Social care staff carrying out tasks previously undertaken by NHS, without extra funding, say directors

Trend means more people are being charged for care that was previously free and councils are facing additional pressures, with waiting lists rising, says ADASS

Graph showing increasing workload
Image: Hepta/ AdobeStock

Adult social care staff are carrying out tasks previously undertaken by the NHS in most areas, without compensatory funding, council heads have reported.

Seventy per cent of directors said this was the case, in response to an Association of Directors of Adult Social Services (ADASS) survey carried out in September and October of this year.

ADASS described the finding as “startling”.

‘People being charged for previously free care’

“Not only does this add to councils’ financial pressures, it reduces the time that frontline social care staff have to meet people’s essential social care needs and means that some people are being charged for care that would have previously been free at the point of delivery because it was provided by the NHS,” the association said, in its report on the survey.

The pressures on councils were laid bare in other survey results, with directors reporting rising waiting lists for assessments and reviews since the spring and predicting that they would overspend their budgets by 3.5% in 2023-24, despite significant increases in funding this year.

ADASS did not ask directors for details about specific NHS tasks that had been passed on to councils.

Drop in eligibility for continuing healthcare

But the finding comes amid a drop in the rate of people found to be eligible for NHS continuing healthcare (CHC), under which the health service fully funds social care for people whose need for it arises primarily from a health condition.

While a quarter of those assessed for CHC through the standard route were found to be eligible in January to March 2021, this had dropped to a fifth by July to September of this year, according to NHS England data.

There had also been a fall, over the same period, in the proportion of people per quarter found to be eligible following the resolution of disputes between the NHS and councils, from 25% to 18%.

Eligibility for CHC

People can become eligible for CHC in one of two ways:

  1. Through the standard route, following assessment by a multidisciplinary team (MDT), using the decision support tool (DST) to determine eligibility. People are often referred after being screened for potential eligibility using the so-called checklist tool. Between 12,000 and 13,000 are assessed in this way each quarter with 20% to 25% found eligible. As of September 2023, just over 33,000 of this group were receiving CHC.
  2. Through the fast-track procedure, with the assessment carried out by an appropriate clinician (a nurse or doctor), using the fast-track pathway tool. The latter may only be used where the person has a rapidly deteriorating condition and may be nearing the end of life. Between 22,000 and 25,000 are fast-tracked each quarter, with 100% eligibility. As of September 2023, just over 18,000 people were receiving fast-track CHC though the figures exclude data from one integrated care board (ICB).

ICBs are responsible for determining eligibility for CHC. Regulations require them to consult the relevant local authority before making a decision about a person’s eligibility and to co-operate with the council about arranging for its staff, such as a social worker, to participate in the MDT.

The national framework for CHC states ICBs may only depart from the MDT’s recommendations in “exceptional circumstances”. However, there is no requirement for social care staff to participate in an MDT, which may consist of two health professionals from different disciplines.

Each ICB must have a process for resolving disputes with councils about CHC, involving independent arbitration as a last resort.

There are also concerns that councils are taking on responsibilities that should fall to the NHS, because of the drive to discharge people from hospital as quickly as possible, which means people are leaving wards with greater needs than previously.

Hospital discharge ‘a big area of risk’

In its last survey, conducted in the spring, ADASS found that 76% of directors had reported that the average size of care packages for people leaving hospital had increased in the preceding 12 months.

Delivering a legal learning seminar at last month’s Community Care Live, independent specialist CHC consultant Morag Duff said: “Levels of acuity at hospital discharge are getting higher but there’s no corresponding transfer of NHS funding for these people.

“That’s a big area of financial risk for these local authorities as well as the larger risk of local authorities unthinkingly picking up people with health needs.”

Legal limit on councils’ meeting health needs

As set out in the CHC national framework, a health need is “one related to the treatment, control, management or prevention of a disease, illness, injury or disability, and the care or aftercare of a person with these needs”.

Understanding the health-social care boundary

Community Care Inform Adults users can improve their understanding of continuing health and the legal boundary between health and social care by reading Morag Duff’s guides to the CHC legal framework and to applying the primary health needs test. Both were updated in April 2023.

Duff pointed out that, under section 22 of the Care Act 2014, councils may only meet health needs where doing so was “incidental or ancillary” to meeting a social care need and the relevant service was of a nature that a local authority could be expected to provide.

In relation to hospital discharge, she said: “There are a lot of local authorities paying for recovery or rehabilitation services. Then it’s not about reablement, but things that are the NHS’s responsibility, not local authority responsibility.”

Lack of intermediate care

Directors identified a lack of NHS provision, both at the point of discharge and to prevent admissions, in response to the ADASS autumn survey.

Nearly two-thirds of directors (63%) did not feel that ‘step up’ intermediate care, which supports admissions avoidance, was widely available. Though three-quarters reported that ‘step down’ intermediate care was widely available at discharge, the association said it was concerning that about a quarter did not.

On the back of the results, ADASS called for investment in prevention, crisis resolution and recovery services, including intermediate care, to help people stay as independent and health as possible for as long as possible.

ADASS autumn survey 2023: key findings

  • Councils are projecting an overspend of 3.5% of their net adult social care budgets in 2023-24, equivalent to £515m.
  • Just under a third of directors (29%) say they have been asked to find in-year savings from their 2023-24 budgets worth £83.7m in total. This is on top of £806m in savings made in setting budgets.
  • Directors are expecting to deliver savings of £964m in 2024-25, 5% of their budgets.
  • An estimated 249,589 were waiting for an assessment as of August 2023, up 11% on the 224,978 recorded for March this year. Of these, an estimated 84,788 had been waiting at least six months, up 3% on the March figure (82,087).
  • 200,674 were found to have been waiting more than 12 months for an annual review, up 7% on March 2023 (187,112).

NHS leaders’ concern about service shift

The NHS Confederation, which represents health leaders, said it was “concerning that social care directors are reporting that their staff are picking up more and more work that the NHS would once have done”

Rory Deighton, director of the confederation’s acute network, added: “But with pressures on the NHS and levels of resourcing as they are, this is perhaps somewhat unsurprising and health leaders would agree with social care directors that more availability of NHS led community based intermediate care would be beneficial all-round.”

He added: “A preventative approach in health and social care can help support people to live as healthily as possible, both mentally and physically and as a result reduce demand on the NHS. But as social care directors report, at present there is only limited availability of preventative services, and the government must do more to help both social care and the NHS.”

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17 Responses to Social care staff carrying out tasks previously undertaken by NHS, without extra funding, say directors

  1. Anna B November 16, 2023 at 9:24 pm #

    Glad to see this raised. The ICB’s / CHC teams I have worked with across a few local authorities have all been very combative, unprofessional, disinterested in the CHC policy and willing to go to significant lengths to find ‘not eligible’. I have had professionals from ICB tell me a person cannot have capacity if they have cognitive needs. I have spent several days solid on CHC work, and then the family have waited 3.5 months for a response, which deemed not eligible because person ‘was not optimised.’ The DST process has become very gruelling for service users and I dread putting people through it after a positive checklist.
    Fast Track is even worse, with health professionals refusing to complete checklists and if they do, deeming not eligible 3 days before the person passes away. If I had a pound for each time a person passed away before someone did the fasttrack form…..I would be able to pay for the care they needed at the end of their life!! Social care getting contacted and asked to provide urgent 24 hour care because someone is end of life is normal now in my team.

    • Jaded November 17, 2023 at 8:22 pm #

      There’s not much more to add to Anna B’s excellent post. Social care seems to have taken so many backward steps and backseats after Covid – in every aspect – to the point that it is almost expected to be obstructed or fobbed off, particularly with CHC and fast tracking. It’s a disgrace though hardly surprising given the state of the government, just look at the Covid inquiry – let the old and the vulnerable perish, it’s just nature’s way eh Boris?!

    • Tina N November 18, 2023 at 8:55 am #

      We are ready to help in the community to prevent admissions but we are not receiving any referrals. We have trained staff who are barely working 6 hours a day due to lack of packages. I do not understand where the crisis is.

      • Alec Fraher November 18, 2023 at 6:20 pm #

        the Crisis was about 40 years ago when Thatcherism wrecked local government and signalled the slow assault on social services and social work ~ this is now the CHAOS of aftermath; long run feedbacks are just showing up.

        *see Gerrard Wilstow, LSE on the real drivers for ALL policy in health and social services since the 1970’s*

        • Pat November 21, 2023 at 7:41 am #

          @Alec. Spot on. And now we’re in the crisis, created by the govt.

      • Angela Gifford November 20, 2023 at 1:21 pm #

        Hi Tina,

        As a care provider of many years I have recently written to ICB’s and to Adult Social Work teams. There is no acknowledgement of the letters, just zilch. I know in talking to other providers they are experiencing the same thing. They have availability which is not being taken up. Very sad. Angela

  2. Alec Fraher November 18, 2023 at 11:13 am #

    the adage ‘services by one public authority are tobe treated as if the services of the other public authority’ still applies

    these are the words of what was called the s25 agreements, which will now be renumbered but is the basis for how agreements are still made.

    there’s now a schizotopia of virtually-assistive-services as the consequence of buying into the now computationally organised managerialism of the noughties; it’s gone horribly wrong ~ and ‘we’ knew it would in 2007.

    there’s clearly no basis for s25 agreements (or what ever the renumbered clause is) and it’s a fundamental breach of the source legislation.

    The Only Mistake, Council’s make is to stop being Council’s ~ the delegated powers afforded the Executive and Senior Officers, who make these agreements, hoping operational staff will navigate them without too much fall-out and death is a radical error in judgement too ~ welcome to schizotopia you’re call is impossible to us … this has though taken about 40 years to create so stopping it isn’t going to happen and correcting it won’t be easy either.

    *for cpd see Xin Wei Sha Navigating Indeterminacy and for more on schizotopia search digital-autism*

  3. Joe Bradford November 18, 2023 at 3:59 pm #

    I totally agree it appears the new ICB’s are hellbent on finding people ineligible for CHC funding. Decisions are often made which accentuates the positive whilst ignoring the other needs. The Framework for Assessment is often ignored or “fudged”. There is an ongoing battle to make CHC case managers support a persons “social needs” and will only focus on health needs, refusing support for shopping, cleaning etc. there needs to be a total overhaul of CHC to make it fit and more responsive to peoples needs

    • Alec Fraher November 19, 2023 at 6:03 pm #

      the syndication of institutionally organised, and non-democratically elected professional interests, has gathered pace, size and market value. Its an industry wide issue; premised on the separation of means and ends ~ the assessment decision is separated from the service provision decision ~ the foundational idea is though, now, fundamentally and often fatally flawed.

      the talk about crisis is really about how to unwrap the the professionalisation of care; the market mechanism has failed ~ having spent 40 years asking for change successive Governments have only ever invited chaos.

      when SOLACE said ‘we don’t care’ this is what was meant.

      just as the separation of means and ends within the decision-making for health and care is wrecking lives so too is the dualistic constraints of either lumping and splitting.

      this is showing up in the recent coverage of adult adhd/autism/disassociative conditions ~ patient deaths are through the roof ~ diagnostically torn between ICD and DSM, between the Right to Choose v what’s available, between public or private services ~ the means for making an assessment driven more by the pace of bringing a product to market and going Digital than considerations of both the available OR (operational research) and longitudinal research projects.

      the UK is out-of the EU, this means Council’s can, and given the efficiency savings most have to make, can ‘call-off’ and ‘standstill’ on all contracting until such times as greater clarity about local population need and provider stability is assured.

      changing the hold professional power has on any population, and inparticularly vulnerable populations, is the conversation to start.

      I’ve been following social work in the Balkans for some time as they move away from socialism, and by contrast the UK as we moved towards the neoliberalism pushed by the EC (to compete with the US)

      complexity, it’s said, doesn’t emerge from the denial of simplicity but from the very organisations each which offer separately a multiplicity of simple meanings (from Radej (2021) pg 31 citing Waldrop in Bousanquet and Curtis, 2011).

      going to market in health and social services was thought to be an answer yet services substitution, and on a scale most wouldn’t believe, has failed.

      in the Balkans, a post war and post socialism region, facing the trauma, and grasping the difference between approaches to trauma and aftermath, and treating quite separately issues of systemic invalidation and exclusion have much of offer.

      the learning highlights did though require ditching dualistic constraints of a separation between the means and ends … no separation, operationally, of assessment decisions from services provision decisions, neither lumping nor splitting.

      thoughts …

  4. Daniel November 19, 2023 at 8:09 pm #

    There is so much bias in this whole process. ICB’s should delegate this decision making to an independent board.

    • Alec Fraher November 21, 2023 at 3:58 pm #

      the Health and Well-being Board Scrutiny Boards within each Council the ICB area covers have this function ~ the inception of the ICB’s wholly dependent on agreements made with the out-going CCG’s for no substantive changes in the delivery plans at Local Authority level.

      Planitr, eh!

    • Gail November 23, 2023 at 9:59 am #

      That is so true. I spent a few years in a CCG within joint commissioning and as a social worker I was always objective, unlike some of my ‘health’ colleagues who seemed to want to shaft neighbouring Local Authorities showing no regard for service-users and their families. I was horrified by the pressure imposed on us to reduce the CHC budget. I had to leave for my own sanity and no longer work in this area, but it sounds like matters are worse than ever.

  5. Janet November 20, 2023 at 2:29 pm #

    Have they really only just noticed this!!!!?

    It’s not just about CHC. A great deal of what is now described as ‘social care’ (which nobody had heard of 30 years ago) was once done by the NHS via the District Nurse or similar

  6. Jackie Mahoney November 21, 2023 at 10:58 am #

    Glad to see this is being raised as it has been happening for a number of years without challenge.
    The protection of pots of money and determination to put services over to social care is tangible. But all the money is going over the ICBs or Health and nothing coming to Social Care??

  7. Claire H November 21, 2023 at 3:20 pm #

    I work in Adult Social work and the slow push to make social care fund health is more apparent now. I get support plans for packages of care costing several thousands and when I say any funding from health I am met with they are not eligible yet we are managing and paying for health needs. CHC and ICB dont recognise our parameters and dont care as they hold the power. All we get is agree with us or else. I have attended many resolution meetings and been shot down as ICB hold more power over local authorities then people realise. I find this more challenging as work in Learning Disabilities and some needs such as behaviour are not social care
    Why have guidence if this is not followed. I also worked in a CHC team so do understand DST’s and complex needs. What is also apparent is how the NHS view social work and social workers as being inferior. It wont work unless there is respect

  8. Chris Sterry November 21, 2023 at 6:29 pm #

    This is a disgrace for more should be accessing health care than through social care for it should be condition-based and much care is due to health conditions rather than non-health conditions. The real problem was in 1948 when all care be it deemed to be social or health should have been designated as health and none as social.

    But, in those days most care in the home was done by families as the degrees of disabilities and other aspects were not as pronounced as they are now. People are currently living longer be they be disabled or not but the gap between some disability mortality is still a very large gap between persons assessed to have no disabilities.

    Over the years the split between health and social care has created much duplication and confusion which would never have occurred if there had been no split between health and social care.

    But lack of funding in both health and social is a forever problem and much more so with regards to social care, just look at the pay rate for social care workers for one. They are classed as unskilled when to do care as it should be done they have to be very skilled, in how to use hoists both portable and tracking, feeding in many different requirements and so much more.

    Yes, there are staff shortages in both health and social care, but so much more so in social care, even to persons coming from outwith the UK. The visa allocations are also problems and when granted the period length is too short.

    To reduce the shortages in social care staffing the pay rates have to be considerably increased to far more than both the National and Real Living Wages.

    Governments are not listening, but do they ever, but, I they don’t very soon I can see that social care will fail to exist and then the NHS will not be far behind. However, that could be the real intention of the government and that would be the end of any care free at the point of delivery and it could then get even worse than in the USA.

    Now that is unthinkable, but so is the current situation so we have to get a listening government some how.

    • Tony Adam December 2, 2023 at 10:35 am #

      Absolutely agree with Cris and most of the other comments here. CHC is like a bad joke. The process has way too many hoops to jump through and technicalities of conditions and intervention required that make it too easy for health to say not eligible.

      The health and social care split overall is crazy in my area, I work in Mental Health and our social work office is literally 100 yards away from the NHS Mental Health team yet in terms of ease of communication and co-working we might as well be in different countries!