The Four CHC Key Characteristics Explained
The four CHC Key Characteristics – Nature, Intensity, Complexity and Unpredictability – are about looking beyond individual care needs to understand the overall picture.
A person’s needs may appear relatively straightforward when considered separately, but could look very different when you consider what care is actually required, how often it is needed, how those needs interact, and how they change.
As part of a full NHS Continuing Healthcare (CHC) assessment, the multidisciplinary team (MDT) should use the Key Characteristics to consider whether the totality of your relative’s needs indicates a primary health need.
So, what do the four Key Characteristics actually mean – and what should you look for in the Decision Support Tool (DST)?
In this article:
- Understanding the four key characteristics
- Does the DST reflect what actually happens?
- Concerned about the Key Characteristics in your relative’s assessment?
Nature – what care is actually required?
Nature considers the quality or type of your relative’s needs, their overall effect and the interventions required to meet them. For example, a DST might simply state that somebody “requires assistance with medication”, but that description can cover very different levels of need.
An individual who relies on staff to administer their medication routinely has very different needs from someone whose medication regime requires in-the-moment clinical decisions about the timing and/or dose in response to fluctuating symptoms.
When considering Nature, look beyond the description of the task. Instead, consider:
- What do staff actually have to do?
- What could happen if they do not do it properly?
Intensity – how much care is required?
Intensity looks at the extent of your relative’s needs and the amount of care required to meet them. While one intervention may appear relatively routine, the picture may look very different when all their needs are considered together.
Someone might need two carers for transfers, regular repositioning, continence care, supervision at meals, medication throughout the day and continuous monitoring overnight. Those needs may appear under different sections of the DST, but the MDT should also consider their cumulative effect.
The care records can help show what this looks like in practice. If the DST describes interventions as “occasional” or “regular”, check whether that accurately reflects how often staff are actually providing care, and how long these interventions take overall.
Where those descriptions understate the care required, point to the records and ask the MDT to be more specific. For example:
- How many times care is needed each day
- How long interventions take
- How many carers are required
- Whether care is continuous
- How much monitoring is required
These details can help show the frequency, duration and overall amount of care required, rather than relying on broad descriptions that may not capture the true intensity of your relative’s needs.
Complexity – how do needs affect each other?
Having several conditions does not automatically make somebody’s needs complex. The important issue is how those needs interact and whether that interaction makes their care more difficult to manage.
For example, someone with dementia may also have very limited mobility and be at risk of pressure damage. Their dementia may mean they cannot tell staff when they are uncomfortable, do not understand why they need repositioning or sometimes resist being moved. Their cognitive impairment therefore affects how their mobility and skin needs are managed.
When looking at the care records, consider whether they show:
- One need making another more difficult to manage
- Staff having to adapt care because of your relative’s other needs
- Difficulties communicating symptoms, pain or discomfort
- Care taking longer or requiring additional staff because of interacting needs
- An intervention for one need creating difficulties in managing another
Unpredictability: how readily can changes be anticipated?
Unpredictability looks at how needs fluctuate, how readily changes can be anticipated, how staff have to respond and what risks arise if appropriate care is not provided in time. For example, someone with dementia may usually accept personal care but sometimes become distressed and resist it. Staff may know this can happen without knowing when it will happen, how severe the reaction will be, or whether their usual approach will work.
When reviewing the records, look for:
- How often needs fluctuate
- Whether staff can anticipate when a change will occur
- How quickly staff need to respond
- Whether the usual care approach always works
- What happens when it does not
What matters here is what happens in practice. Incident reports, behaviour records and daily care notes may show a very different picture from a general statement that somebody is “usually settled”.
Look at the four Key Characteristics together
One of the most important points to remember is that the same care need can be relevant to more than one Key Characteristic. For example, your relative may become distressed and aggressive during essential personal care, requiring staff to reassure them, stop when their distress increases, return later, and perhaps use restraint or sedating medications to deliver care safely.
This could be relevant to:
- Nature – because it changes how care must be provided;
- Intensity – because the intervention may take longer or require repeated attempts;
- Complexity – because cognition or behaviour affects another care need; and
- Unpredictability – if staff cannot reliably anticipate how your relative will respond.
This does not automatically mean your relative qualifies for CHC because they are non-c-compliant with care. However, it shows why the MDT must consider the overall picture of their needs, rather than looking at each DST domain in isolation.
Does the DST reflect what actually happens?
When you receive the DST, compare the Key Characteristics section with the underlying care records. Ask four simple questions:
- Nature: Does it explain what staff actually have to do?
- Intensity: Does it reflect how much care is required over the day and night?
- Complexity: Does it explain how different needs interact?
- Unpredictability: Does it reflect genuine fluctuations and the response required?
Pay particular attention to descriptions such as “occasional”, “stable”, “well managed” or “predictable” and check whether the underlying records support them.
A need should not be marginalised simply because appropriate care is successfully managing it. Well-managed needs remain needs and should still be considered when the MDT applies the Key Characteristics. Equally, a disagreement with the wording of the DST does not necessarily mean the CHC decision is wrong. The important question is whether the assessment accurately reflects your relative’s needs and the supporting evidence.
If significant needs recorded elsewhere in the DST are missing or understated in the Key Characteristic analysis, this may warrant closer examination.
Concerned about the Key Characteristics in your relative’s assessment?
You do not need to become an expert in CHC terminology.
What matters is identifying what happens in your relative’s day-to-day care and whether that has been accurately reflected in the assessment.
Farley Dwek’s CHC Nurse Advice Line can help if you are preparing for an MDT or are wondering whether your relative might meet the criteria.
If your relative has already been assessed for CHC funding and found not eligible, Farley Dwek’s Appeal Advice Service can assist you in deciding if an appeal is likely to be successful. Our experienced Case Managers will review the DST, discuss your relative’s needs with you and explain where the DST analysis may not reflect what happens day-to-day.
If you are concerned about an upcoming CHC assessment or a completed DST, contact our team to discuss how we may be able to help.
