Fundamental reset for social care?

It is indeed shocking. There have been a number of occasions when I have had to tell people that the information they have received from district nurses is wrong.

But it is such a political hot potato that no-one will deal with it. Theresa May gently chipped away at the edges once and found herself with a bloody nose.

The country needs to decide what can be afforded and what we are willing to spend on the care of those in need. Whatever that is it needs to be administered in such a way that this fight between health and social services is eliminated. It is expensive, time wasting and leads to bed blocking.
There are firms of solicitors raking it in as they exploit this fault line.

There has long been the concern that if the social care funding was to be handed to the nhs to administer, it would be swallowed up by Health

Luckygirl3

It is indeed shocking. There have been a number of occasions when I have had to tell people that the information they have received from district nurses is wrong.

But it is such a political hot potato that no-one will deal with it. Theresa May gently chipped away at the edges once and found herself with a bloody nose.

District nurses can get it wrong- they are not immersed in the complexity of ChC assessments and neither are GPs.

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

If you don’t agree with ICB DST NHS CHC assessment at local appeal request Independent review through NHS England.

I think that would be the worst case scenario myself Iam64. Community health services are already the Cinderella in the NHS, and the NHS is such a monolith already that handing a totally new care service over would result in worse services to clients.

The solution will be very expensive- likely to involve tax or NI payments if some ilk- not a vote catcher in short term…

Agree Casdon

Thank you. Few people realise the complexity of this process.

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!

Well, I agree that questions need to be asked, but I question Baroness Casey’s starting point:
‘she argues that social care has never had a foundational "creation moment" like the NHS and is challenging the nation to mandate a fair, universally understood care system.’

Baroness Casey needs to do her homework, social care had a defining creation moment following the Seebohm Report of 1968 which argued for consistent, unified services and led to the Local Authority Social Services Act 1970. This created Social Services Departments headed by Directors of Social Services, all to be swept aside in 2004 with the separation of Children’s and Adult Services following the Victoria Climbie Report

A good starting point might be to look back at the Seebohm Report’s aims of unified departments, community care and accessible support. It seems to me we’ve gone backwards into a complete mishmash of fragmented services and service providers.

nightowl ... exactly so. And that mishmash has been caused by privatisation. Not only is it fragmented but it is hard to monitor properly.

LemonJam

Doodledog - yes- as I understand it when a married person goes into care home the house equity is usually protected if their spouse continues to live in that property. LAs apply a mandatory property disregard meaning the home value is ignored.

The patient's savings and most of their pension/s ( retaining a small amount for toiletries etc I think- I am not a SW) will be used towards care fees. Thus the spouse in the home has their pension and must pay all household expenses alone. It can be the case the spouse in the home may find it difficult to maintain the home on one pension and may not wish to continue living there alone.

So- If the house is sold , and the remaining spouse moves out or passes away, the Local Council will then *include the resident's share of the property to use against care home fees*- equity released at time of spouse's death or point of sale on moving out.

Usually females outlive males, and many of the cases I see the husband has died, the wife continued to live in the property and then subsequently became unable to live independently and went into a care home. At that stage the home was her asset alone. Thus now a self funder and sons and daughters set about selling the property to fund the care fees if not found eligible for NHS CHC.

Thanks, LemonJam, that is what I thought. If Cossy's cousin is getting no help with fees, it may be worth appealing on that basis, as she shouldn't be paying them. Her husband will be expected to use his personal money to pay, but the cousin should not be expected to do so.

Individual cases aside, though, it really is time that someone came up with a system that is fair to everyone. As it is, those with money will be ok (although the incredibly high cost of fees will eat through money very quickly) and those with none will be ok, as the LA will pay the bills, but those in the middle - the ones who are likely to have worked and saved - end up having to pay for things that others get free and end up with nothing to leave behind.

I know that some see it as 'fair' that those who 'can afford' to pay should do so, but I see it as unfair that there is a two tier system that charges some and not others - particularly when fees are so high for those who have to pay them. Everyone deserves to be looked after when they are vulnerable, so the solution has to work on that basis.

It might be too late for our generation, but IMO there should be compulsory insurance for everyone*, or a cap on the amount that a couple can be charged. Maybe that should be worked out as a percentage of their estate, so that house price differentials are taken into account, and someone with a cheaper house doesn't end up with nothing.

I quite like the idea of IHT being paid by all, but at a lower rate without a nil band. If we all paid 10% on death, it should bring in as much (or more) than 4% of people paying 40% after a million pound nil rate, and would be (or should be, if it's properly regulated) proportionate. There would have to be ways to stop people opting out, though - it would have to be a compulsory scheme, and things like whether a couple would pay 20% would have to be worked out fairly.

*obvious exemptions for the ill or disabled etc.

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.

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?

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.

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.

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.

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.

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.

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.

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?

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.

Thank you 🙏

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.

Thanks 🙏 again…..