Winds of change: how should NHS Continuing Healthcare feature in social care reform? 

Rachel Hutchings, Fellow at Nuffield Trust, discusses why NHS Continuing Healthcare must be a government priority as part of wider conversations on social care reform. 

With a new Prime Minister, social care has firmly been placed on the political agenda. After decades of inaction, it appears we now have a real opportunity to shift the dial on reform.  

Although yet to be mentioned by name in any high-profile speeches so far, the government’s focus on tackling the catastrophic cost of care, supporting better integration with the NHS and delivering person-centred care puts NHS Continuing Healthcare (CHC) firmly in the spotlight. CHC practice mirrors many of the fundamental problems facing our social care system – widespread variation in access, poor integration with NHS services and a damaging experience for individuals and carers – and as such must be a government priority as part of wider conversations on social care reform.   

We have previously argued for policymakers not to place CHC in the “too difficult box” and to tackle the problems in the current system. But more widely, social care reform that does not also seek to tackle CHC – the boundary between health and social care and the unfair distribution of costs that result – will only ever offer a partial solution. If the Prime Minister is serious about social care reform, CHC must be a part of that. 

Why is CHC important?  

CHC is a vital source of support for people at the end of their lives, or for adults with ongoing care needs, but access is a postcode lottery. In our research, we identified shortcomings in a system that is highly inconsistent, with wide variation in eligibility, spending and practice.  

Not only is the process bruising but the stakes are high, with people found ineligible facing potentially catastrophic care costs. This “all or nothing” approach underscores the unfairness that pervades our system, creating a financial cliff edge. At its core, a CHC assessment therefore places people directly on one side or the other of one of the most consequential divides in our health and care system – who pays? 

What needs to change?  

Make CHC a government priority and put it the heart of the Big Conversation on Care 

Baroness Louise Casey’s Big Conversation on Care seeks to engage the public with the million-dollar question of who should support people when they need it, speaking directly to the challenges at the heart of the CHC system and providing a vital opportunity for engaging the public on these questions. In a speech at this year’s Nuffield Trust Summit, Baroness Casey highlighted CHC as an area where some of the most pressing challenges in social care bite, for families but for the system too – reinforcing the “power differential” between the NHS and local government.  

We have a real opportunity to think not only about reform now, but what we want from a future system, which more fairly balances costs not only between individuals and the state but between health and social care. Casey should consider not only the options for a reformed social care system but how CHC – which sits at the interface between the NHS and social care – should evolve to be fit for the future. 

Be clear on the role of CHC in supporting integration 

The Prime Minister has been clear that his ambition is for a social care system that is “highly integrated” with the NHS, though exactly what that means remains to be seen. It’s unclear whether a reformed social care system should sit firmly alongside the NHS, or whether we may end up with a ‘national health and care service’. Regardless of this, taking an integrated approach is crucial. This must go beyond just focusing on social care’s role in supporting discharge from hospital, to encompass how NHS and social care services can work together to provide preventative care for people with complex needs to live independent and fulfilling lives.  

But the Prime Minister mustn’t be naïve to the reality in which these conversations are happening. While some examples of good practice exist, evidence suggests relationships are becoming increasingly strained over CHC. Concerns about ‘cost-shunting’, tightening eligibility criteria and an increase in disputes have been reported by ADASS, indicating the wider system impact of these pressures. This is worrying, with the financial context influencing how people are able to access good quality care when they need it. If the focus is just on who foots the bill – whether the NHS, social care or individuals themselves – we risk losing sight of the bigger ambition to ensure people get high-quality care and support.  

Improve CHC now – address variation and inequalities in access  

While we wait for potential recommendations for reform, challenges with access to CHC persist. Our work showed that the number of people eligible for CHC has fallen over time and varies widely across the country. Inconsistent training, different interpretations of the national framework and poor understanding of who is and who isn’t getting access to support make it difficult to be convinced that the people who need it are getting support from this vital funding.   

Since last year, ICBs have significantly reduced their running costs, and the impact on CHC was the area ICB leaders responding to a recent survey were most concerned about. In this year’s ADASS Spring Survey, 58% of Directors reported seeing ICBs spend less in 2025/26 on CHC than the previous year, with more disinvestment in CHC compared to other areas – putting more pressure on individuals and local government organisations to pick up the pieces. Without immediate action to address the shortcomings in the current process, it’s likely these challenges will worsen before they get better. 

At a crossroads 

We may genuinely have reached a turning point. The Big Conversation on Care is a real opportunity to get the public on board with social care reform – turning it from political failure to a political imperative. The Prime Minister has in the past drawn attention to the artificial divide between health and social care and argued for a system that gives people “dignity, security and the support they deserve”. This is exemplified in the operation of CHC – highlighting fundamental questions about how we draw the boundary between what is health and what is social care – if there is to be a boundary at all. Whichever road is taken, it is vital that CHC is at the centre of the discussions.