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Changes to the Decision Support Tool and checklist for NHS Continuing Healthcare 2018

Following the updated National Framework for NHS Continuing Healthcare in 2018, we analyse the changes to the Decision Support tool and checklist assessments.

The National Framework for continuing healthcare funding has been updated by the Department of Health and these changes come in to effect in October 2018.  The Compass CHC continues its series analysing these changes to the Framework by examining what changes have been made to the Decision support tool and checklist assessments.

What changes have been made to the checklist assessment as a result of the updates to the National Framework for NHS Continuing Healthcare funding 2018?

1. Decision support tool User Guidance

The Guidance at the beginning of the Decision Support Tool has changed in terms of its structure and the information it includes, however these changes do not present any significant procedural alterations. In most instances, information that used to be contained in the National Framework has been moved into the Decision Support Tool.

Here are some paragraphs of particular relevance and a brief overview of their content:

  • Paragraph 5. Relates to the individual having knowledge and giving consent to the assessment as well as the opportunity to participate. Also highlights that the individual should be given the opportunity to be represented by a carer, family, friend or advocate. This is of particular relevance where assessors and clinical commissioning groups may seek to exclude third parties in the absence of there being a Deputyship or lasting Power of Attorney for Health and Welfare.
  • Paragraphs 12 and 13.  Relate to the formation of a Multi-disciplinary team. Paragraph 13 in particular states “CCGs may use a number of approaches (e.g. face-to-face, video/tele conferencing etc.) to arranging these MDT assessments in order to ensure active participation of all members as far as possible.” This information was not previously covered in the Decision Support Tool, but was only in the National Framework.
  • Paragraph 37. States that a copy of the Decision Support Tool should be provided to the individual or their representative where there is the appropriate consent for information sharing (eg. consent from an individual with capacity, consent for a Lasting Power of Attorney for health and welfare or court appointed deputy, or best interests decision). Where the individual has a Lasting Power of Attorney for property and finances, the Decision Support Tool should also be shared with them.

As a result of the changes to the National Framework a number of often relevant paragraphs have not changed in meaning, but have changed in how they are worded and their reference within the Decision Support Tool User Guidance:

  • (Equivalent to paragraph 1 in old Decision Support Tool User Guidance) → 6. Eligibility for Continuing Healthcare is based on whether someone has a primary health need.
  • (Equivalent to paragraph 13 in old Decision Support Tool) →14., 15., and 16. Relate directly to the role of the individual and representative in the eligibility process. It gives clearer guidance to the Clinical Commissioning Group’s about making transparent and clearly documented decisions that involve the individual and family. It appears to be more detailed than previous references.
  • (Equivalent to paragraph 22 in old Decision Support Tool User Guidance) → 21. Relates to how disagreement between the MDT members in relation to a level of need should be dealt with = higher level of need under consideration should be chosen.
  • (Equivalent to paragraph 26 in old Decision Support Tool User Guidance) →24. Single condition can result in separate needs in a number of domains.
  • (Equivalent to paragraph 29 in old Decision Support Tool User Guidance) →27. and 29. Relate to well-managed needs still being needs. Paragraph 28 provides more information than that included in the old DST.
  • (Equivalent to paragraph 32 in old Decision Support Tool User Guidance) →30., 31., 32., and 33. Deal with identifying a primary health need and where a clear recommendation for funding would be expected. There are no changes to that – 1 x Priority or 2 X Severe is a clear recommendation.Where there is either a Severe level of need combined with needs in a number of other domains OR a number of domains with high and/or moderate needs, then the 4 key characteristics (Nature, Complexity, Intensity & Unpredictability) must be considered. This consideration must be used to inform the decision as to whether or not the individual has a primary health need and therefore whether or not they are eligible for NHS Continuing Healthcare.

Same domains, different order of priority

The Decision Support Tool contains the same 12 domains, but they are ordered differently. See below for comparison:


Old Decision Support Tool New Decision Support Tool
1.Behaviour 1. Breathing
2. Cognition 2. Nutrition
3. Psychological and emotional 3. Continence
4. Communication 4. Skin
5. Mobility 5. Mobility
6. Nutrition 6. Communication
7. Continence 7. Psychological and Emotional
8. Skin 8. Cognition
9. Breathing 9. Behaviour
10. Drug Therapies and Medication 10. Drug Therapies and Medication
11. Altered States Consciousness 11. Altered State Consciousness
12. Other significant needs 12. Other significant needs


Changes to the domain descriptors


  • The Low and Moderate now refer to “shortness of breath or a condition” – this means that someone could have asthma (being the condition) that requires an inhaler or nebuliser but no active instances of shortness of breath. In reality, this will probably not alter the way this descriptor is applied as generally a Low level of need is appropriate, at a minimum, where someone has a breathing condition such as COPD or asthma.
  • A Moderate now reads: “Episodes of breathlessness that do not consistently respond to management and limit some daily living activities.” This means the evidence required for a moderate level of need will require several instances or a pattern of the breathlessness not responding, rather than just isolated instances.

Nutrition: no changes


  • High: irrigation is included as an example of a timely and skilled intervention.

Skin: no changes

Mobility: no changes

Communication: no changes

Psychological and emotional needs

  • The Low and Moderate domains now refer to more than just reassurances. They include prompts, distraction and/or reassurance. Practically, this means it is necessary to look beyond simple reassurances to other techniques and determine if they are effective.

Cognition: no changes


  • The listed behaviours have not changed, but it now notes that resistance to necessary care and treatment does not include “situations where an individual makes a capacitated choice not to accept a particular form of care or treatment offered.” This will likely mean that in arguing that someone is resistant to care, it will be necessary to highlight that they do not have the capacity to make an informed decision about that care.
  • High descriptor: now states “Challenging’ behaviour of type and/or frequency that poses a predictable risk to self, others or property. The risk assessment indicates that planned interventions are effective in minimising but not always eliminating risks. Compliance is variable but usually responsive to planned interventions.” Previously it was applicable to state that frequency was not relevant to a High level of need for behaviour. As a result of this change and the National Framework update it now is. Accordingly it is shall be necessary to highlight the frequency of a behaviour to establish the risk.

Drug Therapies and Medication

  • Moderate: the reference to non-concordance has been removed. This means rather than arguing a Moderate where an individual lacks capacity but are compliant, the appropriate level of need is now Low.

Altered states of consciousness: no changes.

So, what’s missing? What changes haven’t been made to the National Framework that perhaps should have been?

  • Well-managed needs: while there are several references to a well-managed need remaining a need, it still lacks some clarity.
  • No further clarification has been provided about the primary health needs test.
  • The domain descriptors that are applied quite differently throughout the country despite appearing quite straightforward have not been clarified, meaning the current level of subjectivity can continue.

If you have any questions of queries regarding any aspect of continuing healthcare funding you should not hesitate to contact and expert at the Compass CHC team today.  Our phone number is 0121 2278940

Author: Tim Davies LLB

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