Key Facts
- 17% of standard CHC assessments now result in eligibility — down from 31% in 2017/18 (Healthwatch England, October 2025)
- 7.3% to 42.5% — eligibility rates across English ICBs (Nuffield Trust, September 2025)
- £47,300 vs £95,085 — annual CHC spend per recipient in most-deprived vs least-deprived ICBs (Nuffield Trust, September 2025)
- The legal test — primary health need — was set by the Court of Appeal on 16 July 1999 in R v North & East Devon HA, ex parte Coughlan (BAILII)
- 1 July 2022 — the date the current National Framework came into force (DHSC)
- From 14 May 2026, CHC quarterly reports will be discontinued and merged into All Age Continuing Care management information (NHS England)
Of every 100 families who reach a full NHS Continuing Healthcare assessment in England today, only 17 are found eligible. In 2017/18, the same figure was 31 (Healthwatch England, October 2025). Most families read that statistic and assume the criteria have tightened. They haven't.
The legal test set out by the Court of Appeal in Coughlan in 1999, codified in the 2022 National Framework, and applied by every Integrated Care Board (ICB) in England, is the same test it was eight years ago. What's changed is interpretation, ICB financial pressure, and — most importantly — the evidence families bring to the assessment. This guide explains exactly what the 2026 criteria require, where the framework draws the line, and why two assessments of identical clinical need can produce opposite results.
Reviewed by legal professionals and social care professionals.
TL;DR: CHC eligibility turns on a single legal test — primary health need. There is no diagnosis list, no means test, no savings cap. The 2022 National Framework applies this test through four key indicators: Nature, Intensity, Complexity, Unpredictability. National eligibility is now 17% (Q1 2025/26), down from 31% in 2017/18 (Healthwatch England, 2025). The criteria are not the problem. The evidence families bring is.
What does "CHC funding criteria" actually mean?
The CHC funding criteria are the legal and clinical tests an Integrated Care Board uses to decide whether the NHS — not the local authority — must pay for someone's full package of care. The criteria are set out in the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care (July 2022) and rest on a single legal concept: primary health need.
It helps to separate two things that often get used interchangeably. The criteria are the legal and clinical bar — what the law requires. The assessment process is how that bar gets applied to your relative's case: a Checklist screening, then a Decision Support Tool assessment, then a multidisciplinary team recommendation, then an ICB decision. The criteria don't move from one stage to another. The threshold of evidence required to meet them does. For the wider process, see our full CHC application process guide.
Who applies the criteria matters too. It is never one clinician on their own. The framework requires a multidisciplinary team — typically a nurse assessor and a social worker, often with a GP, community matron, or care-home manager — to weigh the evidence together. The ICB then ratifies or, in rare cases, departs from the panel's recommendation in writing. This collective structure is intended as a safeguard. In practice, families often experience it as a panel discussion they don't fully follow until after the meeting.
The word "checklist" trips families up. The Checklist is a specific screening form used at the start of the process — a separate tool with a separate, lower threshold. The eligibility criteria themselves are not a checklist of boxes to tick. They're a structured legal judgment. For how the screening stage works, see our guide on the Checklist screening stage.
The legal test — what "primary health need" really means
A person has a primary health need when, taking all their needs together, the main part of the care they require is for health, not social or accommodation support. The test originates in the 1999 Court of Appeal judgment R v North & East Devon HA, ex parte Coughlan (BAILII) and is codified in paragraph 56 of the 2022 National Framework.
The Coughlan judgment concerned Pamela Coughlan, a woman with severe long-term nursing needs whose health authority wanted to transfer responsibility for her care to a local authority. The Court of Appeal ruled that a local authority can only provide nursing services where those services are "merely incidental or ancillary" to the accommodation it is under a duty to provide — and of a nature one could expect social services to provide (Coughlan [1999] EWCA Civ 1871, para 30(e)). Anything beyond that boundary is an NHS responsibility.
That "merely incidental or ancillary" line is the legal anchor of every CHC decision made in England in 2026. If someone's needs are beyond what social care can reasonably handle, the NHS must fund the whole package. The test isn't a percentage. It's a quality-and-character judgment about whether the needs, taken together, are health-led. For the deeper legal analysis — including the Coughlan two-limb test and the 2006 Grogan reasoning requirement — see our primary health need legal test explainer. For a family-side decision tree on who qualifies via which pathway, see our who qualifies for CHC funding guide.
Crucially, "primary" doesn't mean "more than 50% of the time" or "most of the budget". It means the dominant character of the care — the kind of care being delivered. A person whose social-care needs are individually larger than their health needs may still have a primary health need if the health element drives the type of care required.
Why dementia, MND, or end-stage COPD don't automatically qualify
No diagnosis automatically meets the test. The criteria assess needs, not labels. Severe dementia frequently produces a primary health need — when behaviour, cognition, and unpredictability combine into a pattern of care that social workers can't safely deliver alone. But many people with the same diagnosis don't reach that threshold, because their day-to-day needs are still manageable as personal care. We unpack this in detail in our guide on what dementia families need to know about CHC.
The four key indicators — Nature, Intensity, Complexity, Unpredictability
The 2022 National Framework instructs MDTs to assess primary health need through four key indicators: Nature (what kind of needs), Intensity (how severe and continuous), Complexity (how needs interact), and Unpredictability (how much they fluctuate and the risk if care fails). An MDT weighs all four together — no single indicator decides (DHSC National Framework, paragraph 60).
These four words do most of the heavy lifting in every CHC decision. They're also where most refused families lose ground — not because the indicators aren't there in their relative's records, but because the records aren't read in the language of the indicators. Worked examples make the difference between an abstract framework and a usable evidence map.
Nature
"Nature" describes the type of need and the kind of intervention required. For someone with end-stage Parkinson's, nature isn't just the motor symptoms — it's the cognitive, swallowing, postural, and autonomic components combined, and the kind of skilled intervention they require. Skilled clinical observation isn't the same as prompting with personal care. It's that distinction the framework is asking the panel to make.
Intensity
"Intensity" captures the quantity, severity, and continuity of need. Hourly position changes to prevent pressure sores, combined with overnight monitoring for choking risk and twice-daily blood-sugar checks for unstable diabetes, demonstrate intensity. It isn't one need at high severity — it's multiple needs running together, every day, with no respite.
Complexity
"Complexity" describes how needs interact and the skill required to manage them safely. A person whose Type 1 diabetes, vascular dementia, and warfarin therapy interact such that hypoglycaemic episodes can mimic delirium is a complexity case — because the skill lies in distinguishing one from the other before the wrong intervention is delivered. Diagnosis alone doesn't capture this. Daily care notes, when read in the right language, do.
Unpredictability
"Unpredictability" measures how much the needs fluctuate, and the risk to health if care fails. A person who has had three unplanned hospital admissions in six months — for different presentations — is documenting unpredictability without needing the family to make the case. The evidence is in the discharge summaries.
Each indicator must be evidenced from the records. Most families don't lose because the indicator isn't there. They lose because the records weren't read in the indicator's language. The structured evidence map that helps families pre-empt this is the kind of work we describe in our guide to evidence preparation for CHC.
The 12 care domains and how scoring works
The Decision Support Tool divides need into 12 domains: Behaviour, Cognition, Psychological and Emotional, Communication, Mobility, Nutrition, Continence, Skin, Breathing, Drug Therapies, Altered States of Consciousness, and Other Significant Care Needs. Each is scored on a Priority / Severe / High / Moderate / Low / No-needs scale — but not every level is available in every domain (GOV.UK DST guidance, October 2022).
The scoring rules that trigger eligibility are deliberately narrow. A single Priority score in any domain produces a clear eligibility recommendation. Two or more Severe scores across the 12 do the same. A pattern of High and Moderate scores can also indicate primary health need if it demonstrates the four key indicators together — but here the decision becomes more interpretive, and the evidence pack matters most (DHSC National Framework, paragraph 161).
The four Priority-capable domains aren't random. They're the domains where a single severe presentation — uncontrolled drug regime, life-threatening behaviour, unstable breathing, or recurrent loss of consciousness — can produce immediate clinical risk on its own. The framework's logic is that one Priority score is enough to establish primary health need. Where a family's evidence sits on the boundary between Severe and Priority in one of these four domains, that single line can decide the case.
For the Checklist's separate A/B/C scoring, see our Checklist screening guide. For a deeper walk-through of how the panel uses the DST itself, see our Decision Support Tool guide.
The "well-managed needs" trap
If a need is currently managed well by intervention, the National Framework requires the MDT to consider what the underlying need would be without that intervention. A diabetic whose blood sugar is stable on a strict regime still has the underlying need — management doesn't erase it. This is the single most common point at which families lose evidence (DHSC National Framework, paragraph 162).
The trap looks like this. The panel asks how your relative is doing. You answer honestly: she's settled, she's eating well, her skin is intact. Each of those things is true because the care home staff are doing something difficult and skilled — three carers for every transfer, hourly position changes, two-person supervision at meals, a specific antipsychotic that took six months to titrate. The panel scores the present, not the underlying need. The framework asks the panel to score the underlying need.
The Parliamentary and Health Service Ombudsman has repeatedly found ICBs misapplying this principle in upheld complaints. "Well managed" is not the same as "not severe". The framework specifically tells assessors that a need does not disappear because the intervention is working.
How families present the without-intervention scenario matters. It isn't speculation. Pressure-area care is the clearest example: a person whose skin is intact because of two-hourly turns has a Severe (or higher) need in Skin, not a Low one, because the underlying tissue viability depends on the intervention continuing. Same logic for behaviour managed by medication, nutrition managed by skilled feeding, or breathing managed by oxygen therapy. We unpack this further in our guide on the well-managed needs trap.
Why your postcode matters more than the criteria say it should
The criteria are national. The application is local. The Nuffield Trust's September 2025 analysis found a five-fold variation in CHC eligibility rates between English ICBs — from 7.3% in Gloucestershire to 42.5% in Leicester, Leicestershire and Rutland (Nuffield Trust, September 2025). Two relatives with identical needs may receive opposite decisions thirty miles apart.
The Nuffield analysis also found a near two-to-one spend-per-recipient gap by deprivation. Least-deprived areas saw an average annual spend of £95,085 per CHC recipient; most-deprived areas, £47,300; the England average sat at £65,012 (2022/23 data, Nuffield Trust, September 2025). People in poorer areas aren't less ill. They are less likely to receive the full funding when they qualify.
There's also context families should know. From 14 May 2026, NHS England is discontinuing the standalone CHC Statistical Release and merging quarterly reporting into All Age Continuing Care management information (NHS England, 2026). The numbers will still be published — but the visibility of CHC-specific outcomes is changing at exactly the moment families most need it.
For the related news context, see our coverage of ICBs cutting eligibility, the broader CHC postcode lottery, and the Healthwatch evidence on family experience. For the mechanics — what CHC actually pays for, top-up rules, Personal Health Budgets, and retrospective claims — see our continuing healthcare funding family guide.
Checklist criteria vs DST criteria — two thresholds, not one
Two thresholds, not one. The Checklist applies the criteria at a screening level — its job is to identify cases that might be eligible, so the bar is deliberately lower. The Decision Support Tool then applies the criteria at the eligibility level — a higher bar requiring clear evidence of primary health need across the four indicators (GOV.UK Checklist guidance, July 2022).
The Checklist uses an A/B/C scoring system across 11 domains (DHSC National Framework, paragraph 113) — one fewer than the DST. A represents a high level of need at the screening threshold, B moderate, C low. Four of those 11 domains carry an asterisk because they carry a priority level in the DST: Breathing, Behaviour, Drug Therapies and Medication, and Altered States of Consciousness.
A full assessment is required where the Checklist records any one of three combinations (NHS Continuing Healthcare Checklist guidance, paragraph 19): two or more A's; five or more B's (or one A plus four B's); or one A in a starred priority domain, regardless of the other scores. The threshold is intentionally set low so anyone who might be eligible gets the chance of a full assessment (Checklist guidance, paragraph 3). A positive Checklist doesn't mean eligibility is decided — it means the case proceeds. At full assessment, the panel applies the DST's Priority/Severe/High/Moderate/Low/No-needs scale across the 12 DST domains — a different, more demanding scoring system. Many families pass at Checklist and fail at DST. That isn't inconsistency. It's two different tools applying the same legal test at two different thresholds.
The Fast Track Pathway sits outside both. It's for people whose condition is rapidly deteriorating and may be entering a terminal phase. There is no Checklist or DST in Fast Track — an appropriate clinician completes a Fast Track Pathway Tool, and the ICB must act on it immediately. The eligibility bar there is fundamentally different, and the framework intends it to be. For more, see our guide on the Fast Track Pathway and on the Checklist itself.
What to do if the criteria were applied wrongly
Families have several routes when they believe the criteria were applied wrongly. The most common is a Local Resolution Meeting with the ICB — an internal review of the original decision. If that doesn't resolve it, an Independent Review Panel convened by NHS England (regionally) takes the case. Beyond that, the Parliamentary and Health Service Ombudsman investigates procedural failures, and PUPoC — Previously Unassessed Period of Care — handles retrospective entitlement for periods when no assessment was offered.
All four routes turn on the same question: was the evidence considered against the four key indicators, or against a checklist of diagnoses and behaviours that doesn't reflect the framework? Where the original assessment treated diagnosis as the test, scored "well-managed" needs as low, or failed to weigh complexity and unpredictability together, the appeal route exists precisely to correct that.
Where evidence preparation makes the most visible difference is at the written submission stage for Local Resolution Meetings and Independent Reviews. Verbal advocacy still has weight, but written evidence — structured against the four indicators, mapped to the relevant domains, dated and sourced — is what panels engage with weeks after the meeting. The submission outlives the conversation.
If you're preparing for a CHC Checklist now, our Checklist Evidence Pack (£597) is our family-priced evidence preparation service — the structured evidence document the assessor reads. If you've already been refused, the free Eligibility Screener triages your case in three minutes before you commit to an appeal. For the deeper appeal route, see our guide on how to challenge a CHC decision, and for retrospective entitlement, our guide on claiming retrospectively under PUPoC.
Conclusion
Three things to take away from the 2026 CHC funding criteria:
- The legal test hasn't changed — primary health need, set out in Coughlan and codified in the 2022 National Framework, is still the only question that decides eligibility
- The four key indicators — Nature, Intensity, Complexity, Unpredictability — are what the MDT actually applies; framing your evidence around them is the highest-leverage thing a family can do
- Interpretation is variable, evidence is decisive — postcode, deprivation, and ICB pressure shift outcomes, but a structured evidence pack remains the single biggest correlate of a successful case
The system around the criteria is in flux. The Casey Commission is due to deliver Phase 1 recommendations on adult social care in 2026, with a final report in 2028 (GOV.UK). NHS England is being absorbed into the Department of Health and Social Care over the next two years. From 14 May 2026, CHC reporting merges into All Age Continuing Care management information. None of that changes the legal test. It changes how visible the outcomes are.
This guide is for information and is reviewed by legal professionals and social care professionals. It is not a substitute for legal advice or for individual case representation. CareAdvocate provides CHC evidence preparation — the structured document the assessor reads — not legal advice.
Frequently asked questions
What are the criteria for CHC funding? CHC eligibility rests on a single legal test: primary health need. An ICB multidisciplinary team applies this test through four key indicators set out in the 2022 National Framework — Nature, Intensity, Complexity, and Unpredictability — using a 12-domain Decision Support Tool. There is no diagnosis list, no means test, and no savings cap.
Is CHC means-tested? No. NHS Continuing Healthcare is fully NHS-funded regardless of savings, income, or property. It is the only NHS funding route that ignores wealth — a major reason families self-funding £50,000+ per year of care often turn out to have been wrongly assessed for their relative's primary health need.
Does dementia automatically qualify for CHC? No diagnosis automatically qualifies. The criteria assess needs, not labels. A person with severe dementia may qualify; a person with mild dementia probably won't. The evidence has to demonstrate primary health need across the four key indicators — diagnosis alone is not sufficient, even for late-stage dementia. See our guide on whether dementia qualifies for CHC.
Why are CHC eligibility rates falling? Eligibility fell from 31% in 2017/18 to 17% in 2025/26 (Healthwatch England, 2025). The legal criteria are unchanged. ICBs face severe financial pressure and apply the same framework more strictly. Nuffield Trust found five-fold variation between ICBs (7.3% to 42.5%), suggesting local interpretation drives outcomes more than national criteria do.
What is the difference between the Checklist and the DST? The Checklist is a screening tool — it decides whether your case proceeds to a full assessment. The Decision Support Tool (DST) is the full assessment — it produces the eligibility recommendation. The Checklist threshold is deliberately lower; the DST threshold tests primary health need against all four key indicators.
Who decides whether someone gets CHC? A multidisciplinary team (MDT) — typically a nurse assessor, a social worker, and any clinicians who know the person — completes the DST and makes a recommendation. The Integrated Care Board (ICB) then ratifies (or rejects) the recommendation. The MDT advises; the ICB decides. Family members are entitled to attend the MDT.