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:
- 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.
- 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.”