In this article, we explain what is meant by a ‘primary health need’ and why it is central to eligibility for NHS Continuing Healthcare (CHC) funding. Although the term is not clearly defined in law, it plays a crucial role in determining whether the NHS or local authority is responsible for meeting an individual’s care needs. We’ll break down what a primary health care need looks like in practice, how it is assessed against the four criteria, and what it could mean for you or your loved one.
How is a primary health need defined?
As mentioned, the term ‘primary health need’ is not defined in law and does not appear in legislation. The National Framework for NHS Continuing Healthcare (page 51 paragraph 3.3) does clarify that someone should be considered to have a primary health care need when the nursing or health treatment and services they require are:
- more than incidental or ancillary to the provision of accommodation which Social Services would be required to meet if the individual were under the means testing threshold or;
- ‘of a nature beyond which Social Services could be expected to provide’.
The National Framework confirms that ‘where an individual has a primary health need and is therefore eligible for NHS continuing healthcare, the NHS is responsible for providing all of that individual’s assessed needs – including accommodation if that is part of the overall need’.
However, interpretations of a what constitutes a primary health need can differ; we attempt to shed some light on this.
Perhaps unhelpfully, the definition of a primary health need is open to subjective interpretation. The law seeks to further clarify this point by stating that the local authority can only meet nursing and healthcare needs when the requirements are below this level. When an individual’s nursing and healthcare needs are beyond the lawful powers of the local authority, the patient has a primary health need.
This is why it is crucial that Social Services are represented in the multidisciplinary team meeting for the Decision Support Tool assessment. Clearly, if a social worker or representative for the local authority is not present, how can it be stated or considered that a patient’s needs are within the lawful power of the local authority to meet if no one from the local authority is able to give their opinion that this is the case?
Continuing healthcare is not means-tested, and as confirmed by the National Framework, funding covers the full cost of care, including accommodation and associated costs.
It is important to remember that a primary health need is not diagnosis-led. For example, having a particular condition does not automatically entitle an individual to be considered to have primary health care needs; rather, it is about the individual’s overall day-to-day care needs.
Therefore, it can be the case that somebody without any formal diagnosis of a particular condition is considered to have the required complex, intense or unpredictable nature of needs that would constitute primary health needs and an entitlement to the funding, whereas somebody with a diagnosed condition such as Alzheimer’s or dementia does not meet the criteria.
The four characteristics tested to establish a primary health need
There are four characteristics that are tested to determine whether a primary health need is present: nature, intensity, complexity and unpredictability. The presence of any one or a combination of these characteristics will determine whether an individual has a primary health need.
1. Nature
This characteristic examines the individual’s needs and the care interventions required to meet them. The National Framework for continuing healthcare funding provides a number of questions that can be useful in determining whether an individual’s needs constitute the required nature characteristic to be considered primary health needs. Examples include;
- What is the impact of the need on overall health and wellbeing?
- What are the types of interventions that are required to meet the need?
- Is the individual’s condition deteriorating or improving?
- What would happen if those needs were not met in a timely way?
2. Intensity
The characteristic of intensity concerns the quantity, severity and continuity of needs. The areas for consideration in this domain include;
- How severe is this need?
- How often is each intervention required?
- How long is each intervention required?
- How many carers are required at any one time to meet the needs?
Therefore, there is an argument that there is an intensity of need where there are numerous interventions required over and above what might ordinarily be expected and where these care interventions are requiring the involvement of a greater level of staff and for a longer period than, again, might ordinarily be considered to be the norm.
3. Complexity
This characteristic examines the level of skill and knowledge required to meet the individual’s needs, as well as the interaction between two or more domains.
Points to consider include, as highlighted by the National Framework;
- How difficult is it to manage the needs?
- Are the needs interrelated?
- How much skill is required to address the needs?
- How problematic is it to alleviate the needs and symptoms?
Importantly, is there an interaction between a number of domains? Someone who has marked cognitive impairment will therefore be unable to assess even basic risks.
Where they are at risk of aspiration due to dysphagia, there is an argument for an increased risk in this area and increased complexity of the management of their nutritional needs if they are unable to follow instructions and assess the risks of not following instructions that could lead to them choking. Equally, somebody who is unable to assess risk and who presents with extreme, challenging, aggressive behaviour is not aware of the consequences of their actions and the risks that they pose to themselves and others.
4. Unpredictability
This characteristic considers the degree to which needs fluctuate and pose challenges in managing them.
Points to consider, as highlighted by the National Framework include;
- Does the level of need often change?
- Is the condition unstable?
- What happens if the need isn’t addressed when it arises?
- What level of monitoring or review is required?
A domain in which unpredictability often arises is behaviour. Someone who presents with unpredictable behaviour can be more difficult to manage if and where there are no triggers to their behaviour occurring. They may require a much higher level of supervision and interaction from staff if they pose a risk to themselves or others without warning.
In summary, the concept of a primary health need is crucial for determining whether someone has an entitlement to continuing healthcare funding.
What is clear is that there is no automatic entitlement to continuing healthcare funding, and, in fact, there is a degree of complexity and subjectivity in interpreting the evidence on whether these criteria are met.
Understanding whether someone has a primary health need can be complex, particularly as decisions are based on detailed assessments and subjective interpretation of care needs. What’s most important is ensuring that all aspects of an individual’s needs, across nature, intensity, complexity and unpredictability, are fully recognised and presented.
If you’re unsure whether you or a loved one may be eligible for NHS Continuing Healthcare funding, you don’t have to navigate the process alone. Compass CHC are here to support you at every stage, from initial advice through to assessment and beyond. Our expert team can help you understand your position, gather the right evidence, and give you the best possible chance of a successful outcome.
Frequently asked questions
What is a primary health care need?
A primary health care need (often called a primary health need in NHS Continuing Healthcare) is the key factor used to decide who pays for someone’s care.
Is a primary health need defined in law?
No, a primary health need is not defined in legislation. It comes from case law and is applied through NHS guidance.
How do you prove a primary health need?
To prove a primary health need, you need to show through evidence that a person’s care is mainly health-related and beyond what a local authority can provide.
This is done through a CHC assessment, using the Decision Support Tool, detailed records and demonstrating the four key characteristics.
Does having a diagnosis mean you have a primary health need?
No, having a diagnosis does not automatically mean you have a primary health need. Eligibility for NHS Continuing Healthcare is based on the overall level of care required, not the condition itself.
Unsure if you or a loved one qualifies?
If you think you or a loved one may be eligible for CHC funding, don’t delay. We’re here to guide you through every step.
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