Author and Publication
Author: Ben Slater, Registered Social Worker, Founder and Managing Director of Nellie Supports
Reviewed by: Kerry Slater, Director of Operations
Last reviewed: 20 July 2026
Citation
1. Department of Health and Social Care (2022) National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care. Available at: https://www.gov.uk/government/publications/national-framework-for-nhs-continuing-healthcare-and-nhs-funded-nursing-care
2. R v North and East Devon Health Authority, ex parte Coughlan [2000] 2 WLR 622.
3. R (Grogan) v Bexley NHS Care Trust and others [2006] EWHC 44 (Admin).
4. Care Act 2014, c. 23. Available at: https://www.legislation.gov.uk/ukpga/2014/23/contents
Copywright
Copyright © 2026 Nellie Supports Ltd. All rights reserved.
This article is made available for general information, education and professional reference. It may be downloaded, printed and shared for non-commercial purposes, provided that it is reproduced in full, is not altered in any way, and is properly cited as the work of Nellie Supports Ltd. This material must not be edited, adapted, sold, republished, incorporated into commercial products, or used for commercial training, assessment, report-writing or advisory services without prior written permission from Nellie Supports Ltd.
This article does not constitute legal advice, clinical advice or a substitute for a decision-specific professional assessment. Where legislation, government guidance, court forms or external professional materials are referred to, those materials remain subject to their own copyright, licensing and re-use terms.
Abstract
This guide explains the levels used in the NHS Continuing Healthcare Decision Support Tool, from no needs through low, moderate, high and severe to priority. It covers which domains carry which levels, what the combinations of levels indicate, why the levels are evidence rather than a score, and how the levels relate to the primary health need judgement.
CHC domain levels explained, from no needs to priority
The Decision Support Tool uses twelve care domains, but not every domain has Severe or Priority levels. The correct level is the descriptor best supported by the evidence. This guide gives the exact level ranges and explains how the domain evidence contributes to the overall primary health need decision.
The levels in outline
The Decision Support Tool uses a graded scale running from no needs, through low, moderate, high and severe, to priority. Not every domain uses the full range. Some stop at high, some go to severe, and only four can reach priority. The descriptors for each level are set out in the tool itself, and the assessment should record the level whose description best fits the evidence, rather than the level that produces a preferred outcome.
Which domains can reach Priority?
Priority is available only in Breathing, Behaviour, Drug therapies and medication: symptom control, and Altered states of consciousness. A Priority level would be expected to indicate a primary health need, subject to the evidence and the ICB’s reasoned decision.
Which domains can reach Severe?
Severe is available in Breathing; Nutrition — food and drink; Skin and tissue viability; Mobility; Cognition; Behaviour; Drug therapies and medication: symptom control; and Other significant care needs. Severe is not available in Continence, Communication, Psychological and emotional needs, or Altered states of consciousness.
The exact domain-level matrix
Breathing: Low to Priority. Nutrition: Low to Severe. Continence: Low to High. Skin: Low to Severe. Mobility: Low to Severe. Communication: Low to High. Psychological and emotional needs: Low to High. Cognition: Low to Severe. Behaviour: Low to Priority. Drug therapies and medication: Low to Priority. Altered states of consciousness: Low to Priority. Other significant care needs: Low to Severe. Read the full official descriptors before selecting any level.
Why the levels are not a score
This is the point most often misunderstood. The levels are not added up and there is no total that produces automatic eligibility. They are structured evidence, feeding an analysis of nature, intensity, complexity and unpredictability, which in turn supports the primary health need judgement. A recommendation that moves directly from a set of levels to an outcome without that reasoning has missed a step, and that gap is a legitimate ground for asking the Board to look again.
Getting the level right
Assess the current need, the continuing support required and the evidence. A well-managed need remains relevant, but official guidance says not to score every condition as though medication or routine care were absent. If evidence lies between descriptors, record the uncertainty and reason for the chosen level.
Reading a completed tool
When you receive the completed Decision Support Tool, read it domain by domain against the descriptors. Look for levels that do not match the narrative recorded underneath them, narratives that describe the managed presentation rather than the underlying need, domains left thin or blank, and any absence of reasoning on the four key characteristics. Those four checks will identify most of the problems that arise in practice.
Disagreeing with a level
Disagreement is best expressed domain by domain. Name the domain, quote the descriptor you say applies, and set out the dated evidence supporting it. That is far more effective than disputing the outcome as a whole, because it gives the reviewer something specific to engage with and it maps directly onto how the tool is structured.
Key takeaway
Only four domains reach Priority and eight reach Severe. Domain levels are evidence rather than a points score. Use the official descriptors, record the care that manages the need and explain how all needs combine under nature, intensity, complexity and unpredictability.
Frequently asked questions
Does one priority level mean eligibility?
A single priority level would be expected to indicate a primary health need, and it is the strongest single indicator in the tool. The Integrated Care Board still makes the decision, but a priority level that is properly evidenced is difficult to depart from.
How many severe levels are needed?
Two or more severe levels would be expected to indicate a primary health need. One severe level alongside several high or moderate levels may also indicate eligibility, depending on how the needs interact.
Can every domain be scored severe?
No. The available range varies by domain. Only behaviour, breathing, drug therapies and medication, and altered states of consciousness can reach priority, and communication and other significant care needs do not carry the higher levels in the same way.
Related NHS Continuing Healthcare pages
These links take you to the most relevant Nellie Supports service page and to the supporting guides that explain the surrounding process.
Speak to an independent CHC specialist
Nellie Supports prepares independent needs evidence for NHS Continuing Healthcare assessments, reviews and appeals across England and Wales. Our reports are written by registered social workers on a permanent employed team, with internal peer review before release. Call 0333 987 5118 or send an enquiry and we will talk through where you are in the process.