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De-mystifying the Decision Support Tool Assessment
20th April 2026 |
The Decision Support Tool sits at the centre of the full assessment process for NHS Continuing Healthcare. By the time this stage is reached, an initial positive Checklist will have been completed, providing a clear indication that the individual’s needs require detailed and structured consideration. The purpose of the Decision Support Tool is to bring together evidence from across a multidisciplinary assessment and apply that evidence to the legal test for eligibility.
That test is concerned with whether an individual has a “primary health need”. In broad terms, this requires consideration of whether the nature, intensity, complexity or unpredictability of the care the individual requires goes beyond what a local authority can lawfully provide under the Care Act 2014. Where that threshold is met, responsibility for funding rests with the NHS and the package of care is not subject to means testing. Although the structure of the Decision Support Tool is clearly set out within the National Framework, the way in which it operates in practice is not always well understood. Families are often encountering the process for the first time at a point where care needs have already become significant, and the assessment itself can feel both detailed and difficult to follow. A clear understanding of how the Tool is intended to function, and how it is applied in practice, is therefore essential. 
What exactly is the Decision Support Tool?
The Decision Support Tool is not an assessment in its own right, but a structured framework used to record and analyse the evidence gathered during a full multidisciplinary assessment of needs. Its function is to ensure that relevant information is considered in a consistent way and that the outcome is aligned with the legal principles set out in the National Framework for NHS Continuing Healthcare and NHS-Funded Nursing Care (revised July 2022) and the Standing Rules Regulations (2012). The Tool organises evidence across twelve care domains. These domains are intended to capture the range of health and associated care needs that may be present, including breathing, nutrition, continence, skin integrity, mobility, communication, psychological and emotional needs, cognition, behaviour, drug therapies and medication, altered states of consciousness, and any other significant needs that do not sit comfortably within the defined categories. Within each domain, the individual’s needs are described and assigned a level. These levels follow a structured progression, beginning with no needs and moving through to low, moderate and high. In a number of domains, this range extends further to include severe, and in specific domains where the potential for immediate and significant risk arises, a priority level of need is available. The availability of these higher levels is not uniform across all domains. For example, cognition, mobility, nutrition and skin integrity allow for a severe level of need but do not extend to priority. By contrast, domains such as breathing, behaviour, drug therapies and medication, altered states of consciousness, and the additional category of other significant needs include both severe and priority levels, reflecting the potential for acute or life-threatening presentations. This structured approach can give the impression of a scoring system. In practice, the Decision Support Tool does not operate on a numerical or cumulative basis. The levels assigned within each domain are not added together to produce an overall score, nor do they determine eligibility in isolation. Their purpose is to build a coherent and evidence-based picture of need, which is then considered in the round through the application of the four key characteristics: nature, intensity, complexity and unpredictability. It is through this analysis, informed by the professional judgement of the multidisciplinary team, that the question of a primary health need is determined. 
Who carries out the assessment?
The Decision Support Tool is completed by a multidisciplinary team, as required by the National Framework and the Standing Rules Regulations. This is not intended to be a single-professional exercise. The process is designed to bring together different perspectives so that the individual’s needs are considered in a balanced and informed way. At a minimum, the team must include either two professionals from different healthcare disciplines, or one healthcare professional together with a professional involved in assessing care and support needs under the Care Act 2014. The assessment is led by an NHS Continuing Healthcare nurse assessor, with input from those directly involved in the individual’s care, including care home staff and relevant clinicians. The individual, and those representing them, should be actively involved throughout the process. This is a core requirement of the assessment, not an optional element. The National Framework is clear that the process must be person-centred, and that the individual’s own experience of their needs should be considered alongside the professional evidence. In practical terms, this means that the individual should be invited to attend the assessment wherever possible, or to be represented if attendance is not feasible. Family members, attorneys or other representatives often play a central role in this, particularly where needs are complex or where the individual has difficulty communicating or participating fully. Their input can provide important context about how needs present on a day-to-day basis, how they fluctuate, and what level of care is required to manage them safely. This contribution is not simply supplementary. It is often essential to ensuring that the assessment reflects the full picture. The Decision Support Tool requires that the individual’s views, and those of their representative, are taken into account and appropriately recorded. Where there is disagreement about how needs are described or assessed, that disagreement should be documented as part of the process. There are also clear legal considerations. Consent must be in place for the assessment to proceed and for information to be shared. Where an individual lacks capacity to make those decisions, the requirements of the Mental Capacity Act 2005 apply, and decisions must be taken in their best interests with appropriate involvement from those close to them. The involvement of the individual and their representatives also serves an important function in ensuring transparency. It allows the reasoning behind the assessment to be understood and, where necessary, challenged. This is particularly important given the significance of the outcome and the consequences that follow from it. Alongside this, the involvement of the local authority remains a central part of the process. The purpose of the assessment is to determine where responsibility for care sits, and that cannot properly be considered without input from both health and social care. Where that input is limited or absent, the assessment may not fully address the question it is intended to answer. 
How does the Decision Support Tool work in practice?
In practice, the Decision Support Tool is worked through one domain at a time, beginning with breathing and moving through each of the twelve areas of need in turn. Each domain is discussed in detail, drawing on clinical records, care notes and the contributions of those present. This is not simply an exercise in describing what care is provided. The focus is on understanding the underlying need, how it presents, and what is required to manage it safely and consistently. Within the mobility domain, for example, the discussion should go beyond whether assistance is required. It should consider how that assistance is provided, whether one or two carers are needed, whether equipment is required, and whether there are associated risks such as falls, resistance or difficulty with repositioning. The level of support required to maintain safety is often as important as the task itself. Within nutrition, the assessment is not limited to whether someone is eating and drinking. Consideration should be given to issues such as weight stability, the risk of choking, the need for modified diets, and the level of supervision or encouragement required. Where specialist input has been needed, this forms part of the overall picture. Across all domains, the same principle applies. The assessment is concerned not only with what is happening, but with how complex it is to manage, how often intervention is required, and what risks arise if that support is not in place. Once each domain has been considered, a level of need is agreed. These levels are important, but they are not an end point. The Decision Support Tool is not a form that is completed and totalled. Instead, the levels across the twelve domains are brought together and considered in the round. At that stage, the multidisciplinary team applies the four key characteristics: nature, intensity, complexity and unpredictability. Nature refers to the type of needs present and their overall effect. Intensity considers the quantity and severity of those needs. Complexity looks at how needs interact, particularly where multiple issues are present at the same time. Unpredictability considers the extent to which needs fluctuate and the risks that arise as a result. It is through this broader analysis that the question of a primary health need is addressed. 
The Primary Health Need Test
Once the Decision Support Tool has been completed, the multidisciplinary team must apply the Primary Health Need test in order to reach a recommendation on eligibility for NHS Continuing Healthcare. The purpose of this test is to determine whether the individual’s needs are primarily health-related, such that responsibility for meeting those needs rests with the NHS rather than the local authority. It is not a question of diagnosis, setting or funding arrangements to date, but of the nature and extent of the needs themselves and the level of care required to manage them. The Decision Support Tool provides the framework for the multidisciplinary team’s analysis. The levels identified across the twelve care domains form part of the evidential picture, but they are not determinative in isolation. The task for the multidisciplinary team is to consider the individual’s needs holistically, across all domains, and to assess them through the four key characteristics of eligibility: nature, intensity, complexity and unpredictability. It is this analysis of need in its totality that underpins the determination of whether a primary health need is present. Nature relates to the type of needs present and their overall effect on the individual. Intensity considers both the severity of those needs and the extent of care required to manage them. Complexity reflects the way in which needs interact, particularly where multiple issues are present and require skilled oversight. Unpredictability addresses the extent to which needs fluctuate and the risks that arise if care is not delivered in a timely and consistent way. In some cases, the conclusion will be clear. A priority level of need within one of the domains that permits that level, or a combination of two or more severe needs, will ordinarily indicate that the threshold for NHS Continuing Healthcare is met. In other cases, the position is less straightforward. A combination of high and moderate needs across multiple domains may still give rise to a primary health need, depending on how those needs interact and the level of intervention required to manage them safely. The role of the multidisciplinary team is to consider the totality of the evidence and to explain how that evidence leads to the conclusion reached. The recommendation should be supported by a clear and reasoned rationale which sets out how the domain levels have been interpreted, how the four key characteristics have been applied, and why those factors, taken together, demonstrate or do not demonstrate a primary health need. The final decision rests with the Integrated Care Board. In the majority of cases, the recommendation of the multidisciplinary team is accepted. Where it is not, the reasons should be clearly set out and should engage properly with the evidence and the analysis undertaken. The outcome is then confirmed in writing, usually together with a copy of the completed Decision Support Tool. This should include a record of the reasoning applied, any differing views expressed during the assessment, and information about how the decision can be reviewed if it is disputed. 
Timescales
Once a Checklist has triggered a full assessment, the process is expected to move forward without undue delay. The National Framework indicates that, in most cases, a decision should be reached within 28 days of the Checklist being received. Where that timeframe is met, and eligibility is established, funding will usually begin from the date of the decision itself. In practice, however, this timescale is not always achieved. Where there is a delay that cannot be justified, and eligibility is subsequently confirmed, funding is generally backdated to reflect the point at which the decision ought reasonably to have been made, typically from the 29th day following receipt of the Checklist. 
What can go wrong at DST stage?
Although the framework itself is clearly set out, difficulty often arises in the way it is applied in practice. One of the most significant issues concerns the treatment of well-managed needs. The National Framework is explicit that a need does not cease to be a need simply because it is effectively managed. In reality, however, the success of care arrangements is often taken as an indication that the underlying need is less significant. Where an individual remains stable because of continuous oversight, timely intervention and skilled care, that stability can be mistaken for a lack of need. The level of input required to maintain that position is not always reflected in the analysis. There are also difficulties in how needs are described. Care that arises directly from illness or disability may be framed in terms that align it with routine social care, particularly where similar tasks are commonly carried out within care home settings. This can shift the focus away from the nature of the underlying need and towards the setting in which care is delivered. The structure of the Decision Support Tool can contribute to this. Because needs are divided into separate domains, there can be a tendency to consider each in isolation. The interaction between needs, and the way in which they combine to create overall risk, is not always given sufficient weight. Practical and procedural issues are not uncommon. These can include incomplete evidence, limited involvement from the local authority, or a lack of clear reasoning within the final recommendation. In some cases, the written rationale does not fully reflect the discussion that took place during the assessment itself. Taken together, these issues can result in an assessment that does not accurately reflect the reality of the individual’s needs, and consequently, an ineligible decision. 
Why representation matters
By the time a case reaches the Decision Support Tool stage, the question is rarely whether needs exist. The issue is how those needs are identified, described and carried through into the analysis that determines eligibility. The process is evidence-based, but evidence does not speak for itself. It is shaped by the way in which needs are presented, the language used to describe them, and the emphasis placed on particular aspects of care. A need described in functional terms may be viewed very differently from the same need described in terms of risk, intervention and clinical oversight. Families are often describing care in practical terms, focusing on what is done and how often. The assessment, however, requires those needs to be understood in a different way. It requires a clear articulation of how needs present, how they fluctuate, what level of skill is required to manage them, and what risks arise if care is not delivered in a timely and consistent way. Where that translation is not made clearly, important aspects of need can be underrepresented or misunderstood. The assessment may appear complete on its face, but the analysis underpinning it does not fully reflect the reality of the situation. Ensuring that this translation is accurate is central to the process. It is not a question of changing the underlying facts, but of ensuring that those facts are properly recognised, consistently described, and correctly applied within the framework that determines responsibility for funding. 
How ARROW can help at the DST stage
For some families, a clear understanding of how the Decision Support Tool operates is sufficient to approach the assessment with confidence. For others, particularly where there are concerns about how needs are being interpreted or how the process is being conducted, more structured input can be helpful. Where a more informed view is needed before the assessment takes place, the CHC Eligibility Review provides a structured, domain-based discussion aligned with the Decision Support Tool. This allows for a detailed exploration of the individual’s needs, how those needs are likely to be viewed within the assessment, and where the key issues may arise. It is intended to provide clarity and direction, rather than a full evidential analysis. For those managing the process themselves but who would value targeted input at key points, one-off consultancy support can be used to prepare for the multidisciplinary meeting. This may involve discussing how particular needs should be presented, considering how the four key characteristics are likely to apply, and ensuring that relevant points are not overlooked during the assessment. Where a more detailed and evidence-led approach is required, support can extend to a full review of care records, clinical input and supporting documentation, mapped against the twelve domains of the Decision Support Tool. This level of work sits within ARROW’s Comprehensive Support Package, which provides ongoing involvement through the assessment process, including preparation for the multidisciplinary meeting, advocacy at the meeting, and follow-up once the outcome letter has been received. In cases where a decision has already been made, support may also be needed to review the completed Decision Support Tool and the rationale provided, and to advise on whether the outcome properly reflects the evidence and the applicable framework. Key Takeaways The Decision Support Tool is not simply a document to be completed. It is the mechanism through which responsibility for care is determined. You do not have to navigate this complex system alone — and your relative should not miss out on funding to which they may be legally entitled.
ARROW Continuing Healthcare Consultants offer independent, expert support to ensure families receive the funding they are legally entitled to. Get in touch for a confidential, no-pressure chat. |
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At ARROW, we provide expert guidance and hands-on support throughout the NHS Continuing Healthcare (CHC) process. We can: ✔️ Arrange an initial Checklist assessment for you or your loved one. ✔️ Fully prepare you for the Checklist and Decision Support Tool (DST) assessments. ✔️ Gain access to healthcare records (for relatives, a certified Power of Attorney or Court Deputyship Order is required). ✔️ Build strong evidence using medical and care records to support your case. ✔️ Draft evidence-based supporting statements for assessment and appeal panels. ✔️ Represent and advocate for you or your loved one at any stage of the process. ✔️ Manage appeals if you’ve been wrongly assessed as ineligible for CHC funding. 💡 If you believe you or your loved one may qualify for NHS Continuing Healthcare, don’t go through it alone--let ARROW guide you every step of the way! 📞 Contact us today for a FREE consultation! |
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