What is National Eligibility Criteria in Health and Social Care?

Nell Hendy

February 24, 2023

5 min read

The National Eligibility Criteria in health and social care is a framework that is used to determine whether an individual’s assessed needs are eligible for support from the Local Authority. The National Eligibility Criteria falls under Section 13 in the Care Act 2014 and everyone who works in health and social care should be aware of what it is. In this article, we will explain what the eligibility criteria is and how it works. We will also outline what the outcomes are, along with how it is applied.

What is the National Eligibility Criteria?

The National Eligibility Criteria is a framework that is used for determining whether an individual’s assessed care and support needs or, in the case of carers, any support needs, meet the threshold for support from the Local Authority.

When an individual is referred to the Local Authority, an assessment is completed to identify the individual’s presenting needs. Following the assessment, a determination of eligibility will be carried out to assess whether the identified needs require support from the Local Authority. This determination of eligibility is completed using the National Eligibility Criteria.

The National Eligibility Criteria is set out in Section 13 of the Care Act 2014 and has three conditions.

The conditions for individuals are:

The individual’s needs must arise from, or be related to, a physical or mental impairment or illness.
As a result of the individual’s needs, they must be unable to achieve two or more of the specified outcomes (the specified outcomes are listed below).
As a consequence of being unable to achieve these outcomes, there is, or is likely to be, a significant impact on the individual’s wellbeing.

If you are supporting a carer, the conditions are:

The needs must arise as a consequence of providing necessary care for an adult.
The effect of the carer’s needs is that their physical or mental health is, or is at risk of, deteriorating, or the carer is unable to achieve any of the specified outcomes.
As a result, there is, or is likely to be, a significant impact on the carer’s wellbeing.

The specified outcomes are as follows:

The needs arise from a physical or mental impairment or illness.
The needs mean that the individual is unable to achieve two or more of the listed outcomes.
Consequently, there is a significant impact on the individual’s wellbeing.
The individual’s physical and mental health is at risk of, or is, deteriorating.

The National Eligibility Criteria is used to determine whether a person’s (or carer’s) assessed needs are eligible for support from the Local Authority. It is not a determination about suitability for a particular service provision or even about what nature of support the Local Authority should or should not provide.

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As mentioned, the National Eligibility Criteria is set out in Section 13 of the Care Act 2014. Therefore, if you hear someone talking about Section 13 of the Care Act, they are referring to the National Eligibility Criteria. Once you are aware of the Eligibility Criteria, you can learn how it is applied.

How to Apply the National Eligibility Criteria

The National Eligibility Criteria should be applied against the information gathered during a needs assessment in order to determine which, if any, of the person or carer’s needs are eligible for the Local Authority to meet under the Care Act 2014.

For each need the individual has in the areas listed in the framework, a judgement must be made by the Local Authority as to whether the person or carer is able to achieve that need and if not, whether not being able to has a significant impact on their wellbeing.

As mentioned above, once an individual has been referred to the Local Authority and their needs have been assessed, the National Eligibility Criteria will be used to determine whether the individual requires support from the Local Authority.

Only when the Local Authority is satisfied on the basis of a needs assessment (or carers assessment) that a person has needs for care and support (or that a carer has needs for support), should it determine whether any of the needs meet the National Eligibility Criteria. This means that the Eligibility Criteria cannot lawfully be applied before a needs assessment has been completed.

The criteria will be applied against the information gathered during the needs assessment to determine which, if any, of the identified needs are eligible for support from the Local Authority.

What are the Outcomes of the National Eligibility Criteria?

The specific outcomes which are measured as part of the National Eligibility Criteria will be tailored to each individual’s situation.

Examples of what the outcomes could be include:

Managing and maintaining a healthy, balanced diet.
Managing your personal hygiene.
Managing your toilet needs.
Being able to dress appropriately.
Being able to access your home safely.
Keeping your home clean and safe.
Developing and maintaining personal relationships.
Accessing education, employment or volunteering opportunities.
Safely accessing and using local community services.

When a determination has been made following the National Eligibility Criteria, the Care Act requires that the Local Authority must give the individual a written record of the determination, including the reasons for it. The written record should outline the needs that are eligible for support from the Local Authority, as well as those which are not.

Needs that are Eligible

If the individual’s assessed needs meet the Eligibility Criteria, the Local Authority must consider what can be done to meet the needs, ascertain whether the individuals want to have their needs met by the Local Authority and establish whether the individual is ordinarily a resident in the Local Authority area.

If the carer’s assessed needs meet the Eligibility Criteria, the Local Authority must consider what can be done to meet those needs and establish whether the individual needing care is ordinarily a resident in the Local Authority area.

Needs that are Not Eligible

If none of the individual’s assessed needs meet the eligibility criteria, the Local Authority must provide advice and information about what can be done to meet or reduce the needs; and prevent or delay the development of needs for care and support.
It is important that the outcomes of the National Eligibility Criteria are communicated to the individual as the outcomes can have a significant impact on their life and the support they receive.

The National Eligibility Criteria in health and social care is a framework that is used for determining whether an individual’s assessed care and support needs or, in the case of carers, any support needs, meet the threshold for support from the Local Authority. If the criteria determines that the individual’s needs are eligible, the Local Authority will consider what can be done to meet their needs. If the individual is not eligible for support, they will receive guidance about what can be done to meet their needs.

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