Funding at the boundary of health and social care – a mixed-methods study of NHS Continuing Healthcare in England

Background: The boundary between health and social or long-term care is a complex issue. Like many other countries, in England this is characterised by a more generous health offering (with NHS services free at the point of use) but less generous means-tested social care. Where this is particularly problematic is for people whose complex conditions mean they require both health and social care. A funding stream called NHS Continuing Healthcare (CHC) has evolved to bridge this gap but it is fraught with difficulties, dysfunction and variation. It provides a case study of how two misaligned systems are failing to meet needs.

 

Approach: This mixed-methods study took place between January 2024 and June 2025 and aimed to explore access and variation in CHC. We reviewed 42 Integrated Care Board (ICB) annual reports from 2022/23 and 11 local CHC policies. We analysed publicly available data on CHC from NHS England. We sent Freedom of Information (FOI) Requests to NHS England and ICBs, and conducted 16 semi-structured, virtual interviews with 20 people working in local authorities and ICBs. We also held three online focus groups with care providers.

Qualitative data was analysed using inductive thematic analysis. Our understanding of the issues and research approach was informed by conversations with 44 stakeholders and three people with lived experience of CHC. We held a stakeholder workshop to share findings and develop our recommendations.

 

Results: The number of people eligible for CHC has fallen over time and varies significantly across England. Deprivation and age can explain some of this variation but do not tell the full story. Although spending on CHC has increased over time it is not distributed equally.

CHC practice is complex, driven by many factors at individual, organisational and system level.

 

This includes local relationships and approaches to delivering CHC including where referrals come from, the knowledge and awareness of CHC among the people involved and commissioning processes. CHC acts as an indicator of the effectiveness of integration at a local level. Where there are challenges, this can have a damaging effect on relationships, jeopardising wider efforts. Poor practice in CHC can reinforce the divide between the NHS and social care.

 

Implications: CHC is a vital funding source for people who need complex care outside hospital and acts as a window into understanding problems with delivering integrated care. This research identifies several challenges that result from the way that health and social care are treated as separate systems, with different funding streams, accountability structures and eligibility thresholds. Our findings offer insight into how to improve consistency and fairness in how CHC currently operates, that will be important to UK policymakers as they consider options for social care reform.

 

These findings also have broader applicability, as countries around the world experience an ageing populations living with increasingly complex needs. The question of how to create integrated, sustainable long-term health and care services with clarity of entitlement, consistency of quality – and crucially – stable funding is increasingly important.