What is the CHC Decision Support Tool (DST)? A Family Guide

The Decision Support Tool — the DST — is the single piece of NHS paperwork that decides whether a relative gets fully-funded care or pays for it themselves. Most families never see it before the meeting. A small number of them spend the meeting staring at a printout they don't understand. The smallest number read it cover-to-cover, name the descriptor language back at the assessors, and walk out with the score they came for.

This guide is for families in the second or third group — the ones who need to understand what the DST is, what it measures, how the panel uses it, and what they can do at the meeting and afterwards to make sure the recorded scores actually reflect their relative's needs.

Reviewed by legal professionals and social care professionals.

TL;DR: The DST is the NHS document that records care needs across 11 domains during a full CHC assessment. A multidisciplinary team scores each domain on a descriptor scale (No needs → Priority) and weighs the totality against the primary health need legal test from Coughlan [1999]. It is not a points-based calculator. National CHC eligibility at full assessment has fallen to 17% (Healthwatch, 2025) — families who arrive with a structured evidence pack mapped to each domain's published descriptors meaningfully outperform that average.

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What is the Decision Support Tool, in plain English?

The Decision Support Tool is the NHS document — published and maintained by the Department of Health and Social Care — that a multidisciplinary team (MDT) completes during a full NHS Continuing Healthcare assessment. It records care needs across 11 domains, captures the supporting evidence, and produces a recommendation on whether the person has a primary health need and therefore qualifies for fully-funded NHS care.

Two things the DST is not. It is not a points-based calculator — domains are not added up to a total. And it is not the eligibility decision itself. The DST is the record the panel uses to make a qualitative judgement against the legal test. The decision is the panel's; the DST is how the decision is justified in writing.

The legal anchor matters. CHC eligibility turns on the primary health need test from the Court of Appeal's 1999 Coughlan judgment (BAILII) and the High Court's 2006 Grogan ruling that the test must be applied with reasons — assertion is not application. The DST is the document that records those reasons. A DST without dated, descriptor-aligned evidence in each disputed domain is a DST that is legally vulnerable on appeal.

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When does the DST come into your relative's case?

The DST sits at Stage 2 of the NHS CHC assessment pathway. Stage 1 is the CHC Checklist — a screening tool that decides whether a full assessment is even warranted. A positive Checklist triggers a Stage 2 DST/MDT assessment, which must be carried out within a 28-day target under the 2022 National Framework. A negative Checklist closes the case at screening, with a separate route to challenge that outcome.

In practical terms, a family meets the DST in one of three scenarios. The first is a planned community assessment — the person lives at home or in supported living and the Checklist has been positive. The second is the post-hospital pathway — a Checklist completed during admission or at discharge, with the DST scheduled before the move to a long-term setting. The third is the care home review — an annual or change-of-needs review for someone already in residential care, where the DST is used to confirm continued eligibility or trigger a fresh decision.

In each case the family should expect to be told the date, location, attendees, and chair of the DST/MDT meeting in advance. The right to take part is statutory under the National Framework, and the right to see the draft DST scoring before the meeting concludes is one of the most under-used family protections in the system. For the full procedural walkthrough of who attends and what happens on the day, see our CHC MDT assessment process guide.

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How the 11 DST domains work

The 11 domains of the DST are the categories of care need the panel considers. Each is scored independently, and the scoring is anchored to published descriptors in Annex C of the National Framework. The domains are:

1. Behaviour — challenging or disturbed behaviour, including frequency, predictability, and the skill required to respond
2. Cognition — orientation, memory, capacity, decision-making
3. Psychological and Emotional Needs — mood disturbance, anxiety, distress, the impact on engagement with care
4. Communication — ability to express needs verbally or non-verbally; the skill required to interpret
5. Mobility — independence with movement, transfers, falls history, equipment requirements
6. Nutrition — eating, swallowing, weight management, risk of aspiration or dehydration
7. Continence — bladder and bowel management, catheter care, complexity of intervention
8. Skin and Tissue Viability — pressure damage risk, wound management, specialist input
9. Breathing — respiratory support, oxygen therapy, ventilation
10. Drug Therapies and Medication — complexity of regime, controlled drugs, monitoring
11. Altered States of Consciousness — seizures, episodes of unresponsiveness, hypoglycaemic events

A twelfth catch-all — Other Significant Care Needs — captures anything that does not fit the eleven above (most commonly palliative care input that crosses several domains, or specialist nursing for rare conditions). For more on each domain and how the descriptors map to evidence, see our 12 CHC care domains guide.

Two practical points. First, the four "Priority-eligible" domains — Behaviour, Breathing, Drug Therapies, and Altered States of Consciousness — can reach the "Priority" descriptor level. The other seven top out at "Severe". A single Priority score or two or more Severe scores typically generate a strong recommendation of eligibility under the National Framework. Second, the panel is required to consider the interaction between domains under paragraph 56 of the Framework — a "cluster" case of several Moderate or High scores across interacting domains can amount to a primary health need even where no single domain reaches Severe.

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What each scoring level means

Each domain is scored against published descriptors. The five (or six) levels are:

• No needs — the person has no recorded needs in this domain
• Low — needs are present but managed through routine care without specialist input
• Moderate — needs that require some skilled intervention or oversight on a planned basis
• High — needs that require regular, skilled clinical intervention or management, often unpredictable in nature
• Severe — needs that are intense, frequent, or require continuous skilled supervision, with significant risks if care is not delivered
• Priority (Behaviour, Breathing, Drug Therapies, Altered States of Consciousness only) — needs so severe and unpredictable that they require immediate and continuous clinical intervention; in practice, Priority is rare and typically involves life-threatening situations

The descriptors themselves are published in Annex C of the National Framework and are quoted verbatim in the DST form. A family preparing for the meeting should have the exact descriptor language for each disputed domain ready — quoting it back at the panel removes the room for reinterpretation. ICBs cannot lawfully reduce a score because care is "well-managed"; paragraphs 119–121 of the Framework require the assessor to consider what would happen if the skilled inputs were withdrawn. See our well-managed needs guide for the rebuttal pattern.

The single most common scoring failure we see at CareAdvocate is a Moderate where the evidence supports a High — and a High where it supports a Severe. The descriptor language is the discipline that prevents this drift.

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What the family can do at the DST meeting

Three things in particular are within the family's gift on the day, and most families don't realise it.

Ask to see the draft DST before the meeting closes. The chair will typically work through the domains in order, recording scores. The family has the right to ask for the draft scoring to be summarised back before the panel closes and a final recommendation is made. This is the only moment to surface an undersore while the evidence is still in the room. A polite, structured request — "Can we walk through each scored domain before we close?" — works.

Use the four-line domain rebuttal pattern. For each domain where the recorded score under-represents the evidence, the family states: (1) the score the panel has recorded; (2) the score the evidence supports; (3) the quoted descriptor language from Annex C for the higher level; (4) the specific dated evidence reference. Reviewers can change a recorded score in response to that structure; they cannot in response to an emotional appeal that does not engage the descriptor language. This is the same pattern used in post-decision appeal letters — and it works at the meeting too.

Record a written objection. If the panel proceeds to a score the family disputes, ask for the objection to be recorded in the meeting notes — by name, by domain, by descriptor reference. Recorded objections form part of the evidence base for any subsequent Local Resolution challenge. A meeting note that records "the family disagreed with the Behaviour score and pointed to incident logs from 4 February 2026 and 18 March 2026 supporting a High descriptor" is materially stronger evidence on appeal than a contemporaneous memory.

For families who want this level of preparation built for them before the meeting — domain-by-domain evidence mapping against Annex C descriptors — the MDT Preparation Pack is the £499 / £799 service specifically designed for the Stage 2 DST hearing.

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How to challenge a DST that doesn't reflect the evidence

If the DST has already been completed and the family disagrees with the recommendation or the underlying domain scores, the route is Local Resolution within six months of the date on the decision letter. About 13% of Local Resolution requests result in eligibility being granted on average (Nuffield Trust, June 2024, Q4 2023/24 data), and the rate rises meaningfully with a structured, descriptor-mapped evidence pack.

The challenge mechanics are identical to the in-meeting pattern, scaled up: a written appeal letter built around the four-line rebuttal per disputed domain, anchored to the Coughlan/Grogan legal framework, and supported by an indexed evidence pack. The appeal letter anatomy walks through the structure section by section.

Two things to settle before drafting the appeal. First, get the records via a Subject Access Request to the ICB, GP, hospital, and care home — the decision letter is the summary; the SAR returns the underlying file that produced it. Second, decide whether the evidence supports the appeal before committing 30–60 hours of family work. A Case Strength Report at £97 returns a structured evidence-strength rating in five working days, telling families whether the disputed domains have the descriptor-aligned evidence to support an appeal or whether the original DST was substantively correct.

For the full appeal map — Local Resolution, Independent Review Panel, PHSO — see our complete CHC appeal guide.

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What this means for your next steps

The DST is the document that decides who pays for the care. Most families meet it once, under time pressure, with no prior preparation. The 17% national eligibility rate at full assessment (Healthwatch, 2025) is the headline figure, but the unstated reality is that a meaningful share of refusals turn on scoring failures the family could have surfaced at the meeting if they had known the descriptor language and the four-line rebuttal pattern.

Three rational starting points:

• Not yet at the DST stage? Use the free CHC eligibility screener (four minutes) to test whether a Checklist is worth requesting. If the relative is on a Checklist pathway, the Checklist Evidence Pack (£597) is the assessor-facing document that supports the Stage 1 screening before the DST is ever scheduled.
• DST scheduled in the next four weeks? This is the highest-leverage moment. The MDT Preparation Pack (£499 upgrade / £799 standalone) builds the descriptor-mapped evidence pack and family briefing that supports the live meeting. The pack is purpose-built for the Stage 2 hearing.
• DST already completed and you disagree with the outcome? Start with a £97 Case Strength Report before committing to a full appeal. It tells you in five working days whether the evidence supports a Local Resolution challenge, which domains to dispute, and what the realistic chance of overturning the scoring is.

The DST is the document, but the descriptor language is the discipline. Families who learn the language win the scores they came for. Families who do not, do not.

This guide is reviewed by legal professionals and social care professionals. CareAdvocate provides advocacy and evidence preparation, not legal advice. The DST domain framework is taken from the 2022 National Framework for NHS Continuing Healthcare published by the Department of Health and Social Care; case-law references (Coughlan, Grogan) cite the original Court of Appeal and High Court judgments on the BAILII archive. Individual outcomes vary and no result is guaranteed.