Introduction to NHS Continuing Healthcare and the Decision Support Tool
The journey through senior care can often lead to questions about funding and eligibility for support. In the UK, one of the most significant systems is NHS Continuing Healthcare (CHC), a package of care arranged and funded solely by the National Health Service (NHS) for adults with significant long-term health needs. The term 'DH decision support tool' refers to the Decision Support Tool (DST) originally developed under the Department of Health (DH), which is central to this process. A common question arises: what are the 12 care domains in the DH decision support tool?
Interestingly, while the question refers to 12 domains, the official framework outlines 11 specific care domains. The '12th domain' is often considered the final, crucial section for noting any other significant needs that don't fit neatly into the other categories. This ensures every aspect of a person's condition is considered. This tool provides a standardized framework for multidisciplinary teams to assess the nature, complexity, intensity, and unpredictability of an individual's health needs to determine if they have a 'primary health need'.
Understanding these domains is vital for families and individuals navigating the CHC assessment process, as they form the basis of the eligibility decision.
The 11 Core Care Domains Explained
Each domain is assessed and assigned a level of need, ranging from 'No Needs' to 'Low', 'Moderate', 'High', 'Severe', or 'Priority'. Here is a detailed breakdown of each of the 11 core domains:
1. Behaviour
This domain considers any challenging behaviour that could pose a risk to the individual, others, or property. This includes aggression (verbal or physical), severe anxiety, wandering, or resistance to care. Assessors look at the frequency, severity, and the level of intervention required to manage the behaviour.
2. Cognition
Cognition focuses on a person's mental processes, such as memory, decision-making, and understanding. Assessors evaluate the extent of cognitive impairment, its impact on daily life, and the person's ability to make their needs known or recognize risks to their own safety.
3. Psychological and Emotional Needs
This domain assesses mood disturbances, hallucinations, depression, anxiety, or distress resulting from a health condition. It considers the impact on the individual's mental wellbeing and whether specialist intervention, such as from a mental health team, is required.
4. Communication
Communication evaluates the ability to express needs and understand others. This covers any difficulties arising from sensory loss, stroke, or other neurological conditions. The assessment considers whether the person needs specialist support or equipment to communicate effectively.
5. Mobility
This domain looks at a person's ability to move and transfer independently. It considers risks of falls, the need for assistance from carers or equipment, and whether the individual is bed-bound. The level of need is determined by how much help is required to move safely.
6. Nutrition - Food and Drink
Nutrition assesses the ability to eat and drink, including any risks of choking or aspiration. It considers whether a person requires enteral feeding (e.g., a PEG tube), specialist dietary textures, or significant prompting and assistance from carers to maintain adequate nutrition and hydration.
7. Continence
This domain covers the management of bladder and bowel function. It assesses the level of incontinence and the complexity of management required, such as the need for catheter care, stoma management, or a rigorous toileting schedule to maintain skin integrity.
8. Skin (including tissue viability)
This domain focuses on the health of the skin, including the presence of pressure ulcers (bed sores), wounds, or other skin conditions. The assessment considers the severity of any wounds, the risk of breakdown, and the complexity of the treatment required.
9. Breathing
Breathing assesses any respiratory issues, such as shortness of breath or the need for oxygen therapy or mechanical ventilation. It considers the impact on the person's daily life and the level of medical supervision required to manage the condition.
10. Drug Therapies and Medication: Symptom Control
This domain looks at the complexity of managing an individual's medications. It's not just about the number of drugs but the challenges in administering them and managing side effects. This is particularly relevant for conditions requiring complex pain management or symptom control, such as in palliative care.
11. Altered States of Consciousness (ASC)
This domain is for individuals who have a reduced level of consciousness, such as being in a coma or a vegetative state. It assesses their responsiveness and the level of skilled care required to manage their condition, which is almost always considered a high level of need.
The '12th Domain': Other Significant Care Needs
After the 11 domains are completed, there is a space on the DST to document any other needs that are significant but have not been fully captured. This ensures that the assessment is truly holistic and person-centered, allowing the multidisciplinary team to consider unique or rare conditions.
How Domains Translate to Eligibility
Eligibility for NHS CHC is determined by the overall picture of needs. It is not a simple scoring system. An individual may be eligible if they have:
- A 'Priority' level of need in any of the four domains that carry this level.
- A 'Severe' level of need in at least two domains.
- A 'Severe' level of need in one domain, plus needs in a number of other domains.
The final decision rests on whether the person's primary need is for healthcare rather than social care.
Care Domain Needs Level Comparison
To illustrate how needs are graded, here is a simplified comparison table for two domains:
| Level of Need | Mobility | Continence |
|---|---|---|
| Low | Can move independently but may need minor assistance or supervision. | Occasional incontinence, can be self-managed or requires minor prompting. |
| Moderate | Needs assistance from one person to move or transfer. At risk of falls. | Regular incontinence requiring management with pads. Needs help with personal care. |
| High | Cannot bear weight or needs assistance from two people to transfer. High risk of falls. | Double incontinence (bowel and bladder). Requires regular intervention to manage and maintain skin integrity. |
| Severe | Completely immobile and unable to assist with any transfers. | Bowel incontinence requiring active and ongoing management. Stoma care or other complex needs. |
Conclusion
The Decision Support Tool and its care domains are a cornerstone of the NHS Continuing Healthcare system. They provide a structured method to ensure that individuals with complex, intense, or unpredictable health needs receive the funding and support they are entitled to. By understanding what the 12 care domains in the DH decision support tool are—or more accurately, the 11 core domains plus the provision for other needs—individuals and their families can better prepare for the assessment process and advocate for their needs effectively. For more information, refer to the official NHS guidance on Continuing Healthcare.
