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. Department of Health and Social Care (2022) NHS Continuing Healthcare Decision Support Tool.
3. Department of Health and Social Care (2022) NHS Continuing Healthcare Checklist.
4. R v North and East Devon Health Authority, ex parte Coughlan [2000] 2 WLR 622.
Copywright
Copyright © 2026 Nellie Supports Ltd. All rights reserved.
This article is made available for general information, education and professional reference. It may be downloaded, printed and shared for non-commercial purposes, provided that it is reproduced in full, is not altered in any way, and is properly cited as the work of Nellie Supports Ltd. This material must not be edited, adapted, sold, republished, incorporated into commercial products, or used for commercial training, assessment, report-writing or advisory services without prior written permission from Nellie Supports Ltd.
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 communication domain of the NHS Continuing Healthcare Decision Support Tool. It covers expressive and receptive communication, the effect of sensory impairment, communication aids, the skill required to interpret needs where a person cannot express them, the interaction with cognition and behaviour, and the evidence that supports an accurate level.
The communication domain in the CHC Decision Support Tool
Communication covers the ability to express needs and to understand others. Where someone cannot reliably communicate pain, distress or discomfort, the risk that a need goes unrecognised is itself a significant clinical concern.
What the domain covers
The ability to express needs and to understand information, including speech difficulties following stroke or neurological illness, the effect of hearing and visual impairment, the use of communication aids, and the extent to which others must interpret behaviour or non-verbal signals to identify needs such as pain, hunger or distress.
Expressive and receptive difficulty
Both directions matter. A person may understand well but be unable to express themselves, or may speak fluently while understanding little of what is said. Each creates different risks and requires different support. The narrative should distinguish between them rather than describing communication as poor, which tells an assessor very little.
Interpretation as a skilled task
Where a person cannot express needs, the skill required to interpret them becomes the need. Staff who know the person may recognise that a particular sound or movement indicates pain, and that knowledge is a genuine intervention. Where consistency of staffing is required for safe interpretation, that should be recorded explicitly.
The levels available
This domain does not carry a priority level, so the highest available levels are lower than in the four priority domains. Its importance often lies in how it compounds other needs, particularly cognition, behaviour and psychological needs, and in the unpredictability that arises when needs cannot be reliably communicated.
Interaction with other domains
Communication difficulty makes pain assessment harder, which affects skin, medication and behaviour. It makes distress harder to interpret, which affects psychological needs and behaviour. It makes safe eating harder to supervise, which affects nutrition. Describing those interactions is how the domain contributes to the complexity analysis.
Evidence that helps
Speech and language therapy assessments, audiology and optometry reports, communication passports or plans, care records describing how needs are identified, records of occasions when a need was missed because it could not be communicated, and any record of pain assessment tools used for non-verbal people.
Key takeaway
Communication covers both expression and understanding, and its significance often lies in the risk of unrecognised need. Record the skill and consistency required to interpret needs, and describe how communication difficulty compounds cognition, behaviour and pain management.
Add a Title
Add paragraph text. Click “Edit Text” to update the font, size and more. To change and reuse text themes, go to Site Styles.
Add a Title
Add paragraph text. Click “Edit Text” to update the font, size and more. To change and reuse text themes, go to Site Styles.
Frequently asked questions
Can the communication domain reach priority?
No. Only behaviour, breathing, drug therapies and medication, and altered states of consciousness carry a priority level. Communication contributes through its effect on other domains and on complexity.
Does deafness belong in this domain?
Yes, where it affects the ability to receive information and communicate needs. Record the aids in place, whether they are used effectively, and what support is required for reliable communication.
What if the person cannot communicate at all?
Record what others must do to identify needs, including which staff can interpret reliably, what signals are used, what tools such as pain assessment scales are in place, and any occasions when a need was missed.
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.