Fundamental reset for social care?

Ah yes - how can the pot be funded!?

That's the critical question ......

It definitely needs a national solution- the fundamental issue is how can the pot be funded?

A joint system between health and SSD was tried here many moons ago as a pilot project - it was not a success as interests were too entrenched on either side.

It needs a national solution with one local funding pot for care, whatever its nature.

propped = people

DaisyAnneReturns

I'm still interested in thoughts on the original question - "What should adult social care actually look like, and how should it be paid for?"

It's a tough one because of the costs involved.

Social care would I guess look like it is now and as set out in the NHS CHC Framework document. That is any continuing care need that is not a professional health care need.

The. simplest way perhaps would be an insurance based model, perhaps with a ring fenced dedicated NI contribution during working lives to build up the pot necessary to fund Social Care.

Someone else has mentioned current late middle age. already STATE PENSION age popped have not paid into such a. scheme- so perhaps levy a % proportion on estate at death on a sliding scale downwards from those already over SP age downwards to a middle age threshold?

It needs a bold plan, with some options therein and cross party working and engagement. The electorate would need understand this is not a lefty problem, not a quick fix problem, has costs, not shoot down incumbent cabinet bold plan in the media, but all to engage over a period to agree a solution.

As to the question of how care should be both funded and organised, the basic problem, apart from the intrinsic complexity, is that any government who picks up this poisoned chalice is going to get clobbered at the ballot box, because there will be winners and losers and likely more tax. They know this - which is why it gets kicked down the road all the time!

I think it is important that the false distinction between health and social care should go somehow, both on a practical and a financial level.

As long as there are competing financial interests between the health authorities and the local authority social services departments this chaos will continue.

It seems to me that if for instance someone at home needs help then the relevant people should be sent in whether they are wearing a health or a social care hat and that the means of paying for this should be uniform. Ditto if in residential or nursing care.

The dialogue (a nice neutral word!) between these two is responsible for a great deal of bed blocking as setting up care can get delayed.

There is often a very fine line between what is social care and what is medical - at the extremes it is obvious, but in the main there is a mixture of both and in the end that should not matter or be a consideration in providing what is needed. These crazy minutely-detailed assessments that take up time and money (and generate canny lawyers' involvement as they see a chance to make some dosh!) need to go.

The truth is that at present however hard people try to create foolproof assessment criteria there is still an element of interpretation and the iniquitous postcode lottery holds good.

Good professional assessment of needs by both health and SSD should be done for each person for the purpose of ensuring that their needs are met, rather than to decide who pays.

If there were an overarching payment system for all this then the costly and time-consuming layer of assessment could go.

Luckygirl3

By the way Beacon CHC is funded by the government to provide the public with advice on applications. It is free, unless you ask them to actually take your care on or launch an appeal then they charge. But if you just need to know if someone should apply they will give good advice for free and tell you what to do next.

When I had to appeal my OH's refusal I organised the appeal myself but was able to run it past Beacon beforehand for no charge. If you ask them to take on the appeal themselves then there is a charge.

Absolutely agree Luckgirl.

In my experience Beacon would be destination of choice to help family's understand the process if they cannot manage alone. Much, much better than Hugh James and better than Compass CHC.

Well done you for organising CHC appeal 👏👏👏

Feeling overwhelmed- I agree DAR- at the beginning of the process is entirely understandable and usual for families. I also understand husbands and wives of patient ma be elderly themselves and stressed and tired re their loved one in care home. Daughters, sons and or friends need to step in to help where they can if around. If not entirely understandable why people turn to legal firms.

But it is doable with a lawyer. All the lawyer can do is. gather evidence and write a slick appeal submission document. Trust me- they use a template, it's not onerous really and they have no knowledge of the patient. I spend time at many IRP meetings refocussing lawyers away from their legal jargon back to the assessment questions and care need evidence the panel is looking for.

What family's really need is:

1) a good explanation by ICB of the process with a written leaflet
2) a copy of a blank DST assessment document from the ICB to understand the process and questions asked for the care domains1)
3) to keep a diary over a few weeks of your loved ones care needs form your observations during care home visits and discussion with the carers- matched to the assessment questions in the care domains
4) to attend the DST assessment, with the diary observations and chip in with those observations of their loved one in each of the relevant care. need domains
5) ask a carer form the care home who knows patient to be present also
6) ask the DST Nurse assessor and Social worker assessor to record family and carer comments verbatim in the DST document.

Having a calm, logical friend or a relative who is comfortable with detail to guide the family through this is a huge asset. Someone who can write simple, plain English family observations for each care domain to put forward as an appeal document if initial assessment does not find eligibility is an asset. Much much cheaper than a solicitor.

Such a simple document would be warmly received by an Independent Review Panel and *would bear more weight than the legalese template submission documents from a lawyer.

By the way Beacon CHC is funded by the government to provide the public with advice on applications. It is free, unless you ask them to actually take your care on or launch an appeal then they charge. But if you just need to know if someone should apply they will give good advice for free and tell you what to do next.

When I had to appeal my OH's refusal I organised the appeal myself but was able to run it past Beacon beforehand for no charge. If you ask them to take on the appeal themselves then there is a charge.

I'm still interested in thoughts on the original question - "What should adult social care actually look like, and how should it be paid for?"

"As an aside- for DAR- 12 care domains- you can see the extent of detail and comprehensiveness of the assessment. But is it not a legal process it is a care assessment process."

I do understand that LemonJam. Thank you for clarifying; I certainly didn't want to mislead anyone. What I was trying to convey was that it's something most of us don't have to deal with so may feel out of our depth - that would be normal. That it is structured and that the people dealing with it will understand it in the way someone understands there own job. That there are sources of help (free and paid for) that it may be helpful to use.

If anyone needs the precise criteria for CHC, they can be found here: www.gov.uk/government/publications/nhs-continuing-healthcare-checklist
Or contact beaconchc.co.uk who will advise over the phone for a particular individual ...it's free.

It would be remiss of any of these individuals not to advise families ... so often they do not and then is is often misinformation.

Thanks 🙏 again…..

If I could work out how to do a link I would- but you can find on line ronib:

NHS Continuing Healthcare Decision Support Tool July 2022 document.

The NHS CHC checklist document and

A DST prompts document that sets out all the assessment questions and evidence looked for to demonstrate level of need.

Thank you 🙏

ronib

I know this is a bit cheeky LemonJam but..
91 years old currently in hospital unable to mobilise, needs two carers 4 times a day when home, prone to kidney infections. Has been suggested care at home but completely bed bound 24/7.
My issue is that such immobility will further add to problems - bed sores, pneumonia possibly, increased loss of muscles from lack of movement, dvt and so on. So in your opinion, LJ is this worth asking about NHS continuing healthcare?

Ask the hospital staff to complete an NHS Checklist to see whether merits a full DST assessment- always worth asking ronib.

You're also right lack of mobility can adversely impact skin integrity, poor nutrition can also impact on skin integrity. How the 12 care domain interrelate is also key to the assessment.

There are 12 care domains to be assessed- mobility is one of the 12 Two severe weightings across all the 12 domains is more likely to lead to a Primary Health Need. Or a range or High and Moderate needs taken together with the PHN test.

5 Mobility Questions to consider could include: Evidence which might be useful to consider

• What level of mobility does the individual have?
• Are they mobile without aid or with aid? (if so, which aid?)
• What level of supervision is required?
• What level of assistance is required and what number of carers?
• Are they unable to weight-bear?
• How many carers are needed to assist with transfers/positioning and can the individual co-operate?
• What type of equipment is required (e.g. for transfers)?
• How often do they require repositioning?
• Are there any specialist positioning requirements?
• Are they at moderate/high risk of falls (bearing in mind that a falls risk assessment might use the term 'high
risk' but this doesn't necessarily equate to the high level on the DST)?
• Have they received any specialist input from e.g. occupational therapist, physiotherapist, specialist nurse?
• Does the person experience any contractures or spasms? (if yes, what treatment is required and what
impact is this having on the individual and delivery of their care?)
• Are there any risks associated with moving and handling/interventions e.g. risk of physical harm?
• Care plans
• Are Specialist assessments required (e.g occupational therapist, physiotherapist, specialist nurse)
• Look at Daily logs, Risk assessments, Manual handling assessments, Falls risk assessments, Falls diary/incident forms for evidence

The assessment asks these questions and determines whether the level of need is No Needs, Low Needs, Moderate Needs, High Needs, Severe Needs, Priority Needs

Thresholds to determine levels of need

Independently mobile No Needs

Able to weight bear but needs some assistance and/or requires mobility equipment for daily living. Low Needs

Not able to consistently weight bear. OR Completely unable to weight bear but is able to assist or cooperate with transfers and/or repositioning. OR Completely unable to weight bear and is unable to assist or cooperate with transfers and/or repositioning. In one position (bed or chair) for the majority of time but is able to cooperate and assist carers or care workers. OR At moderate risk of falls (as evidenced in a falls history or risk assessment) Moderate Need

Due to risk of physical harm or loss of muscle tone or pain on movement needs careful positioning and is unable to cooperate.
OR At a high risk of falls (as evidenced in a falls history and risk assessment). OR Involuntary spasms or contractures placing the individual or others at risk High Need

Completely immobile and/or clinical condition such that, in either case, on movement or transfer there is a high risk of serious physical harm and where the positioning is critical Severe Need

As an aside- for DAR- 12 care domains- you can see the extent of detail and comprehensiveness of the assessment. But is it not a legal process it is a care assessment process

I need to understand the law to make sure the ICB has performed its duties and oversee the final review/appeal process- but families do not need to understand the law only understand the various 12 domains of the assessment process and the PHN test and know what evidence would need to be demonstrated to demonstrate Moderate to Higher levels of care across the 12 domains.

I know this is a bit cheeky LemonJam but..
91 years old currently in hospital unable to mobilise, needs two carers 4 times a day when home, prone to kidney infections. Has been suggested care at home but completely bed bound 24/7.
My issue is that such immobility will further add to problems - bed sores, pneumonia possibly, increased loss of muscles from lack of movement, dvt and so on. So in your opinion, LJ is this worth asking about NHS continuing healthcare?

DaisyAnneReturns

Thank you for your detailed explanation (Tue 07-Jul-26 14:07:09) LemonJam.

I was suprised to see ronib's unevidenced claim as I am aware that NHS Continuing Care is so difficult to obtain that many people are turning to solicitors to help. It's difficult because it is a legal process.

We are of an age group where this is likely to become pertinent one way or another so I’m sharing info to help understanding.

The NHS CHC assessment is a legally mandated process but not a legal process in itself. In my experience families turn to legal firms to represent them in appeals because they find the process hard to understand at first. Those legal firms, who specialise in NHS CHC vary in quality and in my experience sometimes don’t help their client’s case. Some have a service model whereby the family appeal applicant client signs a contract (please read the small print!) expecting payment at each stage and contractually must complete each stage and can’t drop out. Some offer a contract on a no win no fee basis- but a sizeable chunk of money is then due if say a year or more care fee £sum is recompensed when the Independent Review Panel over turns the ICB assessment findings and awards eligibility.

What a family actually needs is to understand the assessment process and the detail of the process it broken down to small chunks so they then do not need a solicitor for appeal. As when they get to IRP stage greta care is taken to ask plain English questions of the family about heir loved one's care needs- this they know themselves.

To help the family understand the assessment processes the job of the ICB. If you or a family member ever represents someone who is to have a CHC DST assessment KEEP ASKING QUESTIONS TILL YOU UNDERSTAND THE ASSESSMENT PROCESS as you will have greater personal knowledge of your loved ones care needs than any solicitor .

At the beginning of the Independent Review Panel meeting I always ask the family what was their experience of communication with the ICB. And what concerns if any did they experience at any stage of the ICB assessment process. Part of my job is to make sure the ICB carried out the assessment process properly and I make recommendations where improvement could be made and also whether the ICB communicated well with the family and explained the report. I must comment on this in my final report for example I begin that section:

NHS Continuing Healthcare, a person centred approach puts the individual’s needs at the heart of assessment and care planning. It is legally mandated and vital because it guarantees the person is treated with dignity and ensures professionals look holistically at how a person’s needs impact on their daily life rather than reducing them to a medical condition or label. Many individuals, however, may lack capacity and so rely on their families and loved ones to represent their needs and speak on their behalf. Therefore, the person centred approach must necessarily extend to families, from the outset of and throughout the NHS CHC assessment process.

........then say what actually happened and how it could be better

Most ICBS are reasonably good at this communication I hasten to add.

LemonJam Wed 08-Jul-26 08:42:15 It is so good to get the information you are putting forward.

I think what might help is to remember that these are legal agreements with the State. Most of us would not undertake other legal situations without employing a solicitor. I'm not suggesting that people necessarily need to do that but that understanding it is that type of transaction helps.

NI is not an insurance as such but works in a similar way. I have been dealing with insurance (following a car accident) for some months. I quickly realised "my" insurance company is not working for me, it is working for the contract. Just as dealing with this - not my area of expertise - has meant I needed advice. Applying for Care or NHS CHC could mean you also need expert advice.

ronib

Well I agree with your proposal for insurance based care into old age.DAR
Let’s hope the policy makers arouse themselves sufficiently to tackle the problems so far ignored.

I think there's an important distinction to make.

The proposal isn't simply about introducing an insurance-based system for care in old age. Many of today's pensioners have already spent their working lives contributing (although not fully covering) to healthcare through National Insurance, but they have never contributed to a dedicated scheme that funds lifetime social care.

Because of that, there would inevitably need to be a transitional arrangement. For those who have paid for healthcare but not into a lifetime social care fund, part of the cost could be recovered through a levy on their estate. As future generations contribute throughout their working lives to both healthcare and social care, any estate levy could reduce accordingly, eventually disappearing once people have fully funded both systems through their lifetime contributions.

The aim isn't to penalise today's older generation, but to bridge the gap fairly while moving to a sustainable (new) system where everyone knows what they are paying for and what it covers.

Luckygirl3

*Anyone can request a CHC assessment from their local NHS Integrated care Board- approach them for advice and assessment*

In general people do not know this - why would they? How would they? They are suddenly presented with a sad family situation and they are told they don't qualify by whoever (DN, GP) and they simply believe them. As you say - it is mega complex and why should the DN be well-versed in it all - they have other important things to do. What they should not do is to make bald statements to patients that they do not qualify.

In any event a lot of patients and their carers simply do not know this funding exists and no-one tells them - in the absence of that awareness how would they know to request an assessment?

The solution is hard to find and whatever it is it will cost a very great deal of money. I have no idea what the solution is but this mess we have at present certainly is not it!

I agree in general people don't know about the NHS CHC assessment process- until they need continuing care or their families are representing their needs and have Enduring Power of Attorney for Health and Welfare and/or POA for Finances. Then they become acutely aware of care home costs.

The DN, GP, Social Worker, hospital discharge staff and care home staff all know that a CHC DST care assessment can be requested each of them can ask the Local Integrated Care Board ( ICB) to carry out a CHC Check list to trigger the assessment process and should do so if they feel the patients needs merit such an assessment.

The GP, DN, hospital discharge and care home staff have some knowledge of how the process is triggered (or should do) but they are not immersed in the assessment process as that is carried out by a Local Authority representative and a member of the ICB CHC assessment team, staff trained in NHC CHC assessments and do it as their day job. So the GP, DN, hospital discharge and care home staff etc may not have the same extent of knowledge of the actual assessment process.

Or the family can approach the ICB directly to request an assessment themselves. If they are seeking financial support with care home fees the family is likely to ask either the care home staff or GP or DN etc involved in care what they should do and they should be advised accordingly or given a CHC leaflet, or directed to the ICB if that individual does not know what to do.

It would be remiss of any of these individuals not to advise families as expected, particularly the care home manager directly. Care Home managers should be well aware of funding sources and also keen to have fees paid on time.

Well I agree with your proposal for insurance based care into old age.DAR
Let’s hope the policy makers arouse themselves sufficiently to tackle the problems so far ignored.

ronib

I personally know the family involved and the rough estimate of the family’s wealth. This family could easily afford to pay for care out of the sale of the family home. I also know of another elderly lady who is fast losing all her savings and will soon be begging from her brother to help pay for carers at home. What sort of evidence do you need DAR?

Those aren't really evidence because they aren't verifiable. They're descriptions of private situations, but we don't know the relevant facts. For example, what does "the family" mean - children, siblings, or the older person's own assets? Are the people receiving NHS Continuing Healthcare, which is funded by the NHS, or means-tested social care? What are their actual financial circumstances, legal obligations, or care needs? Without that information, it's impossible to draw any conclusions.

You ask what evidence I would need. Personal examples don't answer the policy question. What I'd need is evidence that a proposed alternative is affordable and sustainable. For example, supporting figures showing how everyone could continue paying a form of "insurance" for healthcare beyond State Pension Age, and how an additional insurance scheme could realistically fund lifetime social care costs. Without that sort of actuarial and economic evidence, individual stories don't tell us whether a different system would work.

I personally know the family involved and the rough estimate of the family’s wealth. This family could easily afford to pay for care out of the sale of the family home. I also know of another elderly lady who is fast losing all her savings and will soon be begging from her brother to help pay for carers at home. What sort of evidence do you need DAR?