What counts as evidence

What the official guidance says

This part sets out what the National Framework and the Decision Support Tool (DST) say. It is written so that you can share it with the assessment team. Every point comes from the official guidance, listed on our guidance and sources page.

Part 1: Principles the assessors must apply

The test is the person's needs, not their diagnosis. A primary health need depends on the level and type of day-to-day care needed, not on why it is needed. A diagnosis alone does not decide eligibility.

The four characteristics. The assessment considers the nature, intensity, complexity and unpredictability of the person's needs. Each of these may show a primary health need on its own or in combination.

Needs are considered together. The assessment should look at all needs in the round, including how they affect each other.

Well-managed needs are still needs. A need should not be discounted because good care keeps it under control.

Where care is given does not decide eligibility. CHC can be provided in any setting, including the person's own home.

Money is not part of the decision.

Reasons that may not be used. The reasons for a decision should not rest on the diagnosis, the setting, the provider's ability to manage care, whether NHS staff or specialist staff are involved, the fact that a need is well managed, other NHS-funded care, or any other input-related reason.

The DST supports judgement. It is not a calculator. The tool cannot decide eligibility on its own, and its threshold guidance is not to be applied mechanically.

Likely deterioration counts. Where deterioration can reasonably be expected soon, it should be taken into account.

Evidence should be proportionate. Evidence is about an accurate picture, not a legal standard of proof, and more is not always better.

Part 2: Your right to contribute

• The person and their representative should have a central role in the assessment.
• The person's own view of their needs, and any evidence they provide, should be given appropriate weight alongside professional views.
• Oral evidence from carers should be taken into account and recorded on the DST where it is relevant.
• The DST has a section for the person or representative to record their views, including whether they agree with the domain levels, and the reasons for any disagreement.
• The MDT meeting should be arranged so the person can give their views on the domain levels before they leave.
• Where needs vary, a diary of needs and interventions may be requested, including good days and bad days.

Part 3: The 12 DST domains

The DST records needs in 12 care domains, each with levels from lowest to highest need. The domain names below are as printed in the DST. The notes on evidence come from the DST's own guidance for each domain, and from the Framework's list of evidence sources.

The DST records needs, not conditions.

1. Breathing

Record the needs that come from a breathing condition, such as shortness of breath and the help needed with it.

Evidence that helps: specialist nursing assessments (for example, a respiratory nurse) and care records that show how often help is needed.

2. Nutrition – Food and Drink

Where there is a risk of malnutrition, dehydration or aspiration, there should be an assessment and a management plan. The trend in weight matters, not only a single weight.

Evidence that helps: weight records over time, food and fluid charts, and any Speech and Language Therapy (SALT) swallowing assessment.

3. Continence

Where there are continence problems, a full continence assessment should exist or be carried out.

Evidence that helps: the continence assessment, and care records showing how often help is needed day and night. The DST also asks for any underlying causes and risks to be looked at.

4. Skin (including tissue viability)

Evidence of wounds should come from a wound chart or tissue viability assessment.

Evidence that helps: wound charts, repositioning charts and risk scores such as the Waterlow score.

5. Mobility

Where there are mobility problems, a moving and handling assessment and a falls risk assessment should exist. A "high" score on a falls risk tool does not by itself mean a high level in this domain.

Evidence that helps: the moving and handling plan, physiotherapy or occupational therapy assessments, and records of falls.

6. Communication

This domain is about difficulty expressing needs and understanding.

Evidence that helps: records of how staff find out what the person needs (for example picture cards or reading body language), and any speech and language assessment.

7. Psychological and Emotional Needs

This domain records psychological and emotional needs and their effect on health and well-being, whatever the underlying condition. Where the person cannot express these needs, this should be recorded and a professional judgement made.

Evidence that helps: care notes on mood, distress and anxiety, and how staff respond.

8. Cognition

A key consideration is the degree of risk to the person. The Mental Capacity Act principles apply where capacity is in question.

Evidence that helps: memory or dementia assessments, and records of disorientation and the supervision needed.

9. Behaviour

Challenging behaviour here includes, among other things, aggression, severe restlessness and resistance to necessary care. Where behaviour is well managed, the need still counts.

Evidence that helps: behaviour charts, incident records and a behavioural assessment. A summary of incidents may help more than every original form.

10. Drug Therapies and Medication: Symptom Control

The person's experience of their symptoms, and how intense they are, is an important factor. What counts is the skill needed to manage the need.

Evidence that helps: medication records, pain assessments, and the person's own account of their symptoms.

11. Altered States of Consciousness (ASC)

This covers episodes such as seizures or blackouts. General drowsiness would not normally count.

Evidence that helps: seizure or episode charts showing how often episodes happen, how long they last and what help is needed.

12. Other significant care needs to be taken into consideration

This domain is for needs that do not fit the other 11. The assessors must record the extent and type of these needs.

Evidence that helps: records of any care that is needed regularly but is not covered elsewhere.

This guide summarises official guidance. It is not legal or clinical advice, and it does not say whether anyone is eligible.

Contains public sector information licensed under the Open Government Licence v3.0.