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.
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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 records a level of need in each of twelve care domains. Understanding what those levels mean, and which domains can reach the higher ones, makes it far easier to see whether an assessment has recorded the picture accurately. This guide explains the levels and what they do.
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
Only four domains can be scored at priority: behaviour, breathing, drug therapies and medication, and altered states of consciousness. These are the areas where need can present the most immediate risk to life or safety. A single priority level in any of these domains indicates a primary health need. That is the clearest route to eligibility in the whole tool, and it is why the descriptors for those four domains repay careful reading.
Which domains can reach severe
Severe is available in a wider group, including behaviour, cognition, psychological and emotional needs, breathing, nutrition, continence, skin, mobility, drug therapies and altered states of consciousness. Two or more severe levels also indicate a primary health need. Communication and other significant care needs do not carry the higher levels in the same way, which sometimes surprises families whose main concern sits in one of those areas.
What the combinations indicate
The Framework describes combinations that would be expected to indicate a primary health need: one priority level, or two or more severe levels. Beyond that, a range of combinations may indicate eligibility, including one severe alongside a number of high or moderate levels, or a larger number of high and moderate levels across several domains. These are indicators rather than a formula, and the decision still rests on the overall judgement.
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
The correct level is the one whose descriptor best matches the evidence, considering the need as it would be without the current intervention. Where the evidence sits between two descriptors, the assessment should say so and explain which has been chosen and why. Where evidence is missing, the tool should record that rather than defaulting to a lower level. Blank or unevidenced domains are a common weakness in completed tools and worth checking for.
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
The levels run from no needs to priority, only four domains reach priority, and the combinations are indicators rather than a score. Read each level against its descriptor and against the need as it would be without intervention, and raise any disagreement domain by domain with dated evidence.
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.