Demystifying the 'Primary Health Need' Criterion
Unlike social care, which is means-tested and designed to meet everyday personal care needs, NHS Continuing Healthcare (CHC) is a package of care for those with significant ongoing healthcare needs. A 'primary health need' assessment is the gateway to this fully-funded NHS care. This assessment focuses entirely on the nature of a person's needs, not their medical diagnosis. A person's needs must be complex, intense, or unpredictable to be considered primarily health-related. While a dementia diagnosis can lead to a primary health need, it is the impact of the condition on daily life that is measured, not the condition itself. This distinction is the most important factor for families to understand when seeking funding.
The Critical Difference: Health Needs vs. Social Care Needs
Many families are confused about why their loved one's dementia care is not fully funded, leading to difficult conversations about financing care. The NHS and local authorities have different funding responsibilities, and this hinges on the health versus social care needs distinction. Health needs are those that require clinical intervention and management, often arising from a disability, accident, or illness such as dementia. Social care needs are more about support with daily living activities, like getting washed, dressed, or preparing meals. For a person with dementia, needs can often be a mix of both, but if the primary reason for the care is complex health needs, the NHS is liable for the full cost.
For example, if a person with dementia requires round-the-clock supervision due to unpredictable and aggressive behaviour, this would likely be considered a health need. Conversely, if the person primarily requires help with dressing and meal preparation but their cognitive state is stable and predictable, this is more likely to be classified as a social care need.
The Continuing Healthcare Assessment
Securing CHC funding involves a two-stage assessment process overseen by a local Integrated Care Board (ICB).
Stage 1: The Continuing Healthcare Checklist
This initial screening tool is completed by a health or social care professional to determine if a full assessment is required. It evaluates the person's needs across 11 key domains, including cognition, behaviour, and communication. The assessor gives a rating (A, B, or C) for each domain based on the level of need. If a person receives a specific number of 'A' and 'B' ratings, they are referred for the next stage. It's crucial for family members and caregivers to provide detailed and accurate information during this stage, focusing on the person's worst days to illustrate the full extent of their needs.
Stage 2: The Decision Support Tool (DST)
If the checklist is passed, a Multi-Disciplinary Team (MDT) composed of health and social care professionals conducts a full assessment using the DST. The DST considers 12 domains of care, adding 'Other Needs' to the original list. This assessment is far more detailed and results in a recommendation for or against CHC eligibility. The MDT looks for needs that are complex, intense, and unpredictable in combination, not just in isolation. For many with advanced dementia, their needs will inevitably reach this threshold, covering not just cognitive issues but also physical and behavioural challenges that require a high level of skilled care.
The Role of Evidence in the Assessment
To build a robust case for a primary health need, families should gather comprehensive evidence. This includes:
- Care plans and daily records: Detailed notes from care providers showing the frequency and nature of care needs.
- Health records: Medical notes from doctors, nurses, and other specialists detailing health conditions and medication requirements.
- Personal diaries: Notes from family members describing daily challenges, incidents, and the unpredictable nature of the person's condition.
For an excellent resource on preparing for this process, you can refer to the official NHS Continuing Healthcare information.
Case Study Comparison: Needs, Not Labels
This table illustrates how two individuals with the same diagnosis can be assessed differently for funding.
| Assessment Criteria | Mrs. Jones | Mr. Smith |
|---|---|---|
| Diagnosis | Early-stage Dementia | Advanced Dementia |
| Behaviour | Mild confusion, occasional agitation | Frequent, unpredictable aggression and wandering |
| Cognition | Memory lapses, some difficulty with complex tasks | Severe disorientation, complete loss of problem-solving ability |
| Mobility | Requires some assistance with mobility and transfers | Requires hoisting and is largely non-ambulatory |
| Continence | Occasional accidents, manages with reminders | Double incontinence, requires constant management |
| Eligibility Conclusion | Needs largely manageable through social care support | Complex, intense, and unpredictable needs constitute a primary health need |
Conclusion: Looking Beyond the Diagnosis
While a diagnosis of dementia is the starting point, it is not the deciding factor for being classed as a primary health need. The assessment is a holistic evaluation of the individual's specific care needs and how they present. Families must actively participate in the assessment process, providing detailed evidence of the complexity, intensity, and unpredictability of their loved one's needs. This proactive approach can make a significant difference in securing the necessary funding for high-quality care.
