NHS Continuing Healthcare
The Decision Support Tool and the 12 Care Domains
How the twelve care domains are scored, and what the completed tool has to show to point to a primary health need.
What is the Decision Support Tool?
The Decision Support Tool, or DST, is the assessment used to decide eligibility for NHS Continuing Healthcare after a positive Checklist. A multidisciplinary team scores need across twelve care domains, from no needs up to a ceiling that varies by domain, and records the reasoning for each. The completed tool supports a recommendation to the Integrated Care Board, which makes the final decision. The DST is not a points total; it is a structured way of describing need so the primary health need question can be answered.
Plain English
For families and professionals
England and Wales
National coverage
Registered professionals
Written and reviewed
The Decision Support Tool is where a Continuing Healthcare case is really won or lost. It follows a positive Checklist and turns the evidence about a person's needs into scores across twelve care domains. Those scores, read against four key characteristics, are what the multidisciplinary team uses to recommend whether the person has a primary health need. Understanding how the tool weighs need is what lets you make sure the scores reflect reality rather than a tidy version of it.
The four key characteristics
Where the markers are not clear cut, the team must weigh need against four characteristics:
- Nature: the type of need and the kind of care it demands
- Intensity: the quantity, severity and continuity of needs, including the support required
- Complexity: how the needs interact and how skilled the response has to be
- Unpredictability: how far needs fluctuate and the risk that arises when they do
How to prepare for the DST meeting
The tool can only score what the team can see. Preparation is what puts the real picture in front of them:
- Ask for the evidence pack in advance and read it against your own knowledge
- Record needs at the level they would be without the care currently in place
- Bring night records, incident logs, medication and continence charts
- Be ready to describe a typical bad week, not a calm day
- Ask for reasoning and any disagreement to be recorded against each domain
Where people often go wrong
- Letting well-managed needs be scored low because current care keeps them stable
- Accepting domain levels that are agreed quickly without evidence
- Treating the total as a points score rather than a description of need
- Not challenging a domain left blank or marked no needs without discussion
- Leaving the meeting without the reasoning recorded against each domain
- Letting well-managed needs be scored low because current care keeps them stable
- Accepting domain levels that are agreed quickly without evidence
- Treating the total as a points score rather than a description of need
- Not challenging a domain left blank or marked no needs without discussion
- Leaving the meeting without the reasoning recorded against each domain
The twelve care domains
The twelve domains are behaviour, cognition, psychological and emotional needs, communication, mobility, nutrition, continence, skin and tissue viability, breathing, drug therapies and medication, altered states of consciousness, and a final domain for other significant care needs. Each is scored on a scale that runs from no needs through low, moderate, high and severe, with four domains, behaviour, breathing, drug therapies and altered states of consciousness, able to reach the highest level of priority. The maximum level differs by domain, which is deliberate: it reflects how serious a need in that area can be.
Frequently Asked Questions
How many domains do you need to qualify?
There is no simple number. A single domain at priority, or two or more at severe, clearly indicates a primary health need. Otherwise the team weighs the whole picture using the four key characteristics, so a combination of high and moderate needs can also be enough.
What is a well-managed need?
It is a need that looks under control only because care is in place. The framework says needs must be recorded at the level they would be without that care. Scoring a well-managed need as minor is one of the most common reasons families lose funding.
Who completes the Decision Support Tool?
A multidisciplinary team of at least two professionals from different backgrounds, usually a nurse assessor and a social worker, with input from others involved in the person's care. The person and their representative should be invited to take part.
Is the DST the final decision?
No. The team makes a recommendation. The Integrated Care Board makes the decision and must confirm it in writing. If the Board departs from the recommendation it should give clear reasons.
This page explains the NHS Continuing Healthcare Decision Support Tool in England. It is general information rather than legal advice, and it does not replace an assessment of an individual's needs.