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. R (Grogan) v Bexley NHS Care Trust and others [2006] EWHC 44 (Admin).
4. Social Work England. Professional standards. Available at: https://www.socialworkengland.org.uk
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 why NHS Continuing Healthcare outcomes are determined by the evidence rather than by the Decision Support Tool as a document. It covers the function of the tool, why domain levels are conclusions rather than facts, what makes a narrative persuasive, the effect of thin recording, why arguing about levels rarely works, and what to focus on instead.
Why the evidence matters more than the form
Families spend a great deal of energy arguing about domain levels. Levels are conclusions, and a conclusion can only be changed by changing what it rests on. The evidence is where the case is actually won.
The tool is a container
The Decision Support Tool does not decide anything. It is a structure for recording assessed needs so that a decision can be made consistently. Everything in it is a summary of something else, namely the person's actual needs as evidenced by records, observation and professional knowledge. Change the evidence and the summary has to change with it.
Levels are conclusions
A domain level is a judgement about what the recorded narrative amounts to. Arguing that a level should be high, without changing the narrative beneath it, asks someone to reach a different conclusion from the same material. That rarely succeeds. Changing the material underneath is what makes the conclusion move.
Thin narrative produces low levels
The most common cause of an understated assessment is not disagreement about the person but thin recording. A domain narrative reading that the person is doubly incontinent and managed with pads describes an outcome, not a need. The same person described with frequency, staffing, night time pattern and skin consequence produces a different level from the same facts.
What makes a narrative persuasive
Specificity. Numbers, frequency, staffing, duration, and the consequence of omission. Compare two versions of the same need. Requires assistance with transfers. Or: requires two staff and a hoist for every transfer, six times daily and twice overnight, with a documented injury in March when attempted by one. The second is not a stronger argument, it is a fuller record.
Why the four characteristics need evidence too
Nature, intensity, complexity and unpredictability are also conclusions, and they are the ones most often asserted without support. Unpredictability in particular needs dated events with the warning available and the consequence stated. Naming a characteristic without evidence behind it carries no more weight than naming a level.
What to focus on instead
Obtain the care records, including night records. Identify what is missing from each domain narrative. Provide the missing material with dates. Ask for it to be attached to the tool. That approach changes what the decision rests on, which is the only thing that reliably changes the decision.
Key takeaway
Do not argue about levels, change what they rest on. Specific, dated, numerical description of need and its consequences is what moves an assessment, and a thin narrative is the most common reason a case fails.
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Frequently asked questions
Should we argue the domain levels are wrong?
Only alongside the evidence that shows why. A level is a conclusion about the narrative beneath it, so asking for a different conclusion from the same material rarely succeeds.
What makes a domain narrative strong?
Specificity. Frequency, staffing numbers, duration, night time pattern, skill required and the consequence when the care is not delivered. Numbers carry far more weight than adjectives.
Our records are thin. What can we do?
Provide what is missing yourself, with dates, and ask for it to be attached to the Decision Support Tool. A family log of overnight needs and difficult episodes is legitimate evidence.
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.