The Decision Support Tool (DST), Explained in Plain English

By Len Burgess, Senior Care Advisor · Published 22 May 2026

The is the part of our Jargon Buster series goes inside the single most important document in the NHS Continuing Healthcare process. What the Decision Support Tool actually is, what it covers, and how to walk into the meeting knowing exactly what is about to happen.

This is the part of our Jargon Buster series that goes inside the single most important document in the NHS Continuing Healthcare process. What the Decision Support Tool actually is, what it covers, and how to walk into the meeting knowing exactly what is about to happen.

If you have read our post on the CHC Assessment, you will already have come across the Decision Support Tool, the DST, as one of the stages on the road to a CHC decision. This post zooms in on that stage. The DST is the form, the framework, and the conversation that decides whether the NHS pays for your relative's care, and for most families, it is the one and only chance to put the case properly. Understanding it before you walk into the meeting genuinely changes the outcome.

Most families arrive at a DST meeting having never heard of it, never seen the form, and never had the language of "domains," "levels," and "primary health need" explained to them. Within an hour or two, they are being asked to defend their relative's needs against all three. This guide closes that gap.

One quick orientation note. The DST is part of the NHS Continuing Healthcare process in England and Wales. It is not connected to school decision support panels, IT decision support systems, or any of the other things that share the abbreviation "DST." If you are here for the NHS one, read on.

What is the Decision Support Tool?

The Decision Support Tool is the formal document the NHS uses to record someone's care needs across a set of defined categories, and to recommend whether those needs are big enough to qualify for NHS Continuing Healthcare funding.

In plainer language, it is the form a panel of professionals (called a Multi-Disciplinary Team, or MDT) completes during the full CHC assessment. The form is split into three parts:

• Section 1: Personal information, including who is being assessed, who attended the meeting, and what evidence was reviewed.
• Section 2: Care domains, the heart of the document, where the team scores the person's level of need across 12 categories.
• Section 3: Recommendation, where the team records its overall view on whether the person has a "primary health need" and should therefore qualify for CHC.

A few foundational points:

• The DST is mandated by the National Framework for NHS Continuing Healthcare, the official guidance that governs CHC across England and Wales.
• It must be completed by a multi-disciplinary team of at least two professionals from different healthcare or social care backgrounds.
• It is not the Checklist. The Checklist is a quick screening tool to decide whether you should be assessed in full. The DST is the full assessment itself. Confusing them is how families end up unprepared for the meeting that actually matters.
• The DST does not make the decision on its own. It produces a recommendation which is then signed off (or, in rare cases, overturned) by the local Integrated Care Board (ICB).

How does the DST work?

The DST works by combining two things: a structured scoring exercise across 12 care domains, and a professional judgement about the overall picture using four key characteristics. Both have to be done together.

Step 1: The MDT scores each of the 12 domains. For every domain, the team agrees on a level of need based on the evidence in front of them: care records, GP and specialist letters, family input, observations from the care home, and so on. The levels are: No needs (N), Low (L), Moderate (M), High (H), Severe (S), and Priority (P). Not every domain reaches the top of that scale. Only four (Behaviour, Breathing, Drug Therapies, and Altered States of Consciousness) can reach Priority. The others top out at Severe.

Step 2: The MDT applies the four key characteristics. Scoring alone does not determine eligibility. The team has to step back and ask whether, taken as a whole, the person's needs amount to a primary health need, judged against four characteristics: Nature (what kind of needs and what interventions they require), Intensity (how severe and continuous the care is), Complexity (how needs interact and how skilled the response must be), and Unpredictability (how likely the situation is to change suddenly).

Step 3: The MDT records a recommendation. The team writes a recommendation in plain language, supported by the domain scores and their judgment on the four characteristics. The recommendation is eligible or not eligible for CHC, with reasoning attached.

Step 4: The ICB makes the formal decision. The recommendation goes to the local Integrated Care Board, which formally accepts it (the normal outcome) or, occasionally, sends it back for further work. The written decision is then sent to the person and their representatives.

There is a useful rule of thumb on what the scores tend to mean. One Priority-level need is usually enough on its own to trigger eligibility. Two or more Severe-level needs is usually enough. A combination of Severe and High needs across several domains may also qualify.

But the scores never decide on their own. People do qualify with apparently modest scores when the picture is complex and unpredictable. People also fail with high scores when the needs are stable and routinely managed. The judgement matters as much as the maths.

Who tends to be approved after a DST?

A clear pattern emerges from cases that come out positively.

People with multiple severe needs across several domains. CHC rewards combinations. Someone with severe cognitive impairment, plus high physical needs, plus unpredictable behaviour, scores better than someone with one very intense single need.

People whose needs are genuinely unpredictable. Stable, well managed conditions, even serious ones, often fail to qualify because they do not require the rapid, skilled NHS response CHC is built for. Conditions that can change without warning score higher on the Unpredictability characteristic.

People with strong written evidence. The DST is heavily weighted towards documented evidence. Detailed care notes, GP letters, specialist reports, behaviour logs, medication charts, and incident records carry far more weight than verbal descriptions.

People whose families know the framework. Families who understand the 12 domains, the levels of need, and the four key characteristics, and who use that language during the meeting, do markedly better than families who simply describe symptoms. Free help from Beacon CHC, Age UK, and Citizens Advice can dramatically tilt the odds.

People with complex clinical interventions. Tracheostomies, PEG feeding, ventilator support, complex wound care, frequent seizures, and unstable diabetes all push the complexity and unpredictability up.

Where DSTs tend to result in a "not eligible" recommendation is when needs are framed primarily as personal care (washing, dressing, eating, mobility) without enough emphasis on the underlying clinical management, risk, and unpredictability that drive those needs. The DST is built to identify health needs, so the language matters enormously.

How does this apply to me?

These are the five questions families ask most often once they understand the basics.

1. What does DST stand for, and where does it come from?

DST stands for Decision Support Tool. It is a specific document published by the Department of Health and Social Care, used by the NHS in England (and a separate but very similar version in Wales) to decide eligibility for NHS Continuing Healthcare funding.

The DST was introduced as part of the National Framework for NHS Continuing Healthcare, the official guidance that governs how CHC decisions are made. The framework has been revised several times, most recently in 2018, with a further revision expected in 2026 following the Casey Commission. The DST itself has been broadly stable across those revisions, with the 12 domains, the six levels of need, and the four key characteristics remaining the central architecture.

A short note on names. You may hear the DST referred to as "the DST form," "the full assessment," "the MDT assessment," or simply "the meeting." All of these point to the same thing. If a professional uses one of these terms, they are talking about the same document and the same meeting.

2. Who attends a DST meeting?

A DST meeting must be run by a Multi-Disciplinary Team (MDT) of at least two professionals from different healthcare or social care disciplines. In practice, that almost always means:

• A nurse assessor, usually employed by the local ICB, leads the meeting.
• A social worker, who brings the social care perspective.

Other people may attend depending on the case, including a GP or other doctor, a specialist nurse (for example, a dementia or community matron), a physiotherapist or occupational therapist, the care home manager or a senior member of staff who knows the person well, and any other clinician involved in their care.

Crucially, you can attend too. You, the person being assessed, a family member, an advocate, or a representative (such as a solicitor or a Beacon CHC adviser) all have the right to attend and contribute. You can ask questions in real time, provide evidence, challenge proposed scores, and ask for things to be recorded in the notes. Families who attend do markedly better than those who rely on written submissions, because there are details about day-to-day care that simply do not make it into clinical records.

3. What are the 12 care domains in the DST?

The 12 domains the MDT scores during a DST are:

1. Behaviour: for example, aggression, agitation, lack of inhibition, or self-harming behaviour.
2. Cognition: memory, orientation, ability to make decisions and process information.
3. Psychological and Emotional Needs: anxiety, depression, distress, trauma.
4. Communication: ability to express needs and understand others.
5. Mobility: ability to move safely, risk of falls, transfers between bed and chair.
6. Nutrition (Food and Drink): ability to eat and drink, swallowing difficulties, risk of malnutrition.
7. Continence: bladder and bowel needs and the support required.
8. Skin: pressure ulcer risk, wound care, skin integrity.
9. Breathing: respiratory needs, including oxygen, tracheostomy, or non-invasive ventilation.
10. Drug Therapies and Medication, Symptom Control: complexity of medication regimen, pain management.
11. Altered States of Consciousness: seizures, episodes of unconsciousness.
12. Other Significant Needs: an open domain for anything significant that does not fit the other 11.

Only four of these domains (Behaviour, Breathing, Drug Therapies, and Altered States of Consciousness) can reach the Priority level. The others top out at Severe. This matters because a single Priority-level score is usually enough on its own to trigger eligibility, while elsewhere you typically need two Severes to reach the same threshold.

4. When should a DST be completed?

A DST should be completed when someone has passed the CHC Checklist (the screening tool) and a full assessment of eligibility is required.

The most common situations that trigger a DST are:

• A new request for CHC funding, often around hospital discharge, a move into a nursing home, or a significant change in health.
• An annual review of an existing CHC award, to confirm eligibility continues.
• A three-month review after CHC has been awarded, to check that needs have settled into the expected pattern.
• A reassessment when something significant has changed, such as a major deterioration or improvement.

A DST should not be completed in the middle of an acute hospital stay if the person's long-term needs are still settling. The 2022 framework revisions tightened this, encouraging assessments to take place once the picture of ongoing needs is clearer. If a DST is being rushed through while your relative is still recovering from a hospital admission, it is reasonable to push back.

The whole process from referral to formal decision is supposed to take 28 days. In practice it routinely takes longer, but if it overruns and the person is found eligible, the NHS must backdate funding.

5. How long does a DST meeting last, and how long is the decision valid for?

These are two slightly different questions, both worth answering.

A DST meeting usually takes around 2 to 4 hours, depending on the complexity of the case. If you have a particularly involved set of needs, it can run longer, and the MDT should not rush. If you feel the meeting is being hurried, say so and ask for the time to cover the domains properly. The meeting is your one main opportunity to put your case.

A DST decision, once made, is not permanent. It is reviewed at fixed points: a three-month review after the original decision, and then annual reviews thereafter. Outside those scheduled reviews, an assessment can be triggered earlier if the person's needs change significantly. So a "yes" today is not a guarantee forever, and a "no" today is not a permanent bar either. If your relative's situation changes, you can ask for a fresh assessment.

You should also expect the written DST document and decision letter within a few weeks of the meeting. Ask the chair of the MDT when you can expect them, and chase if they do not arrive on the timescale promised.

The takeaway

The Decision Support Tool is the single most important document in the NHS Continuing Healthcare process, and the meeting at which it is completed is the one place where the case is genuinely made or lost.

Families who walk in unprepared, who do not understand the 12 domains, do not know the levels of need, and have not thought about the four key characteristics, find themselves unable to challenge scores in real time. Families who do prepare often surprise themselves with how effectively they can contribute.

Three things genuinely tilt the odds in your favour. Bring detailed written evidence, organised so the MDT can see it without hunting through paperwork. Attend the meeting, with an advocate if you can, and speak up. Use the framework's own language: talk about the domains by name, refer to the four key characteristics directly, and frame your relative's needs as health needs with clinical management, not as social needs with personal care.

Our funding calculator can show you how a successful CHC outcome would affect the overall cost of care, alongside FNC, council funding, and other support. And keep an eye on the next post in this series, where we tackle the Multi-Disciplinary Team (MDT) itself.

This article is for general guidance only and reflects the way the Decision Support Tool is used in NHS Continuing Healthcare assessments in England and Wales as of 2026. The National Framework is under review, with a refresh expected later in the year, but the underlying structure of the DST (12 domains, six levels of need, four key characteristics) is stable. Scotland phased out CHC in 2015 and uses a different system. For tailored advice, contact your regional NHS England CHC team, Beacon CHC, Age UK, or Citizens Advice. You should never need to pay for help with a CHC assessment.

Sources

• NHS: NHS Continuing Healthcare
• GOV.UK: Care and support statutory guidance
• Age UK: Money and legal, paying for care

Frequently asked questions

What evidence should I bring to a DST meeting?

The more specific and well organised, the better. Useful evidence includes the current care plan, daily care notes from the last three to six months, recent GP records, consultant or specialist letters, medication charts, behaviour and incident logs (especially anything documenting falls, episodes of confusion, or distress), continence records, wound or pressure ulcer reports, and any therapy notes from physio, OT, or speech and language. If you are a family member, also prepare your own log of how needs present day to day, including frequency and unpredictability, because the MDT will not see that anywhere else. Bring printed copies if you can, organised by domain. The DST is heavily weighted towards documented evidence, and a clear pile of paperwork is far more persuasive than a verbal summary.

What if I disagree with a domain score during the DST meeting?

Say so at the time. The DST is meant to be a collaborative process and you have the right to challenge scores in real time, provide additional evidence, and ask for your disagreement to be recorded in the notes. If the MDT proposes a score that does not match the evidence, ask the assessor to talk through the descriptor for that domain at the level they have chosen, and explain how the evidence supports it. If they cannot justify it convincingly, push back. Even if the final score is not changed during the meeting, having your disagreement formally recorded gives you a much stronger foundation if you later need to appeal. Generic complaints rarely succeed at appeal; specific, evidenced disputes about particular domain scores frequently do.

Can a DST be completed without a face to face meeting?

In most cases the meeting still happens, but the format is now flexible. Since the pandemic, DST meetings are routinely held on Microsoft Teams or by phone rather than face to face, and many ICBs use digital DST systems where the form is filled in on screen during the meeting itself. A purely paper based DST without any meeting is not consistent with the National Framework, which requires a multi-disciplinary discussion. If the council or ICB tries to complete a DST without any meeting at all, push back and ask for one to be arranged. You can request a face to face format if you prefer it, and reasonable requests should normally be accommodated.

Does the DST cover mental health needs as well as physical ones?

Yes, very much so. Several of the 12 domains are explicitly about mental health and cognition: Behaviour (including aggression and disinhibition), Cognition (memory, decision-making, orientation), Psychological and Emotional Needs (anxiety, depression, distress), and Communication. Mental health needs are treated on the same footing as physical ones for CHC eligibility, and serious mental health conditions, severe dementia, or significant behavioural issues can all support a finding of primary health need. If the assessment seems to be ignoring mental health needs, or treating them as less important than physical care, that is a legitimate point to raise during the meeting and to record in the notes.

What happens if no agreement can be reached at the DST meeting?

The MDT is supposed to reach consensus on each domain and on the overall recommendation, but this is not always possible. If there is genuine disagreement between members of the MDT, that should be recorded openly in the DST itself, with both views set out and the chair explaining how the decision was reached. If there is disagreement between you and the MDT, your view should also be recorded. The recommendation still goes to the ICB, but a contested DST is more likely to be queried, and a clearly recorded disagreement gives you a much stronger basis for appeal. The worst outcome is a DST that records "agreement" when there was none, so make sure your dissent is on paper if you have one.