The Decision Support Tool, explained

What is the Decision Support Tool?

The Decision Support Tool is the second formal stage of the NHS Continuing Healthcare process. It follows a positive screening result at the Checklist stage, which we cover in our guide to the CHC Checklist. Where the Checklist asks whether a full assessment is needed, the DST is that full assessment's working document. It gathers the person's assessed needs into one structured picture.

The DST supports a recommendation rather than making the funding decision itself, and its levels weigh needs rather than adding up points. The multidisciplinary team completes it, forms a view on whether the person has a primary health need, and sends that recommendation to the ICB, the NHS body that makes the eligibility decision. The National Framework covers the tool in its body paragraphs 151 to 161, paragraph numbers the Framework confirms in its own cross-references.

The primary health need test is the legal heart of the whole process. The Framework defines it like this:

"An individual has a primary health need if, having taken account of all their needs (following completion of the Decision Support Tool), it can be said that the main aspects or majority part of the care they require is focused on addressing and/or preventing health needs. Having a primary health need is not about the reason why an individual requires care or support, nor is it based on their diagnosis; it is about the level and type of their overall actual day-to-day care needs taken in their totality."

National Framework, page 22, paragraphs 55 to 67

Two related rules protect families here. The diagnosis of a particular disease or condition is not in itself a determinant of eligibility, and eligibility is not determined by the setting where care is provided or by who delivers it (National Framework, page 24). Money is excluded too: "Financial issues should not be considered as part of the decision on an individual's eligibility for NHS Continuing Healthcare" (National Framework, page 24).

What are the 12 DST domains?

The DST looks at the same 11 areas of daily life as the Checklist and adds a twelfth, "other significant care needs" (DST guidance, paragraph 23). Each domain is weighed against written descriptors and given a level. The levels run: no needs, low, moderate, high, severe and priority. Not every domain reaches every level (DST guidance, paragraph 24). The table below shows the ceiling for each one.

Only four domains can reach the priority level: Breathing, Behaviour, Drug therapies and medication, and Altered states of consciousness. These are the same four domains that carry an asterisk on the Checklist, where a single A score in any one of them triggers a full assessment on its own. The ceilings matter when you read a completed DST: a "high" in Continence is the top of that domain's scale.

How is the DST completed?

A multidisciplinary team, usually called the MDT, completes the DST. The National Framework sets out who the team is and how it should work in its body paragraphs 139 to 143, per the Framework's own cross-references. The Framework glossary defines the MDT as a team of at least two professionals, usually from both the health and the social care disciplines (National Framework glossary, page 167). The process order is fixed: Checklist screening, then the DST completed by the multidisciplinary team, then the ICB's eligibility decision.

The team's task is bigger than filling in levels. For each domain it should read the person's assessed needs against the written descriptors and record the evidence behind the level it selects. It then stands back and judges the overall picture against the four characteristics the Framework uses to describe a primary health need: nature, intensity, complexity and unpredictability (National Framework, pages 23 to 24, paragraph 60). The Framework says each of these characteristics "may, alone or in combination, demonstrate a primary health need, because of the quality and/or quantity of care that is required to meet the individual's needs" (National Framework, page 24). Our guide to the CHC eligibility criteria walks through all four characteristics in detail.

One principle governs every level the team selects. Needs that are managed well can look small on the day, because good care hides them. The Framework closes that gap:

"The decision-making rationale should not marginalise a need just because it is successfully managed: well-managed needs are still needs. Only where the successful management of a healthcare need has permanently reduced or removed an ongoing need, such that the active management of this need is reduced or no longer required, will this have a bearing on NHS Continuing Healthcare eligibility."

National Framework, page 51, paragraphs 162 to 166

So a person whose challenging behaviour produces no incidents because a skilled support plan prevents them still has a behaviour need. The Framework uses exactly that situation as its worked example, and says such well-managed needs "should be recorded and taken into account in the eligibility decision" (National Framework, page 51).

What scores indicate eligibility?

The DST guidance sets out the combinations where eligibility would be the expected outcome. This is the passage to know word for word:

"A clear recommendation (and decision) of eligibility for NHS Continuing Healthcare would be expected in each of the following cases: A level of priority needs in any one of the four domains that carry this level. A total of two or more incidences of identified severe needs across all care domains."

DST guidance, paragraph 35, page 10

Lower combinations are not ruled out. The guidance says a severe level combined with needs in a number of other domains, or a number of domains with high or moderate needs, "may also, depending on the combination of needs, indicate a primary health need" (DST guidance, paragraphs 36 to 37). In this second group the argument rests on how the needs interact rather than on any single level.

The Framework is also clear that the tool's thresholds are guides, not rules:

"Indicative guidelines as to threshold are set out in the tool (for example, if one area of need is at Priority level, then this demonstrates a primary health need), but these are not to be viewed prescriptively."

National Framework, page 51

That cuts both ways. A case below the indicative levels can still succeed on the overall picture of nature, intensity, complexity and unpredictability. Equally, the levels alone never settle the question. The recommendation should always rest on the totality of the person's day-to-day needs.

What happens after the DST?

The multidisciplinary team sends its completed DST and its recommendation to the ICB, which makes the eligibility decision. The Framework leaves the ICB very little room to depart from what the team recommends:

"Only in exceptional circumstances, and for clearly articulated reasons, should the multidisciplinary team's recommendation not be followed."

National Framework, page 54

The same page adds that the ICB "should not refer a case back, or decide not to accept a recommendation, simply because the multidisciplinary team has made a recommendation that differs from the one that those who are involved in making the final decision would have made, based on the same evidence" (National Framework, page 54). If a panel overturns its own MDT without exceptional circumstances and clear reasons, that is a strong ground for challenge.

There are timing expectations too. The ICB should normally respond to an MDT recommendation within 48 hours, that is two working days, and the whole journey from the ICB receiving a positive Checklist to its eligibility decision should not exceed 28 calendar days in most cases (National Framework, page 55).

If the decision goes against the person, the process does not end there. There is a local resolution stage, then an Independent Review Panel run by NHS England, then the Ombudsman. Our guide to what to do after a CHC refusal takes each rung in turn.

How should families prepare for the DST meeting?

Preparation for the DST is evidence work, and the Framework names the tool families need. Where good care hides the scale of a need, it says:

"It may be necessary to ask the provider to complete a detailed diary over a suitable period of time to demonstrate the nature and frequency of the needs and interventions, and their effectiveness."

National Framework, page 51

You can keep that diary yourself. Short, dated, factual entries carry far more weight than general statements like "he needs constant care". For example:

• 3 July, 2.15am. Woke breathless and distressed. Sat upright with oxygen for 50 minutes before settling.
• 6 July, teatime. Pushed the carer away during personal care and struck out twice. Two staff needed to finish safely.
• 9 July, 10am. Skin check found a new red area on the left heel. Repositioning increased to every two hours.

Then organise the evidence by domain. For each of the 12 domains, note what the need is, how often it appears, what skill it takes to manage, and what would happen if the current care stopped. That last question is the practical test of the well-managed needs principle. Where you can, frame the overall case in the Framework's own four words: the nature of the needs, their intensity, their complexity and their unpredictability.

Bring the paper trail with you: care plans, behaviour charts, medication records, district nurse notes, hospital letters and falls logs. During the meeting, ask the team to record the evidence behind each level it selects, and speak up where a descriptor for a higher level matches the person's real day. If you want a structured head start, our free screener asks 18 plain-English questions about the same areas of daily care and shows where the case looks strongest. It takes about three minutes.