What is the Decision Support Tool?
The Decision Support Tool (DST) is the official assessment document used to determine whether someone qualifies for NHS Continuing Healthcare. It is the centrepiece of the full CHC assessment — the stage that follows a positive Checklist screening.
The DST is not a medical test. It is a structured framework that helps a panel of professionals evaluate the nature, intensity, complexity, and unpredictabilityof a person's care needs across 12 defined domains. The panel then uses clinical judgement to decide whether the person has a “primary health need” — the legal threshold for CHC eligibility.
Crucially, the DST is not a calculator or points system. There is no magic number of “high” scores that automatically triggers eligibility. The panel must consider the overall pattern of needs, how different needs interact, and whether the dominant reason for care is a health need rather than a social care need.
Key point:The DST is a tool to support the decision, not to make it. The panel must exercise clinical judgement based on the whole picture. If your loved one's needs are complex but spread across several domains, make sure the panel considers how those needs interact — not just the individual scores.
The 12 domains explained
The DST assesses care needs across 12 domains. Each domain covers a specific area of need and is scored independently. Here is what each domain covers and what typically constitutes a high or severe score.
Behaviour
Covers challenging behaviour such as aggression, agitation, wandering, resistance to care, and self-harm. Assessors consider how often episodes occur, what triggers them, how many staff are needed to manage them, and what risk they pose to the person or others.
Indicative threshold: High/severe if behaviour requires trained staff intervention, 1:1 supervision, or poses regular risk of harm.
Cognition
Assesses awareness, orientation, memory, and decision-making capacity. This includes the ability to recognise people and places, understand time, make safe decisions, and retain new information.
Indicative threshold: High/severe if the person has no awareness of surroundings, cannot make any decisions about care, or is completely disorientated.
Psychological & Emotional Needs
Covers depression, anxiety, psychosis, emotional distress, and the psychological impact of physical conditions. Includes response to treatment and impact on engagement with care.
Indicative threshold: High/severe if there is a diagnosed psychiatric condition requiring specialist intervention or if emotional distress regularly prevents care delivery.
Communication
Examines ability to speak, understand speech, use non-verbal communication, and make needs known. Includes use of communication aids and the effort required by staff to interpret the person's wishes.
Indicative threshold: High/severe if the person cannot reliably communicate needs, even with aids, and staff must interpret or anticipate all requirements.
Mobility
Covers walking, transfers, positioning in bed or chair, use of mobility equipment, and falls risk. Assessors look at how many staff are needed for transfers and how often repositioning is required.
Indicative threshold: High/severe if the person is fully dependent on staff for all transfers, requires hoisting, or has a significant falls risk requiring constant supervision.
Nutrition (Food & Drink)
Assesses eating and drinking ability, swallowing difficulties, choking risk, need for modified diet, PEG or NG tube feeding, and SALT (speech and language therapy) involvement.
Indicative threshold: High/severe if the person requires PEG/NG feeding, has a significant aspiration risk, or needs 1:1 supervision at all meals.
Continence
Covers bladder and bowel control, use of pads, catheter care, stoma management, and the frequency and nature of continence care episodes.
Indicative threshold: High/severe if the person requires catheter or stoma management with clinical complications, or if continence care involves managing distressed or resistant behaviour.
Skin & Tissue Viability
Examines pressure sore risk and management, wound care, skin conditions requiring clinical treatment, and the repositioning regime needed to prevent deterioration.
Indicative threshold: High/severe if the person has grade 3 or 4 pressure ulcers, requires complex wound management, or needs repositioning every 2 hours or more frequently.
Breathing
Covers respiratory conditions, oxygen therapy, suction, ventilation, chest infections, and aspiration pneumonia risk. Includes the level of monitoring and intervention needed.
Indicative threshold: High/severe if the person requires continuous oxygen, regular suction, or has frequent chest infections requiring hospital admission.
Drug Therapies & Medication
Assesses the complexity of medication regimes, method of administration (oral, injection, PEG), monitoring requirements, side effects management, and the person's compliance or resistance.
Indicative threshold: High/severe if medication must be given by non-oral route requiring clinical skill, or if the person actively refuses medication requiring specialist management.
Altered States of Consciousness
Covers seizures, diabetic emergencies, transient ischaemic attacks, loss of consciousness, and any condition causing sudden changes in awareness or responsiveness.
Indicative threshold: High/severe if the person has frequent seizures despite medication, requires emergency intervention, or has episodes that pose a risk to life.
Other Significant Needs
A catch-all domain for needs not fully captured elsewhere. Critically, this is where the interaction between needs across multiple domains should be recorded. If several moderate needs combine to create a level of complexity that requires healthcare oversight, this domain captures that.
Indicative threshold: Should reflect the overall burden of care and how needs in different domains interact to create a combined challenge.
Scoring levels: from no needs to priority
Each domain in the DST is scored at one of six levels. The descriptors for each level vary by domain, but the general meaning of each level is as follows:
No needs
No additional support required beyond what any healthy adult would need. The person is independent in this area.
Low
Some support needed but manageable with minimal intervention. Needs are predictable and can be met by care staff with standard training.
Moderate
Regular support needed that may require some oversight or coordination. Needs are generally predictable but require more than basic care.
High
Significant care needs requiring skilled or frequent intervention. May need clinical oversight, specialist equipment, or trained staff. Needs may be unpredictable.
Severe
Intensive, complex needs requiring constant or near-constant intervention. The person is highly dependent on skilled care and their condition may be unstable or deteriorating.
Priority
The most extreme level, reserved for rapidly deteriorating conditions, imminent end of life, or needs so intense that they require immediate and continuous clinical intervention. Rarely used but decisive when present.
Important:The “priority” level is not used in all domains. It appears in domains where needs can be life-threatening or require immediate clinical response. A single priority score in any domain is generally considered sufficient to establish a primary health need.
How the decision is made
This is one of the most misunderstood aspects of the CHC process. The DST is not a points-based system. There is no formula that adds up domain scores to produce an outcome. Instead, the panel must consider the overall pattern of needs and make a qualitative judgement.
The National Framework provides general guidance on what patterns of need typically indicate eligibility:
The critical word is “pattern.” The panel must step back from individual domain scores and consider what the overall picture tells them about the person's care needs. If the dominant reason for needing care is health-related, the person should qualify — regardless of how the individual scores add up.
The primary health need test
The legal test for CHC eligibility is whether the person has a “primary health need.” This does not mean they must have the most health needs of anyone — it means that the main or dominant reason for their overall care package is a health need, rather than a social care need.
The test was established by the Coughlan case(R v North and East Devon Health Authority, 1999), which set the boundary between NHS-funded healthcare and local authority social care. The court held that if a person's needs go beyond what a local authority could be expected to provide, the NHS must fund them.
The four characteristics the panel must consider are:
Nature
What type of care is required? Does it need clinical knowledge, specialist training, or healthcare professional oversight?
Intensity
How much care is needed and how often? Is it continuous, frequent, or sustained over long periods?
Complexity
How do different needs interact? Does the combination of conditions require skilled coordination that goes beyond routine care?
Unpredictability
How rapidly can the person's condition change? Do their needs fluctuate in ways that require constant readiness or clinical judgement?
If any one of these characteristics — or any combination of them — indicates that the person's needs are beyond what social care can provide, the primary health need test is met. The panel does not need to find all four present.
Who completes the DST and the MDT process
The DST is completed by a multidisciplinary team (MDT). This typically includes:
The person being assessed and their family or representative have the right to be involved throughout. The National Framework states that families should be invited to contribute evidence, attend the MDT meeting, and comment on proposed scores. In practice, some ICBs try to complete the DST without family involvement — if this happens, insist on your right to participate.
The MDT discusses each domain, considers the available evidence, and agrees on a score. If there is disagreement, this should be recorded in the DST. The completed document is then sent to the ICB's decision-making panel, which makes the final eligibility decision. In some areas, the MDT meeting and the decision-making panel are the same event; in others, they are separate.
Common scoring errors to watch for
ICB assessors deal with CHC cases daily, and most are professional and fair. But certain patterns of error appear repeatedly, and being aware of them helps you challenge them in real time.
The "well-managed needs" trap
The most common error. The assessor argues that because your loved one's needs are being well-managed by the current care package, they don't demonstrate a primary health need. This reasoning is circular and was rejected by the courts. The 2022 National Framework (paragraphs 162–163) states: well-managed needs are still needs. Needs must be assessed on the basis of what would happen if the care package were withdrawn.
Scoring on average days instead of bad days
Assessors sometimes score based on how the person presents "most of the time" rather than considering the full range of their needs. The Framework requires the assessment to consider the person's needs across the full spectrum, including their worst days. Unpredictability is itself a care need.
Ignoring the interaction between domains
Each domain is scored individually, but the final decision must consider how needs interact. If moderate needs in behaviour, cognition, and mobility combine to create a level of complexity that requires healthcare oversight, the panel must recognise this — even if no single domain reaches "high."
Downgrading scores because needs are "social" not "health"
Some assessors draw an artificial line between health and social care within individual domains. For example, they might score mobility as "moderate" because the person "only" needs help with transfers, not clinical treatment. But the nature of the help needed — hoisting, risk of falls, staff training required — is itself a health consideration.
Relying solely on care home records
Care home daily logs are important evidence, but they often understate needs because staff are busy and documentation is inconsistent. If the assessor relies only on care records without seeking input from family members who observe the person regularly, the assessment may be incomplete.
How to challenge DST scores
If you believe the DST scores do not accurately reflect your loved one's needs, you have several options at different stages of the process.
Challenge during the MDT meeting
The best time to challenge a score is when it is being discussed. If you disagree, say so clearly and explain why, referencing specific evidence. Ask the assessor to read back the domain descriptors for the level you believe is correct, and explain how your loved one's needs match. If the panel does not change the score, ask for your disagreement to be recorded in the DST.
Request a local review
If the final decision is negative, you can request a local review from the ICB. You must usually do this within 6 months. Provide additional evidence, explain which scores you believe are incorrect and why, and reference the domain descriptors. The local review panel should include someone who was not involved in the original assessment.
Escalate to an Independent Review Panel
If the local review does not change the outcome, you can request an Independent Review Panel (IRP) through NHS England. The IRP is conducted by an independent panel that reviews the entire process, including whether the DST was completed correctly, whether relevant evidence was considered, and whether the decision was reasonable. The IRP can recommend that the ICB reassess.
At every stage, focus on specific evidence and reference the DST domain descriptors. Emotional arguments are understandable but will not change scores. What changes scores is clear, documented evidence that matches the descriptors for a higher level. Our Case Strength Report (£97) can map your evidence against all 12 domains and identify exactly where the gaps are.
Frequently asked questions about the Decision Support Tool
What is the Decision Support Tool (DST)?
The Decision Support Tool is the official document used during a full NHS Continuing Healthcare assessment. It provides a structured framework for a multidisciplinary team to evaluate an individual's care needs across 12 domains. The completed DST, along with the panel's clinical judgement, forms the basis of the eligibility decision. It is not a calculator or scoring system — it is a tool to support a qualitative decision about whether someone has a primary health need.
Is the DST a points-based system?
No. This is one of the most common misunderstandings about CHC. The DST does not add up scores to produce a total. Instead, the panel must look at the overall pattern of needs across all 12 domains and use clinical judgement to determine whether the person has a primary health need. A person with several moderate scores that interact with each other can still qualify, while someone with a single high score might not. The interaction and overall picture matter more than individual scores.
Who completes the Decision Support Tool?
The DST is completed by a multidisciplinary team (MDT), which typically includes an NHS nurse assessor, a social worker, and other professionals involved in the person's care such as a physiotherapist or occupational therapist. The person being assessed and their family or representative have the right to be involved in the process, provide evidence, and challenge proposed scores. The final document should reflect input from everyone involved.
What are the scoring levels in the DST?
Each of the 12 domains is scored at one of the following levels: no needs, low, moderate, high, severe, or priority. The priority level is reserved for the most extreme cases, such as someone who is rapidly deteriorating or requires constant clinical intervention. Most domains are scored between low and high. The descriptors for each level are defined in the DST itself and vary by domain.
What does 'primary health need' mean?
The primary health need test is the legal test for CHC eligibility. It asks whether the main or dominant reason for the person's care needs is a health need — meaning needs that go beyond what a local authority could be expected to provide. The test considers the nature, intensity, complexity, and unpredictability of the person's needs. If their care requirements are primarily driven by health conditions rather than social care needs, they should qualify for CHC.
Can I challenge the scores on the DST?
Yes. You can challenge individual domain scores during the MDT meeting itself by presenting your evidence and explaining why you believe a higher score is appropriate. If the final decision is negative, you can request a local review from the ICB within 6 months, providing additional evidence. If the local review is unsuccessful, you can escalate to an Independent Review Panel through NHS England. At every stage, focus on specific evidence and reference the domain descriptors in the DST.
How long does the DST assessment take?
The NHS target is 28 days from the initial Checklist screening to the DST decision. In practice, delays of 2-3 months are common, and some ICBs take much longer. If the process is delayed, write to the ICB citing the 28-day target in the National Framework. If your loved one is approaching end of life or has rapidly deteriorating needs, ask about the Fast Track pathway, which bypasses the standard DST process entirely.
Related guides
CHC Assessment: How to Prepare
Step-by-step guide to preparing evidence for the MDT meeting, including all 12 DST domains.
CHC Checklist Screening
How the initial Checklist screening works and what you need to pass it to reach the full DST assessment.
CHC Eligibility
Who qualifies for NHS Continuing Healthcare and the legal test for eligibility.
NHS Continuing Healthcare Funding Guide
The complete guide to CHC — who qualifies, the assessment process, and what to do if refused.