The 12 DST care domains explained

The Decision Support Tool (DST) is the form a team uses to record a person's needs when deciding whether the NHS should fund their care under NHS Continuing Healthcare (CHC) in England. It has 12 care domains, from breathing to behaviour, and each domain has levels that run from no needs up to priority. It is not a points score: the summary page counts how many domains sit at each level, but levels are never turned into points or added into a total. This guide explains what each of the Decision Support Tool domains covers, where each one stops and which patterns usually lead to a recommendation of eligibility.

This is the current tool, headed July 2022 and last updated on gov.uk on 27 October 2022, not the older versions some guides still quote. The detail matters: in 2025/26 NHS England recorded 50,402 standard CHC assessments completed and 8,776 people found eligible, which is 17.4%.

What the Decision Support Tool is, and what it is not

The DST is not an assessment of needs in itself. It follows a comprehensive assessment by a multidisciplinary team (MDT): at least two professionals from different healthcare professions, or one healthcare professional and one person responsible for Care Act assessments. The team uses that evidence to choose, for each domain, the level that most closely matches the person's needs, then makes a recommendation. The ICB decides. It normally responds to the recommendation within 48 hours and is expected to depart from the MDT's view only in exceptional circumstances.

The form leaves room for the person's voice. Page 2 records their own view of their care needs and page 30 records whether they agree with the levels chosen and why not.

The CHC Checklist comes first, then the full assessment, in which the team completes the DST at the MDT meeting. In most cases the whole process should not exceed 28 calendar days from the positive Checklist. If the answer is no, see local resolution and independent review. Two related routes sit outside it: Fast Track replaces the Checklist and DST for a rapidly deteriorating condition, and NHS-funded nursing care is a separate flat-rate payment to a care home with nursing for people who are not eligible for CHC.

What is a primary health need?

Primary health need is the legal test for CHC. In plain English: is the main or majority part of the care the person needs focused on addressing or preventing health needs? It is about the level and type of day-to-day care actually needed, taken as a whole, not the diagnosis or the reason the care began.

Regulation 21(7) of the Standing Rules Regulations 2012 asks whether the nursing or other health services needed are more than incidental or ancillary to the accommodation a council would have to provide, or of a nature beyond what a council could be expected to provide. If they are, taken together, the ICB must find a primary health need and the person is eligible.

A decision should not rest on the diagnosis, the setting of care, who provides the care, whether a need is well managed or the cost.

How the DST levels of need work: from no needs to priority

Each domain is a ladder of descriptions from the lowest level of need to the highest: no needs (N), low (L), moderate (M), high (H), severe (S) and priority (P). The team picks the closest description and cannot record needs between two levels. Not every one of the CHC domains has every rung:

Four domains reach priority: breathing, behaviour, drug therapies and altered states of consciousness. Altered states of consciousness skips severe. The twelfth domain runs from low to severe and has no “no needs” row, because it is there for needs that fit nowhere else.

The 12 DST care domains, one by one

These summaries paraphrase the July 2022 tool, not its exact wording, so read the form before a meeting. Each domain asks the team to describe the actual needs and the evidence.

1. Breathing (reaches priority)

Records the needs that arise from breathing difficulty, not the diagnosis behind it. Moderate includes low-level oxygen or a CPAP mask at night. High covers breathing independently through a tracheostomy that the person or their carers manage, or breathlessness not responding to treatment that limits all daily activities. Severe covers suction through a tracheostomy, severe difficulty at rest despite maximum treatment or a non-invasive ventilator. Priority means being unable to breathe independently and needing invasive mechanical ventilation.

2. Nutrition: food and drink (reaches severe)

Covers the risk of malnutrition, dehydration and aspiration, which is food or drink entering the airway. Low includes supervision at meals, a special diet or supplementary feeding. High includes swallowing difficulty (dysphagia) that needs skilled input to protect the airway, or nutritional status at risk with significant unintended weight loss. Severe covers all nutrition by artificial means with skilled monitoring over 24 hours, such as intravenous fluids.

3. Continence (stops at high)

Where problems are identified, a full continence assessment should exist. Routine care sits at low, and moderate adds monitoring for risks such as catheters or recurrent infections. High means problematic care needing timely skilled intervention beyond routine, such as frequent bladder washouts or manual evacuation. Continence linked to behaviour is counted under behaviour. Because the domain ends at high, it counts only as part of a wider range of needs.

4. Skin and tissue viability (reaches severe)

Covers pressure damage, wounds and skin conditions. Evidence should come from a wound assessment chart or tissue viability assessment, so ask for one. Moderate includes preventative care several times a day. High covers partial-thickness wounds not responding to treatment, deeper wounds that are responding or a specialist dressing regime. Severe covers deeper wounds not responding, wounds reaching bone, tendon or joint capsule or multiple wounds not responding.

5. Mobility (reaches severe)

Covers impaired mobility; wandering belongs under behaviour. The form expects up-to-date moving and handling and falls risk assessments, and warns that “high” in a falls risk tool does not automatically mean a high level here. High covers being unable to bear weight and unable to help with transfers, needing careful positioning, a high falls risk shown by history and assessment or involuntary spasms or contractures that put people at risk. Severe means complete immobility or a condition where moving carries a high risk of serious harm.

6. Communication (stops at high)

Covers difficulty expressing needs or understanding others, including whether hearing aids, pictures, sign language, Braille or an interpreter are needed. Moderate means needs that are hard to interpret, where carers can anticipate them from non-verbal signs. High means being unable to communicate needs reliably at any time or in any way, even with all practicable help, so others must anticipate most needs.

7. Psychological and emotional needs (stops at high)

Records how mood disturbance, hallucinations, anxiety and distress affect health and well-being. Where cognitive impairment stops the person expressing these needs, the team makes a professional judgement from the overall evidence. Moderate covers symptoms that do not readily respond to reassurance or withdrawal from most attempts to engage the person. High covers symptoms with a severe impact or withdrawal from any attempt to engage them in care or daily activities.

8. Cognition (reaches severe)

Applies to, but is not limited to, learning disability and acquired or degenerative conditions such as dementia. The key consideration is the degree of risk to the person. High covers frequent short-term memory problems and difficulty making decisions about key aspects of life even with help, putting the person at high risk of harm or neglect. Severe covers marked memory loss or severe disorientation, with no ability to judge basic risks and a dependence on others to prevent harm.

9. Behaviour (reaches priority)

The form's examples go well beyond aggression: severe disinhibition, intractable noisiness or restlessness, resistance to necessary care (but not a capacitated choice to refuse it), severe swings in mental state, inappropriate interference with others and an identified high risk of suicide. The team describes when the behaviour occurs, how often, for how long and with what impact. High means a predictable risk to the person, others or property that planned interventions reduce but do not always remove. Severe means a significant risk needing a prompt skilled response that may fall outside the plan. Priority means an immediate and serious risk that needs an immediate skilled response at all times.

10. Drug therapies and medication: symptom control (reaches priority)

The level reflects the knowledge and skill needed to manage the clinical need, not the number of medicines. A care home rule that every medicine is given by a registered nurse does not count in itself. High covers medicines that must be given and monitored by a trained person because of fluctuation or side-effect risks, where monitoring keeps things usually manageable. Severe covers the same monitoring where the condition stays problematic to manage, or severe recurrent pain not responding to treatment. Priority means daily registered nurse monitoring for a rapidly changing or deteriorating condition, or unremitting and overwhelming pain despite all efforts.

11. Altered states of consciousness (reaches priority, no severe level)

Can follow conditions such as transient ischaemic attacks, epilepsy or fainting (vasovagal syncope); general drowsiness does not normally count. Moderate covers occasional episodes, monthly or less often, needing a carer's supervision. High covers frequent episodes needing supervision or occasional episodes needing skilled intervention. There is no severe level. Priority means coma or episodes on most days that do not respond to preventative treatment and carry a severe risk of harm.

12. Other significant care needs (low to severe)

For needs that fit nowhere else. The team describes the need and the evidence and weights it consistently with the other domains. The form is explicit that this domain must not be used to tilt the overall decision. If a real need seems to be missing, ask where it has been recorded.

Priority and severe needs: which patterns usually point to CHC

The DST guidance tells the MDT what to expect. If the team concludes there is no primary health need, it must record clear reasons.

These are guides, not formulas. The National Framework says the thresholds are not to be viewed prescriptively and that professional judgement applies in every case. Levels cannot be traded either: two moderate needs do not equal one high. So do not count levels and predict an answer.

The four characteristics: nature, intensity, complexity and unpredictability

The MDT's recommendation must consider all four. Any one of them, alone or in combination, may show a primary health need. Practice Guidance note 3 suggests useful questions:

• Nature: what type of needs and interventions are involved, what skill is needed to meet them and what happens if they are not met in time.
• Intensity: how severe the need is, how often and for how long care is needed, how many carers are needed and whether the care spans several domains.
• Complexity: how the needs interact and how much skill and knowledge managing them takes.
• Unpredictability: how far needs fluctuate, whether anyone can anticipate them and how often support changes at short notice.

Five rules that decide how the domains are used

Well-managed needs are still needs

A need does not shrink because good staff manage it well. Only where management has permanently reduced or removed the need does it bear on eligibility. Equally, well-controlled conditions should not be recorded as if medication or routine care were absent. If a provider does not record how often needs arise, the team can ask it to keep a detailed diary.

One condition, several domains

Practice Guidance note 30 calls the “no double-scoring rule” a common misconception. Cognitive impairment belongs in cognition and any resulting challenging behaviour in behaviour.

A severe diagnosis is not a severe level

Severe learning disability does not automatically mean severe cognition. The team picks the description that fits the actual needs.

When practitioners cannot agree, the higher level is chosen

The team records the evidence and the differences of opinion. Practice Guidance note 32 says this must rest on clear reasons and must not be used to steer people towards a decision that is not justified.

When the family disagrees, it is recorded

The higher-level rule is for disagreements between practitioners. If the person or their representative disagrees with a level, note 33 says their concerns should be fully considered against the evidence and any remaining disagreement recorded on the DST (page 30).

A worked example in a family's words

Imagine a daughter describing her mother's day to the assessor:

The family described needs, not just a diagnosis, and gave numbers where they could. One condition produced needs in at least five domains, each recorded in its own right. The levels still depend on the evidence, and the team chooses them. Describe what really happens on a typical day and on a bad day: the team weighs your account alongside care records, and it helps when the two line up.

What the figures show

The share of standard assessments ending in eligibility has fallen from 21.1% in 2023/24 to 19.5% in 2024/25 and 17.4% in 2025/26. In local resolution, 398 of 2,666 completed requests to review an eligibility decision ended in eligibility in 2025/26, about 15%. These national averages say nothing about any one case, but they show that a first decision is not always the last word.

Before the MDT meeting

• Write the care down by domain: what is given, how often, for how long, by whom and what happens if it is not. Use counts, not “a lot”. Our free 7-day care diary is set out by domain.
• Gather the evidence: wound charts, falls history, swallowing assessments, medication records, night logs and the home's daily notes.
• Ask for the person's view (page 2) and any disagreement (page 30) to be recorded.
• Check consent: sharing a person's information needs their consent or proper authority, such as a lasting power of attorney for health and welfare, a deputy or a best-interests decision.
• Ask for a copy of the completed DST with the ICB's decision and reasons.

Common questions