The Decision Support Tool (DST) Explained
How NHS Continuing Healthcare Eligibility Is Structured and Applied
The Decision Support Tool (DST) is the national framework document used to bring together evidence when determining eligibility for NHS Continuing Healthcare (CHC).
It is not an assessment in itself.
It is a structured way of recording and analysing assessed care needs so that a recommendation can be made about whether a person has a Primary Health Need under the National Framework.
Understanding how the DST works is central to understanding how CHC decisions are reached.
What Is the Decision Support Tool?
The DST is a standardised document developed by the Department of Health and Social Care to support consistent decision-making across England.
It is completed by a multidisciplinary team (MDT) following a full assessment of health and social care needs.
Its purpose is to:
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Bring together assessment evidence
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Record levels of need across defined domains
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Analyse how needs interact
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Support a recommendation on eligibility
It ensures decisions are not based on isolated incidents, but on the totality of need.
The 12 Care Domains
The DST records needs across 12 domains:
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Breathing
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Nutrition
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Continence
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Skin (including tissue viability)
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Mobility
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Communication
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Psychological and emotional needs
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Cognition
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Behaviour
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Drug therapies and medication
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Altered states of consciousness
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Other significant care needs
Each domain includes descriptors for different levels of need, ranging from:
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No Needs
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Low
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Moderate
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High
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Severe
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Priority
The descriptors are intended to guide professional judgement - not replace it.
How Levels of Need Work
Each level reflects the degree of support required within that domain.
For example:
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A “High” level may indicate regular intervention or supervision.
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A “Severe” level may reflect sustained and significant need requiring skilled input.
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A “Priority” level indicates critical need and is rare.
Importantly, the DST is not a scoring tool.
Eligibility is not decided by counting levels.
Instead, the MDT must consider how the needs, taken together, relate to the four key characteristics of:
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Nature
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Intensity
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Complexity
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Unpredictability
These characteristics determine whether a Primary Health Need exists.
(You can read more about how Primary Health Need is defined here →
What Happens at the MDT Meeting?
The DST is completed during a Multidisciplinary Team (MDT) meeting.
The MDT must include at least two professionals from different healthcare disciplines who have knowledge of the individual’s needs.
During the meeting:
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Evidence is reviewed domain by domain
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Levels of need are agreed and recorded
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Justification for each level must be documented
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A summary of needs is prepared
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A recommendation is made regarding eligibility
The individual, or their representative, should be invited to participate.
The completed DST and recommendation are then submitted to the Integrated Care Board (ICB), which makes the final eligibility decision.
The Summary Section: Where Decisions Are Interpreted
The most important section of the DST is often the summary analysis.
This is where the MDT must explain:
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How needs interact
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Whether risks are compounded
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Whether care requires sustained skilled oversight
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Whether the four key characteristics are present
A DST that lists levels without clear analytical reasoning may be vulnerable to challenge.
The National Framework requires decision-making to be transparent and properly reasoned.
Common Misunderstandings About the DST
It is not.
While certain combinations of levels may indicate likely eligibility, professional judgement must still be applied.
Incorrect.
Eligibility can arise from combinations of Severe or High levels, depending on how the totality of need presents.
Needs that are well-managed can still be significant needs.
The question is not whether care is being delivered effectively, but whether the underlying level of need goes beyond what a local authority can lawfully provide.
Care delivered in a residential care home can still meet the threshold for NHS responsibility.
The assessment focuses on need, not setting.
Why Evidence Structure Matters in the DST
The DST relies heavily on how evidence is presented.
Issues can arise where:
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Care records are not cross-referenced
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Incidents are described but not analysed
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Risks are mentioned without impact assessment
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Domain interactions are not explored
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The four key characteristics are not explicitly applied
Because the DST forms the basis of the recommendation, clarity and coherence are critical.
What Happens After the DST?
Once completed:
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The MDT recommendation is sent to the Integrated Care Board (ICB)
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The ICB considers whether the recommendation is consistent with the evidence
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A written decision is issued
If funding is refused, the decision can be reviewed through the Local Resolution and Independent Review Panel process.
Reviewing a Completed DST
When reviewing a DST - whether preparing for a meeting or considering a refusal - it may be helpful to examine:
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Whether each level of need is justified by evidence
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Whether contradictory records were reconciled
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Whether the summary properly applied Nature, Intensity, Complexity and Unpredictability
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Whether the totality of needs was clearly considered
The DST is central to how CHC decisions are structured and reasoned.
Understanding how it operates is often key to understanding the outcome.
Need Clarity?
Or explore our full Continuing Healthcare Funding Support Service.
This guidance page has been prepared by Nellie Supports’ solicitor-led Continuing Healthcare team, drawing on the NHS National Framework and Decision Support Tool guidance. Last reviewed: [February, 2026]