Caring together: a joint vision for the future of cooperation between adult social care and the NHS

Introduction: meeting the challenge

Deeper integration between the NHS and local-government-commissioned social care can help to better meet the needs of the population and put the social care sector on a more sustainable footing. With NHS and social care alike facing rising demand, higher costs and tightening budgets, the future for both sectors lies in maximising cooperation. 

Social care offers a valuable and essential service to many people, helping them to live a better quality and more independent life. However, as the Darzi Review acknowledged, demand for social care ‘has risen, largely as the result of an ageing population… a colossal gap has opened up between resources and need’. The Care Quality Commission (CQC) found that ‘demand for support funded by a local authority continued to rise [in 2024/25] – new requests for care were 4 per cent higher in 2023/24 than in the previous year, and 8 per cent higher than in 2019/20.’ As a result, NHS and local authority commissioners are being asked to do more with less. Cooperation can help achieve that.

However, despite the best efforts of staff in local authorities and integrated care boards (ICBs), cooperation between the two sectors is inconsistent across the country, as are the terms upon which each provides services. These foundational differences have led to a history of interaction between the two services that has been piecemeal and emergent rather than planned, and this has created a series of 'frictional areas' at key points of interface. Financial pressure on both local authorities and ICBs, given their funding struggles to meet statutory care requirements, can make relationships and cooperation difficult. This in turn impacts outcomes on the ground, from the quality of care to delayed discharge from hospitals.

Change is coming. The 10 Year Health Plan has set out how the NHS will evolve over the next decade and a vision for neighbourhood health; the Casey Commission will lay down how to make the most of existing resources and what long-term reform of social care needs to include. Yet with the final report from the Commission not expected before 2028, how can local government and the NHS strategic commissioners work better to improve care in the meantime? 

This report by the Association of Directors of Adults Social Care (ADASS) and the NHS Confederation – in partnership with RLDatix – sets out a shared vision of what can happen now. It recommends changes that local commissioners could make to improve care within existing resources and for part 1 of the Casey Commission to consider. Central to this is improving the interface between NHS health services and NHS- and local-government-commissioned social care, supporting the ‘consistency of care’ emphasised in the government’s 2024 manifesto.

Already, local government and NHS commissioners are joining up to improve care and are helping stretched budgets go further. This report outlines where leaders in England are making the most of the tools currently available to them. It considers where legislative changes may be needed to better enable joint working ahead of the upcoming health bill expected in early 2026. Based on engagement with NHS ICB strategic commissioners and local authority directors of adult social services, it looks at opportunities from collaborating and harnessing technology to: 

• co-locate teams
• explore joint commissioning teams and pooling budgets
• improve NHS Continuing Healthcare
• delegate health tasks to social carers and empower carer recipients
• support the workforce and realise its potential
• join services to provide S117 mental health aftercare.

Neither the NHS nor local government commissioners can meet the challenges they face alone. Realising the mutual benefits of cooperation between the two sectors will require challenge and change. Given the scale of the pressures impacting health and care, doing nothing is not an option. Better outcomes – including more personalised, preventative care – will require health and social care to learn from each other, mutually supporting the reforms each sector is set to undergo.

Change is achievable. This shared vision of the interface between social care and the NHS sets out both what is possible today and what could become possible in future. 

Making the most of existing resources: learning from successful collaboration

Local authorities and NHS ICBs share responsibility for commissioning public-funded social care services. The Care Act sets out a legal duty for an adult’s ‘eligible needs’ to be met by the local authority, subject to their financial circumstances. Their eligible needs are those that are determined after a Care Act assessment. ICBs have a legal duty to fund NHS Continuing Healthcare (CHC) for people with complex care needs assessed above a defined threshold; Funded Nursing Care (FNC) for people assessed as needing nursing home care from a registered nurse; and Section 117 mental health aftercare (which can include social care) to individuals detained under the Mental Health Act 1983. Additionally, ICBs and local authorities make mandatory contributions to the Better Care Fund (BCF), to which they can voluntarily choose to add and pool further funding, to integration of health, housing and social care in a way that supports person-centred care. 

Despite systemic challenges, there is good practice in NHS and local government joint working across the country to deliver these services, which shows the way forward. By making the most of the tools at their disposal today, these initiatives can offer both a model for others in England seeking to emulate their successes, and also provide some key models to inform the Casey Commission’s considerations.

Co-locating staff

NHS and local authority staff can co-locate to improve joint working, improving and accelerating decision-making. From locality hubs to utilising freed-up hospital wards, staff from local authorities, NHS ICBs, NHS providers and wider partners are physically sharing space so they can talk more easily and reach decisions on social care provision, avoiding delays that are worse for people’s health and waste money.

Joint commissioning teams and pooled budgets

Some areas have gone further than co-locating staff, establishing a single team commissioning both local authority and NHS funded social care across a shared geography. This is often supported by pooled budgets. Many of these partnerships are governed by Section 75 of the National Health Service Act 2006. While this approach may not be immediately appropriate everywhere, it may offer a means to improve co-ordination and reduce cost and duplication. 

However, limitations in the law hinder collaborative working from going further. Section 75 agreements are a tool to facilitate joint working but too often they can be complicated and time-consuming to agree. Some parts of the NHS – such as primary care and voluntary, community and social enterprise (VCSE) providers – still struggle to fall within its scope. This impedes joint working with other organisations such as adult social care providers, alongside other challenges such as governance and data-sharing arrangements. 

Legislative changes by the government could help. Widening the scope and easing the creation of Section 75 agreements could make them more effective. Alternatively, authorities could be given the same freedom as ICBs to delegate some functions. Replicating powers in Section 65Z5 of the NHS Act 2006 for local authorities could enable them to delegate commissioning, providing a simpler and easier alternative to Section 75.

Delegated health tasks and empowering carers and care receivers

Delegated health tasks (DHTs) – healthcare, often clinical, activity carried out by social care staff – can improve the experience of those drawing on care and support with fewer professionals involved in delivering their care. DHTs can also relieve pressure on community and urgent and emergency healthcare. Training, development and pay progression opportunities for social care staff to deliver DHTs, using resultant savings from spend in community care, could help to incentivise staff retention. The delegation of specific healthcare tasks is already underway in some parts of the country.  The Secretary of State for Health and Social Care has already announced his intention to upskill the adult social care workforce more widely, to take on additional tasks that would have been traditionally viewed as healthcare.

To be successful, a more systematic approach is needed across health and social care, setting clear responsibilities and ensuring fair funding for staff taking on additional roles and responsibilities.  The evolution of DHTs could be more strategic and joined up to ensure the best use of existing funding between adult social care and the NHS. Local authority leaders have expressed their concern that professional development remains reliant on one-off, discontinuous funding pots rather than forming a reliable programme. As a result, a majority of directors of adult social care report that their workers are having to perform tasks for which they may not be sufficiently trained or equipped. This also impacts the financial viability of contracts, many of which are already unsustainable. 

The Care Act 2014 defines the circumstances in which adult social care providers may offer healthcare services. The need to satisfy both the ‘quantity’ and ‘quality’ requirements precludes a wider uptake of DHTs by social care without a separate Section 75 agreement, even where the provider is adequately remunerated and staff are correctly equipped to carry out this role. Similarly, social care leaders stated that the Act’s terms can impede innovation, for example the direct employment of nurses. 

Local partners can expand use of DHTs but should ensure social care providers receive remuneration for DHTs and use this to improve pay of those staff delivering DHTs, funded from consequent savings in community care. This should be supported by a national framework of responsibilities. 

Additionally, new technology can empower care recipients themselves as well as their families and unpaid carers to better monitor their own health. They can use remote technology to monitor and self-report their health directly to the NHS, enabling clinicians to spot any deterioration in a person’s health before they need an emergency response and intervene earlier. This helps keep people healthy and reduces pressure on urgent and emergency care services.

Improving Continuing Healthcare

NHS Continuing Healthcare (CHC) comprises non-means tested social care, provided by the NHS free at the point of delivery, for those whose ‘main aspects or majority part of the care they require is focused on addressing and/or preventing health needs’. However, assessment for CHC is a notable challenge to local authorities and ICBs alike, with both demand and complexity of need growing in tandem. Variation in CHC access and spending is well documented. 

The combination of difficulties in assessing need – coupled with the financial challenges faced by the NHS and local authorities alike – can challenge the strong relationship that councils and ICBs require to reach the right decisions about CHC. Data sharing, mutual trusts, clear communication and aligned expectations are all necessary to achieve this, while the focus should always remain on the rights of the individual to access care when they are eligible to do so.

The NHS Confederation has previously proposed that amending the checklist used to refer patients for a full CHC assessment could speed up CHC decision-making by reducing the volume of assessments for cases that are unlikely to meet the criteria for eligibility. While this would not change eligibility, it would reduce the volume of cases turned down for eligibility and speed up access to care within available resources. Additionally, new technology can be used to accelerate decision-making on CHC assessments and access to care, including harnessing ambient voice technology

Many ICB strategic commissioners and local authority directors believe that the existing CHC assessment framework is no longer adequate given the difficulties the sector faces. A revised CHC framework could reduce disputes within the process that undermine relationships between those responsible for care and health locally, which in turn affects access to care for people who need it. Examining how the assessment framework should change needs closer review with the involvement of ICBs, local authorities and care users. 

Supporting the workforce and realising its potential across neighbourhoods

The shortage of staff in the adult social care – short by around 131,000 workers, even as demand on both sectors grows – makes it difficult to maintain and deliver services. Poorer pay, pensions and leave in the social care sector compared to healthcare drive social care staff to move into NHS roles, where there are 100,000 vacancies, exacerbating social care workforce shortages. While experience of both sectors is valuable, at a time of serious staff shortages across the board the loss of experienced staff risks undermining organisational capabilities and therefore the quality of care on offer.  

The government has already recognised the workforce retention challenge through the developing Fair Pay Agreement (FPA) for the care sector. The first details set a positive direction, which is scheduled to begin from 2028. Properly designed and funded, the FPA can deliver fair pay and better terms for frontline care workers and improve recruitment and retention across the sector. People who draw on care and support will benefit from a sustainable and motivated workforce, delivering high-quality care, who feel valued, respected and fairly paid. 

NHS and local authority strategic commissioners need a more flexible workforce across social care and health, able to work across both sectors where needed and respond flexibly to the changing needs of the population by aligning pay, training, career paths and recruitment. To do this, the Department of Health and Social Care (DHSC) should adopt and implement all the proposals in the Skills for Care Workforce Strategy. Additionally, the DHSC should introduce a legislate requirement for a social care workforce strategy in the next health and care bill. This should be similar to requirement in the Health and Care Act to: ‘at least once every five years, publish a report describing the system in place for assessing and meeting the workforce needs of the health service in England.’

Additionally, the skills and knowledge of the social care provider, local authority commissioner workforce and VCSE sector could be better integrated to work alongside the NHS to improve neighbourhood health. The insights of social care providers and commissioners into daily support and continuity of care, the home environment and the social determinants of health is vital to respond to complex needs – especially for those living with frailty, disability or chronic conditions. Therefore, as part of their neighbourhood health strategy, DHSC and NHS England should encourage and support local systems to embed social care providers and local authority directors of adult social care into neighbourhood multidisciplinary teams and joint care planning processes as co-leaders in proactive, preventative care, not just as a recipient of hospital discharges or community referrals. 

Section 117 aftercare

Section 117 (S117) aftercare provides services for people who have been discharged from an inpatient episode following a compulsory period of treatment for their mental disorder and who need aftercare services to reduce the risk of re-admission, keeping them as well as possible and out of hospital. Local leaders believe it has become a ‘flashpoint’ in relations between ICBs and local authorities. 

The Department of Health and Social Care has provided national guidance on how budgets and responsibilities should be shared to pay for S117 aftercare in accordance with the Mental Health Act 1983. Regular review of people on S117 care is needed to check when people should be moved off S117 care, including onto Continuing Healthcare. Joint services can help to better manage S117 care more affordably.

Cherry Tree Cottage provides an alternative to difficult-to-source residential placements, which can cost up to £17,500 a week, enabling these young people to be discharged more quickly from acute mental health care and remain in the area. In all, the cost of Cherry Tree Cottage is much less than the cost of inpatient admission or residential placements. 

The team includes an Ofsted-registered manager employed by Hertfordshire County Council, a Band 7 nurse who is the deputy manager, 4.4 Band 6 nurses with mental health experience, and a consultant psychiatrist offering three sessions per week, via Hertfordshire Partnership University NHS Foundation Trust.  

While only operating on a small scale, the 12-week programme of intensive support has reduced A&E presentations and acute admissions among those young people in the home.  More than this it has improved quality of life, with care home residents proceeding to university and gaining successful employment.

Conclusion and recommendations

Collaboration between the NHS and local authorities is essential to help meet the challenges in social care. However, organisational, financial, legal and human factors are all contributing to substantial friction at the interface between the NHS and social care. The knock-on effects are hindering performance for both sectors and leading to negative consequences for staff and people drawing upon health or social care and support alike. 

Since 1997 there have been 25 social care commissions, select committee inquiries and white papers. None of these resulted in meaningful change but have thoroughly detailed the problems facing social care. Ultimately, Phase 2 of the Casey Commission must result in meaningful reform and multi-year settlements for the sector. But in the meantime, action is needed now, within the bounds of what local commissioners can practically do. There are pragmatic steps that can be taken now to improve efficiency and care outcomes. 

Many NHS and local authority commissioners are finding innovative ways to make best use of their collaborative resources, despite workforce and funding shortages in the face of growing demand for care.  The NHS Confederation and ADASS have shared examples of joint collaborative working to show how we can make the most of existing resources to support people to improve their lives over the medium term, to inform Phase 1 of the Casey Commission. They can also inform how NHS and local authority leaders work together now to make best use of limited resources.

Phase 1 of the Casey Commission should therefore consider the following opportunities from collaborating and harnessing technology: 

While care users, staff and commissioners wait and hope for longer term reform of social care following the Casey Commission’s final report in 2028, there are things that can be done now to make the most of what we already have. Spreading the best practice already in action across the country could help cash-strapped integrated care boards and local authorities to maintain and even improve services with their limited budgets. 

This requires NHS and local authority commissioners to work together. A concerted effort to share resources could reap significant rewards for both sectors. For too long, budget pressures have encouraged cost shunting. This transactional mindset is unhelpful and can undermine the very relationships on which joint working relies. Challenges of commissioning, workforce, flow and scale are shared by the NHS and adult social care alike. Instead of conflict, we need cooperation. 

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