Basics

In response to requests for more information about the 4 Key Indicators, we are developing a series of blogs aimed at addressing some of the important issues you need to know.

Background Introduction

In order to meet the eligibility criteria for NHS Continuing Healthcare Funding (CHC) your relative must have a ‘primary health need’. In short, this means that the primary or overriding reason for their care must be due to healthcare, rather than social care, needs.

Understanding the basic distinction between health needs and social needs is essential as it underpins the whole ‘primary health need’ approach. If you are not familiar with these concepts, we recommend that you read these helpful articles:

Part 1 – Explaining The Vital Difference Between Social Needs vs Healthcare Needs

Part 2 – Explaining The Vital Difference Between Social Needs vs Healthcare Needs

The Assessment Process

In order to be awarded CHC, there is an assessment process which NHS Clinical Commissioning Groups (CCGs) have to follow, starting with an Initial Checklist assessment. The Checklist is a scoring tool to determine whether the individual will pass on to the next stage: a full assessment.

For more information about the Checklist assessment, read: Understanding the Checklist Assessment

The full assessment is carried out by a Multi-Disciplinary Team (MDT) using the Decision Support Tool (DST). The DST is not the assessment itself, but is merely a useful ’tool’ to gather together and record the evidence of needs in one document, and assist the MDT to reach a conclusion as to eligibility for CHC Funding. The DST looks at certain areas of need, called Care Domains, namely: Breathing*, Nutrition – Food and Drink, Continence, Skin integrity (including tissue viability), Mobility, Communication, Psychological and emotional needs, Cognition, Behaviour*, Drugs/Medication/Symptom control*, Altered states of consciousness* & Other.

Below is a copy of the image taken from the National  Framework listing all 12 Care Domains and shows the interaction between the intensity, complexity and/or unpredictability of needs:

Each Care Domain is broken down into a number of levels. The levels represent a sliding scale from the lowest to highest, with: ‘N’ (No needs) at the bottom end of the scale, increasing to ’L’ (Low), ‘M’ (Moderate), ‘H’ (High), ‘S’ (Severe) and ’P’ (Priority) needs at the highest possible level of need and support required.

Completion of the DST should result in a comprehensive picture of the individual’s needs that captures the nature, intensity, complexity and/or unpredictability of their needs and indicates the quality and/or quantity (including continuity) of care required to meet those needs.

The DST contains a summary sheet to provide an overview of the levels chosen and a summary of the individual’s needs, along with the MDT’s recommendation about eligibility or ineligibility. The guidance gives a clear recommendation (and decision) that 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 (also marked * above).
  • A total of two or more ‘Severe’ needs across relevant Care Domains.

You can learn more about the MDT assessment in the blogs at the end of this article.

The MDT’s Approach

When carrying out a full assessment to determine whether the individual has a primary health need, and is therefore eligible for CHC Funding, the MDT are supposed to take a holistic approach and consider the totality of the individual’s care needs.

Eligibility for CHC Funding is not contingent on any particular diagnosis or medical condition, but rather on the daily needs of the individual and whether these fall into the category of health or social care. To correct a common misunderstanding, a diagnosis of Dementia or Alzheimer’s alone, does not guarantee CHC Funding. The MDT have to look at the whole picture of overall needs (holistic) and consider their interaction as a whole (totality). We will explore the interrelation of healthcare needs in more detail later in the series.

While the distinction between health and social care can be difficult to define, social care needs are often thought of as being assistance with the things we all need to do every day: washing, dressing, eating, drinking, moving around, going to the toilet, taking routine medications, applying prescribed creams. The NHS refer to them as Activities of Daily Living (ADL).  If a person’s primary need is for social care, i.e. assistance with such routine daily activities of living, responsibility falls to the Local Authority, who carry out means-testing to gauge the individual’s ability to fund that care.

CHC Funding, however, is concerned specifically with the health needs of the individual; i.e. those needs that can only be met by a registered nurse or other similarly skilled professional. Health needs must be such that a registered nurse, or similarly skilled professional, is required 24-hours a day to provide necessary care. If the individual’s primary (overriding) need is for healthcare, then all of their care (including accommodation and daily social needs) should be funded in full by the NHS, free of charge, via an NHS Continuing Healthcare package. Unlike social care, CHC is not means-tested and is paid by the NHS irrespective of wealth and savings.

Such needs that require the sustained input of a registered nurse, or other similarly skilled professional, might include:

  • Severe behavioural problems, such as unpredictable physical aggression, absconding or self-harm – such that there is a serious risk of harm to self or others.
  • Severe psychological disturbance, requiring regular pharmacological intervention and referrals to Mental Health Services.
  • A physical condition such that there is serious risk of injury upon movement or transfer, or whereby the positioning of the patient is crucial – e.g. to aid breathing.
  • Problems with swallowing food/drink/medication, requiring regular monitoring by Speech and Language Therapy. Even with such intervention, the patient may still aspirate (inhale liquids/food particles into the lungs), requiring skilled intervention and/or suction to clear the airways.
  • Problems with continence beyond routine care; for example, a problematic catheter requiring frequent changes/washouts, or severe constipation requiring the frequent administration of enemas and/or performance of manual evacuations (manually removing faeces from the rectum/sigmoid colon).
  • Significant tissue breakdown caused by pressure sores or other skin conditions, such that the integrity of the underlying tendons/muscles/bones is compromised or at risk. The patient requires regular dressing changes – daily or more frequently – and supervision by Tissue Viability Nurses to ensure the wound does not degrade further.
  • Sustained difficulty in breathing, requiring the regular administration of oxygen or other inhalants. Even with such intervention, the patient continues to have difficulty in breathing and all Activities of Daily Living are affected.
  • A complex or frequently changing medication regime, requiring regular oversight by the GP or Consultant. The route of medication may be complex – intravenous – or the type of medication may be high-risk, e.g. licenced painkillers, such as morphine.
  • Severe and unrelenting pain, such that frequent in-the-moment decisions regarding the administration of licensed analgesics need to be made, and the patient’s mental and physical wellbeing are affected.
  • Frequent (weekly, daily or several times each day) episodes of Altered States of Consciousness – e.g. transient ischaemic attacks, cerebrovascular accidents, epileptic seizures – requiring skilled intervention or A&E admission to minimise the risk of harm.

Eligibility for CHC Funding is not contingent on a certain combination of levels of need across the 12 Care Domains within the DST, (except as above, in cases of automatic award when an individual has one ‘Priority’ level of need or two ‘Severe’ levels of need), but rather on the fulfilment of one or more of the Key Indicators (sometimes referred to as ‘Characteristics’), namely: Nature, Intensity, Complexity and Unpredictability.

A description of the 4 Key Indicators is set out in paragraph 59 of the National Framework for NHS Continuing Healthcare and NHS funded Nursing Care (revised October 2018), and are summarised below:

NATURE: The nature of the patient’s needs addresses the necessary quality of the service to be provided to the patient, and whether a local authority should lawfully be expected to provide it.

INTENSITY: Intensity of needs evaluates the quantity and degree of needs, as well as the continuity of care necessary to treat those needs.  Where a Local Authority funds aspects of healthcare, the primary need must be for accommodation and/or social care.

COMPLEXITY: The complexity of needs is concerned with how the needs present and interact to increase the skill needed to monitor the symptoms, treat the condition(s) and/or manage the care.  This can arise with a single condition or can also include the presence of multiple conditions or the interactions between two or more conditions.

UNPREDICTABILITY: The unpredictability of needs addresses the degree to which needs fluctuate, creating challenges in managing them, and the degree of risk to the person’s health if adequate and timely care is not provided.  For the purposes of this indicator, someone with an unpredictable healthcare need is likely to have either a fluctuating, or unstable or rapidly deteriorating condition.

Each of these 4 Key Indicators 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.

A ‘Priority’ level of need in the Domains of Behaviour*, Breathing*, Medication* or Altered States of Consciousness* would, in and of itself, fulfil at least one of the Key Indicators and demonstrate a primary health need (see Paragraph 141 of the NHS National Framework); either because staff require specialist knowledge to meet the needs (think of a person on invasive mechanical ventilation, or someone whose behaviour is a mortal danger to self or others, or someone who is suffering life-threatening seizures on a daily basis), because interventions take a long time or an increased number of staff, or because the condition is rapidly changing such that Care Plans must be updated weekly, daily or even hourly.

Two ‘Severe’ levels of need in any of the Domains that carry this weighting would result in inherent complexity, due to the interrelation of needs and their impact on one another. It would also likely result in some intensity in terms of the frequency of intervention, the length of time this takes and the number of staff required.

Whereas, Activities of Daily Living – such as eating/drinking, routine toileting/changing of continence pads, changing position/moving around and taking routine medication are considered social needs – none of which require the continued input of a registered nurse or similarly skilled professional. This type of predictable 24 hour care intervention, assistance and support can be delivered routinely by unskilled staff. Even if a person requires full assistance with all activities of daily living, and providing there is no complexity, intensity and/or unpredictability arising from those needs (should they be severely cognitively impaired, unable to communicate, immobile and doubly incontinent), this is classed as social care that can be met by the Local Authority (subject to means-testing).

For example, take an individual who requires full assistance to wash, dress and maintain personal hygiene; who is doubly incontinent and relies on care staff to change their pads regularly and ensure good skin integrity; who is unable to weight bear and requires the use of a full hoist to transfer; who relies on staff to administer their non-complex medication regime, which is routinely prescribed; who is compliant with all care and is described as having a “happy and cheerful outlook”; who does not experience any difficulty in breathing and does not suffer altered states of consciousness; who does not appear to be in any pain. Let’s say, the only Care Domain in which there is some evidence of complexity is ‘Nutrition’ – where the individual has been assessed as being at risk of aspiration and requires their fluids be thickened to assist swallowing; but, there is no evidence of frequent choking episodes requiring skilled intervention to maintain their airway and the individual maintains a healthy weight. A risk of choking is not sufficient to indicate eligibility for CHC Funding, unless there is evidence of a severe impact on wellbeing and the provision of care (i.e. nutritional status at risk; skilled interventions to clear the airway frequently required). In this hypothetical example, the individual’s care interventions would not present with a primary need for healthcare, and as such, they would not eligible for CHC Funding.

For more reading around the subject, look at this selection of articles from our website:

Learning valuable lessons prior to your MDT Assessment and how to avoid pitfalls

Preparing for the Multi-Disciplinary Team Assessment

What Happens At The Multi-Disciplinary Team Meeting?

Don’t let the Decision Support Tool become a ‘tick box’ exercise

What Is The Role Of The MDT Coordinator?

Can The MDT Panel Refuse To Proceed If I Have An Advocate?

Who completes the Decision Support Tool in NHS Continuing Healthcare?

What to do if you’ve been excluded from the MDT Assessment?


  1. Ian 2 months ago

    I have completed the LRM stage that unanimously deemed that the original DST was correct and there was no Primary Health Need. Strange but a unanimous team of two does not seem convincing.
    The LRM minutes state :

    The LRM looked at the ‘nature’ of needs throughout the period to consider whether a ‘Primary Health Need’, and if when taken as a whole, the nursing and other health services/care required during the review period were of a ‘nature’ or type which a local authority could lawfully provide with health intervention e.g. from a GP/nursing services.
    LRM found that the ‘nature’, type or ‘quality’ of health and care needs, as summarised above and fully outlined in the Clinical Dispute Form were not a Primary Health need in the reviewed period.

    My response :
    What is the point of asking the question if the nature of the total needs is within the lawful remit of the Local Authority when you take all the needs that they can’t provide by law out of the total needs.
    The patient is categorised with one SEVERE, HIGH, MODERATE needs and a single no needs. So when taken as a whole all these needs reduce down to a need that is inconsequential with the same health weighting as brushing teeth and plumping pillows.
    What do you think constitutes a full outline ? Something missing the body ?

    • Michelle wetherall 2 months ago

      Hi Ian,
      Appeal! This isn’t the end. A local resolution meeting is with the same people who made the decision at the MDT/DST.
      I guess the one of the two people was a “note-taker”? It was in my case!
      Submit your appeal and request an IRP with the reasons you have outlined above. You have nothing to loose but everything to gain! Make sure you get a copy of the LRM decision and the rationale for upholding the decision and then set out your argument for an IRP. An IRP isn’t guaranteed. Your appeal needs to be robust, so that the Chairman can understand why you remain dissatisfied with the outcome.
      Good Luck!

      • Ian 2 months ago

        Thankyou for replying. It is a rather complicated case. I skipped the LRM initially and complained. A health assessment before the DST was falsified, then was lost and found after 6 months. The CEO of the CCG tackled my complaint rather poorly on two occasions. In the end accepting it to go through the LRM. A month before the LRM I received a letter saying it had been unsuccessful. I confirmed they would address all the issues which they did not. Ignored anything that would point to a Primary Health Need and said one or two outrageous things. I recorded and took a witness to the LRM and have got the documented rationale. There is no PRimary Health Need identified because if you remove all the NHS health needs the local authority can legally take on the care. Well obviously, shame that isn’t the test. In this case although a mix of needs severe, moderate and high they miraculously end up at plumping pillows. I have sent a copy to every executive member of the CCG and CSU. Not one process has worked to procedure or honestly and its all in the documentation.

      • Ian 2 months ago

        PS The DSTs were exactly as described on the Care to be Different website. This was the second attempt with a social worker. When they started the DST form I asked for a copy of the health assessment(s) which they didn’t have. No one else seemed bothered and were quite prepared to conduct the meeting without this information documented. Even brought other people into the meeting to convince me I was wrong. I showed the guidance and requested a document that contradicted this and then we could move on. Oh yes they were only interested in the health and well being of the subject, they dont have anything to do with finances.

        • Michelle wetherall 2 months ago

          Don’t give up! Insist on the paperwork for an IRP. The circumstances you have described show a dismal process that lacks impartiality, transparency and maladministration. The resolution meeting should have answered all the questions you have remaining and clearly this hasn’t happened and is a huge concern. There is no justification for the process you and your loved one has been subjected to.
          I wouldn’t let up now, the only way forward is to insist on an Independent Review.

          • Ian 2 months ago

            Thanks for your words of support. I won’t give up I’ve been at this for 3 years. When the door closes I open it. Fortunately we were in receipt of CHC for most of the care. Every step has included misadministration and lies. Its all documented too.

          • Ian 2 months ago

            Just got the latest response back from my questions regarding the LRM – it is comical.
            1. The LRM was recorded but deleted after 3 months as that was policy. Just before any documents were issued.
            2. GP records have been found in the CSU records, despite the originals going missing but not for the period under review by the LRM.
            3. Everything has been dine by the book despite it clearly not being.

            I can now go to complaints or to an IR if not satisfied. I have already been through complaints to get to where I am. I am trying to find where the system ends, where the pot of truth is but haven’t found it yet.
            You have to wonder what brings probably once decent people to effectively lie and cheat.

        • Michelle wetherall 2 months ago

          Hi Ian,
          I completely understand your frustration!
          I would now be writing to request an Independent Review. Complaints don’t work!
          Insist that an IRP is the only way for you to show that your relative has a PHN.
          They have to send you the documents to complete and then an IRP Chairmain will review
          why you remain dissatisfied with the outcome. However, an IRP isn’t automatic.
          Once you get the paperwork, be sure to complete it comprehensively to secure the IRP.
          Good Luck!

    • Jim 1 month ago

      Ian – Maybe I’m missing something but if the local GP is providing nursing services and/or other health services which are required to meet part of the “whole” nursing and/or other health services then there is a primary health need. This is because, in construing regulation 21(7) of the Standing Rules, the identified and required nursing and/or other health services are not all being provided by the local authority (LA) and the required attribution must, as a consequence be to 21(7)(b). An attribution to 21(7)(a) – leading to there being no primary health need – would only arise if (i) all the nursing and/or other health services are capable of LA provision and (ii) those services are merely incidental or ancillary to the LA provided accommodation services. From what is said, the CCG has erred in law in making its decision.

      • Ian 1 month ago

        Hello Jim,
        You wouldn’t believe the lies that have been documented to avoid this lawful question. I had to make my own record to be added to the DST when I asked this question. They wouldn’t answer, so I requested they make a record of it, which as refused – social worker present as well. The LRM states that the families views are adequately and appropriately recorded in the original DST with a comment that the family dispute this.
        The social worker has recorded in his notes a meeting we had to discuss the existence of a Local Authority Primary Health Test and denies any existence. The CEO of the CCG denies any existence of such a test. The CCG and LA state that all criteria were considered and each organisation states that the other did not contest the others decision , therefore it stands.
        The appeal team co-ordinator states that the process is not a court of law.
        A month before the LRM the CEO sent me a letter stating the appeal had failed but confirming the clause for SI 2996 reg 21 had been applied. At the LRM I spent 40 minutes requesting the answer to this question; nothing. When I indicated the meeting was not closed without answer of this question the minutes came back to say there was no challenge regarding closing the meeting. The assessment nurse at the LRM had never heard of such a test until I pointed it out in the Framework from which she had been quoting. They have recorded in the LRM as quoting this PHN test if you remove all the NHS care, what’s left can be delivered by the LA, therefore no PHN. The CEO and chief nurse of the CCG have confirmed from their thorough investigations that the LRM was conducted appropriately. The CEO has denied the existence of a Local Authority Test for a PHN more than once.
        That is why I have come down to the point of asking what causes, what you would once assume to be decent people, to turn ?
        They have now agreed to pay as a gesture of goodwill.
        I have started to document my case and will probably post it somewhere as what I have explained on this website is just the tip of the iceberg.

  2. Michelle Wetherall 2 months ago

    Great Stuff! Thanks CTBD, I am so pleased that you’ve responded to the request for more understanding of the 4 Key Indicators. I firmly believe that to be successful in proving your case you have to know how to apply these characteristics better than the assessors do. This first article is clear and informative and I look forward to the next articles on how families go about gathering the evidence, choosing what evidence is relevant and how to present it at an MDT/Appeal.
    Thanks again for keeping this forum updated with the excellent articles.
    With so much in the news about Social Care and the proposals that are now coming out, families must fight on for NHS CHC Funding to be reformed. Boris and countless other leaders over the last two decades have failed to sort out social care. Boris has promised no one should have to sell their home to fund their care. We all need to hold him to account!

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