PART 3 – Looking At The Four Key Indicators: Completing the Jigsaw

PART 3 – Looking At The Four Key Indicators: Completing the Jigsaw

In PART 1- Looking At The 4 Key Indicators: Unlocking the basics, we gave an outline introduction to the 4 Key Indicators, what they are, and how they are considered by the Multi-Disciplinary Team’s assessment process when completing their Decision Support Tool (DST).

In PART 2 – Looking At The 4 Key Indicators: Gathering pieces of evidence, we looked in more detail at the 4 Key Indicators and the type of evidence that ought be obtained and considered when building the jigsaw picture of needs in the Decision Support Tool (DST).

In this third blog in the series, we explore the issues around completing the 4 Key Indicators and how the pieces of information gathered, can interact between the various Care Domains.

Practice Guidance Note 21.2 of The National Framework for NHS Continuing Healthcare which provides that “a good quality multidisciplinary assessment of an individual’s health needs… will be holistic, looking at the range of their needs from different professional and personal viewpoints, and considering how different needs interact”.

When you read the 4 Key Indicators, you should know what the individual’s needs are and how they are being cared for.

It is the inter-connection of all the individual pieces of evidence in your jigsaw puzzle that matter. Only once the picture is completed, can you then stand back and survey the overall needs in the DST, and reach your conclusions as to eligibility for CHC Funding.

Looking at the individual Care Domains in isolation, will not tell you the whole story and how the individual’s needs interact (ie how the pieces of your jigsaw fit together). It is this holistic approach that is paramount to a successful application for CHC Funding.

When compiling the 4 Key Indicators, the skill is in drawing all the factual bits of information together and completing a summary of needs and describing how they connect or impinge on one another to reach a decision on eligibility for CHC Funding.

The DST is a prescriptive document, with lots of predetermined boxes for completion, including 12 Care Domains, each with their own descriptors and level of need. For example, see the ‘Continence’ Domain copied below.

3. Continence

Description Level of need
Continent of urine and faeces.   No needs
Continence care is routine on a day-to-day basis;

Incontinence of urine managed through, for example, medication, regular toileting, use of penile sheaths, etc.


is able to maintain full control over bowel movements or has a stable stoma, or may have occasional faecal incontinence/constipation.

Continence care is routine but requires monitoring to minimise risks, for example those associated with urinary catheters, double incontinence, chronic urinary tract infections and/or the management of constipation or other bowel problems.    Moderate
Continence care is problematic and requires timely and skilled intervention, beyond routine care (for example frequent bladder wash outs/irrigation, manual evacuations, frequent re-catheterisation).    High

However, the Key Indicators summary page at the end of the DST is deliberately left blank and is not prescriptive at all. This is to allow the assessors the opportunity to think carefully about the evidence seen and heard at the MDT assessment, and draw their conclusions (rationale) as to whether they recommend eligibility for CHC Funding, or not.

The outcome of the DST should never be pre-determined as that is an abuse of process. That is why the Key Indicators should only be completed at the end of the assessment, and once all evidence has been considered – when you can sit back and evaluate the individual’s overall needs, holistically, in the ‘round’. We’ve set out below the relevant page from the DST:

Decision Support Tool for NHS Continuing Healthcare
Section 3 – Recommendation

Please refer to the user notes

Recommendation on eligibility for NHS Continuing Healthcare detailing the conclusions on the issues outlined on the previous page. This should include the following headings: Overview; Nature; Intensity; Complexity; Unpredictability; and Recommendation.

Each individual’s case has to be reviewed on its own merits as they are all fact sensitive. No two individuals will have exactly the same intense, complex or unpredictable healthcare needs, or require the same level of input or care. Unfortunately, there is no ‘one size fits all’ or specific diagnosis for achieving automatic eligibility for CHC.

It’s a good idea to ask yourself: Who is involved in their care, how long does it take, and what skills are needed to do it? Are the individual’s needs intense, complex and unpredictable, and if so, when did the needs change and what impact does that have on other needs?

Use the pieces of information you have gathered and the personal knowledge that you have of your relative’s needs to your advantage. Each entry in the GP or care home records may be of relevance to one or more Care Domains and help create the overall picture of need. Even if the records are incomplete (as is often the case), you can still build your jigsaw by reading in-between the lines. Try and identify any unmet needs and think about what should have been happening.

From a practical perspective, think about your relative’s day – how do they get up, what practical aspects do carers need to do throughout the day and night to care for them.  This will help you link the Domains and reflect on how they interact.

For example, if the records state that your relative is ‘immobile’, then consider the wider ramifications and impact that is having, which may or may not be recorded (‘unmet’ needs). Always look at the bigger picture and the interrelation with other Care Domains. Take immobility – there is an obvious inference that the individual will:

  • need repositioning or turning frequently, say every two hours (‘Mobility’);
  • may require 2 or more staff members to help them sit up in bed, or need hoisting and assistance with transfers (‘Mobility’);
  • need physiotherapy or gentle massage to keep their joints and skin supple and to avoid pressure sore injuries (‘Mobility’ & ‘Skin Integrity’);
  • require assistance with feeding due to the risk of malnutrition, dehydration, and associated weight loss – becoming weaker and more vulnerable to skin tears (‘Nutrition’);
  • be at risk of rapidly developing pressure sores which can be difficult to access and treat, and turn into a complex and painful medical condition, requiring urgent specialist intervention and necessitating strong pain relief, which has to be administered with skilled intervention (‘Skin Integrity – Tissue Viability’ & ‘Drug therapies & Medication’);
  • impact on their continence needs, especially if sitting or lying for extended periods in wet patches without good hygiene, changes of clothing or incontinence products (‘Continence’).
  • need staff to be alert, observe and regularly monitor and interpret their needs, if they cannot communicate their needs reliably or at all (‘Communication’).

So, from just one entry, you can see how care needs could impinge on other Domains. Look for the evidential entries, missing entries and any clues in the records, care plans, turning charts and risk assessments etc. for both assessed needs and unmet needs. Remember, just because the records don’t contain adequate detail, doesn’t mean that the need doesn’t exist! Step back, look at the whole picture, read between the lines, and think how the needs interact with each other. That is the underlying essence of preparing good Key Indicators.

Some points to consider:

1. Some periods of care can span many years, yet poorly drafted Key Indicators will often read as though it is just one continuous period, almost as if it is a ’one size fits all’ approach. However, that is unrealistic. Most individual’s needs do not remain static and constant for years on end. An individual’s needs will usually fluctuate and vary over time. Their needs upon entering a care home in year one, may be different in year 2, and again in year 3, and so on. Therefore, to provide a single summary under each Key Indicator that extends over a long period of care may be meaningless.

It would be more advantageous and clearer, if each Key Indicator is broken down into smaller periods of time (eg annually) to readily identify and support any changes in need.

2. Good record keeping is essential to success when the arguing the Key Indicators.

You need to adopt a scientific and forensic approach when looking at the records in detail. They will contain nuggets of evidence that you need to complete your jigsaw. Minor details can make a difference and connect needs. You need to find all the entries and clues in the records and match them to the relevant descriptors in each Care Domain to support the delivery of care needed.

3. As we have pointed out in previous blogs, care home records can be hit and miss – often incomplete, inaccurate or misleading. It is therefore not just a matter of looking at what is written in black and white, but also closely scrutinising what has been omitted. You need to read between the lines and look at any unmet needs, too. Ask yourself, what should have been happening? The missing information can be just as valuable when creating your jigsaw – but if it’s in writing, it can be incontrovertible!

For more information, read our blogs:

Why is it important to check your relative’s care home records?
June’s feature on flawed CHC assessments and the importance of good record keeping

4. If you have an entry in the records which could be applicable to more than one Domain, then you should refer to it across all those other relevant Domains to be sure that it is noted. This will also help cross-referencing needs, and so hopefully, they won’t be overlooked.

Unfortunately, the CCG’s assessors only have a limited time allocated to complete the DST and draft the Key Indicators. They may therefore feel that having recorded an entry in the DST under one Care Domain, that is sufficient, and it does not need to be repeated elsewhere. However, we would encourage you to repeat any relevant entries across the Care Domains as it is in your interest to do so to boost your relative’s chances of success.

In PART 2 – Looking At The 4 Key Indicators: Gathering pieces of evidence, we stated that the decision on eligibility should not be based on the following matters italicised below:

  • the person’s diagnosis;

We still suggest that you record what care needs the individual has and their origin. Whilst you shouldn’t be led by the diagnosis, equally, don’t ignore it. Use all available evidence to support your relative’s needs.

  • the setting of care;

It is common for some CCG assessors to be influenced by the care setting and quickly conclude that, because the individual is in residential care, they don’t have nursing needs and won’t qualify for CHC Funding. That is wrong! It’s not the setting that counts. Focus your attention away from the care setting and onto the actual needs, and the 4 Key Indicators. Nursing care alone isn’t a guarantee that the individual will qualify for CHC funding anyway. For example, an individual in a residential care home may have very challenging behavioural needs that don’t require them to be in a nursing home setting. So, beware of CCG assessors basing their judgment on the care setting, as it may not be helpful to you. But, if your relative needs specialist nursing care e.g. for spinal injuries or is in a Dementia Nursing Unit, then specifying the setting may be helpful to your case.

  • the ability of the care provider to manage care;

Record and reflect on any needs and consider whether the care was needed but was not met.

As above, it is essential to view the care home and GP records and look for supporting entries, but equally, look for any missing entries. For example, if an entry states, “mobility – cared for in bed”, or “nutrition – needs feeding”, then ask yourself from a practical nursing perspective – what daily needs does the individual have? They may have lost weight as a result, but this may not be recorded in the records. So do carefully check the records for any unmet needs. Read between the lines. It’s all about identifying the need.

  • the use (or not) of NHS-employed staff to provide care; look only at what was being done.

The DST is very prescriptive and gives a description of everything you need to consider and identify in the level of need from ‘No needs’ to ‘Priority’ needs. The DST is a tool to help make a decision about healthcare needs, so don’t be tempted to refer to social needs, such as help with getting dressed, as it is not particularly relevant or helpful to your cause. Concentrate on healthcare needs, and what it is that makes them challenging and time-consuming.

  • the need for/presence of ‘specialist staff’ in care delivery;

Do mention if your relative needs specialist care e.g. from a Tissue Viability Nurse, as the CCG may seek to downplay this if it is not recorded.

  • the fact that a need is well managed;

You can identify whether a need was ‘well-managed’ or not. Don’t discount it. Identify what care was required and look at what is being done for the individual, and if it is not being done, ask yourself what should be done for them?

Beware! Many CCG assessors do not consider the 4 Key Indicators in sufficient detail. They may look at each individual Care Domain in isolation, but not at the bigger picture. Lots of little incidences and minor detail can build blocks and connect needs, and directly impact on other Care Domains. Use the small details to your advantage and tot them all up in your favour to complete your relative’s jigsaw.

Don’t forget the CCG’s assessors have approximately two hours to review the records, meet with the family, meet and assess the individual, explain the process, gather the necessary information, complete the DST and then write the 4 Key Indicators to reach their recommendation. That’s not really enough time to do the job properly. So, it’s not surprising that much detail is glossed over, omitted or dismissed, given the short space of time allocated.

That is why it is so important for a family representative or appointed advocate to be present at the MDT; to ensure that everything you want to be noted is taken into consideration and that the process is conducted fairly and robustly. As time is short, do your preparation in advance to make the most of this opportunity. If you need professional help and advocacy support, the MDT cannot refuse.

Read our blog: Can The MDT Panel Refuse To Proceed If I Have An Advocate?

It is always a good idea to take someone else with you who can take notes for you – to be another pair of ‘eyes and ears’ – and in case you need to refer to the notes at a later stage.

Just because the MDT assessors may be pressured for time, does not mean that your relative’s application for CHC should be treated in a roughshod manner and your views ignored.

However, because time is short, your preparation in advance is critical. Know your case and your relative’s needs. Don’t get sidetracked and talk about social needs, or irrelevancies that may undermine their case. 2 hours for an MDT assessment is grossly insufficient bearing in mind it really should take at least 4 – 5 hours to write up robust Key Indicators.

No wonder so many cases are rejected for CHC funding post-MDT and go to appeal.

The next blog in this series deals with tips for setting out the Key Indicators and a written example.

For more information around the subject, read our blogs:

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?

Who completes the Decision Support Tool in NHS Continuing Healthcare?

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


  1. Sharon Day 3 months ago

    This website has been of enormous help to me in obtaining CHC funding for my mother. I didn’t know CHC funding existed until a friend, who is a nurse, made me aware of it and pointed me to this website. I also purchased the book ‘How to get the NHS to pay for care’, which was hugely informative, at a time when I knew my mother’s health was declining and she was heading towards needing care due to her complex health conditions/needs and how it was affecting her life. I had some conflict with district nurses who had been assigned to monitor her and undertook an initial assessment without my knowledge and, clearly, had no idea of my mother’s day to day needs because of the scores they allocated (all ‘C’s). Very shortly afterwards, she was admitted to hospital (again), where the doctor advised me she was to be fast tracked for CHC funding as it was clear she needed 24/7 nursing care. Even then, it was stressful as the hospital social worker was adamant they would only fund up to £700 per week and my brother and I would need to top this up since nursing care near to me (her main carer) was closer to £1400 per week. Having found a nursing bed for my mother, with just 24 hours to prepare for a final meeting at the hospital, I took advice from your free helpline, and this really helped. I went into that meeting, fully prepared with notes, armed with the ‘National Framework’ and fought my case on behalf of my mother. My brother said he was so proud of me! I am pleased to report that the following day I heard from the local CCG that they would be transferring my mother to the nursing care that I had found close to my home, which is 40 miles away from her home, under a different NHS authority. Whilst my mother continues to decline, I am relieved that she is now receiving the very best possible end of life care, and I am so grateful to you for your help and advice.

  2. Andy 3 months ago

    One thing that people may not realise is that when the National Framework states: Certain characteristics of need – and their impact on the care required to manage them – may help determine whether the ‘quality’ or ‘quantity’ of care required is more than the limits of a local authority’s responsibilities. The terms ‘quality’ and ‘quantity’ are directly linked to the two conditions of the primary health needs test which in turn has come from the Coughlan case judgement.

    a) are no more than incidental or ancillary to the provision of accommodation which local authority social services are, or would be but for a person’s means, under a duty to provide; and
    b) are not of a nature beyond which a local authority whose primary responsibility it is to provide social services could be expected to provide.

    The first condition is known as the quantity test and the second as the quality test. So when you are assessing the 4 characteristics, what you are really doing is building a case to pass either of these two clauses.

    • Michelle Weth 3 months ago

      Hi Andy,
      I would so like to be at your forthcoming IRP! I’m thinking that the appeal you’ll be making for your mum will be that comprehensive with regard to the K.I the panel will be stuck for questions!
      Thanks CTBD for the series of articles on this important aspect of CHC.

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