Can the NHS Say Your Relative’s Needs Are ‘Only Social Care’?

Why does the difference between healthcare and social care matter?

Social care is associated with assistance with everyday activities: washing and dressing, preparing and eating meals, using the toilet, moving around safely and maintaining independence. 

Healthcare needs relate broadly to the treatment, control, management or prevention of disease, illness, injury or disability, and the care or aftercare associated with those needs. 

In practice, however, the boundary is not always obvious.  

For example, one person may need somebody to prepare their meals because they cannot safely cook. Another may have swallowing difficulties, require modified food and thickened fluids, need close supervision while eating and drinking, and be at risk of aspiration.  

Both might be described as needing “help with meals”. But that description tells you very little about the underlying needs, risks and interventions involved. 

That is why labels can be misleading in a CHC assessment. 

Can the NHS decide that your relative’s needs are social care?

Yes. Following a proper assessment, an Integrated Care Board (ICB) can conclude that your relative does not have a primary health need and is therefore not eligible for NHS Continuing Healthcare. 

That does not mean every decision describing somebody’s needs as predominantly social care is necessarily correct. 

Eligibility should be based on the individual’s assessed needs and the application of the primary health need test. It should not be determined simply by their age, diagnosis, care setting, the job title of the person providing the care or the fact that some interventions resemble ordinary personal care. 

The National Framework requires the totality of the person’s needs to be considered. 

During a full CHC assessment, a multidisciplinary team (MDT) completes a Decision Support Tool. The DST records needs across 12 care domains before applying the “primary health need test”, also known as the Key Characteristics: 

• Nature
  The characteristics of the needs and the interventions required to meet them. 

• Intensity
  The quantity, severity and continuity of the needs and care required. 

• Complexity
  How needs interact and the knowledge or skill required to manage them. 

• Unpredictability
  The extent to which needs fluctuate and create challenges in managing them, including the consequences if timely care is not provided. 

One characteristic can demonstrate a primary health need on its own, or the characteristics may establish it in combination. 

The assessment therefore needs to go considerably further than deciding that your relative “only needs personal care”. 

Five warning signs that the “social care” conclusion may need challenging

Families will sometimes encounter broad descriptions such as “personal care”, “age-related needs”, “stable needs” or “needs that can be managed by carers”. Those descriptions do not, by themselves, answer the primary health need question. 

There may be reason to examine the assessment more closely if: 

1. The assessment describes the task but not the underlying need

A care plan may say that your relative “requires assistance with feeding”, “needs two carers for transfers” or “requires support with continence”. 

That records what staff do. It does not necessarily explain how they do it. 

For example: Does assistance with feeding involve managing a swallowing problem and risk of aspiration? Are two or more carers needed for transfers due to a risk of serious injury, dangerous behaviour, or pain on movement? Does personal care involve recurrent infections, catheter management or significant skin damage? 

The way care interventions are carried out can be crucial. 

2. Risks are recorded without explaining how they are mitigated

It is not enough simply to record that somebody is “at risk of falls”, “at risk of pressure damage” or “at risk of aspiration”. 

The assessment should properly capture the nature of that risk, the care required to manage it and what may happen if intervention is delayed, unsuccessful or omitted. 

3. Needs appear low because the care regime is working

Your relative may not have fallen recently because staff provide continuous supervision. 

Skin damage may be healing because staff have implemented a specialist dressing regime. 

Their behaviour may appear relatively settled because skilled carers recognise triggers and intervene before matters escalate. 

Good care does not necessarily mean that the underlying need has disappeared. A well-managed need is still a need. 

4. Different needs have been considered in isolation

Individual care domains do not always tell the whole story. 

Cognitive impairment may prevent your relative from communicating pain. Their behaviour may make medication or personal care difficult to deliver. Poor mobility may increase their risk of skin damage. Incontinence may add to that risk. 

The interaction between needs can increase the complexity, intensity or unpredictability of the care required. 

5. The primary health need analysis does not match the evidence

Read the reasoning at the end of the DST carefully. 

If the document describes frequent interventions, substantial risks, fluctuating needs or significant interaction between care domains but then concludes, with little explanation, that the needs are routine or primarily social, ask whether the conclusion genuinely follows from the evidence recorded earlier in the assessment. 

A bare statement that needs are “social care” is not a substitute for proper analysis. 

Why the underlying need matters more than the care task

One of the most important points to understand is that the task being performed does not necessarily tell you the nature of the underlying need. 

The relevant questions include: 

• Why is the intervention necessary?  

• What condition or risk is being managed?  

• How often is intervention required? 

• How many staff are involved? 

• How long does each intervention take?  

• What skill or judgement is needed?  

• What could happen if care is delayed or not provided properly? 

• Do the care interventions required change or fluctuate? 

Consider somebody who needs regular repositioning in bed. Viewed superficially, staff are simply helping the person move. But the intervention may be required because they cannot reposition themselves, have existing pressure damage, experience significant pain and need regular monitoring to prevent deterioration. 

Similarly, continence care may appear to be an everyday personal care task. The picture may be very different where continence problems interact with recurrent infections, severe skin damage, challenging behaviour or catheter management. 

The care need is only part of the picture. The intervention required to meet it is what matters. 

“They only need carers, not nurses”

Crucially, the fact that most of your relative’s care is provided by care workers does not automatically make their needs social care. A healthcare need does not necessarily have to be managed by a registered nurse: trained care workers – and even family members – frequently provide an equivalent degree of care.  

What should you do if the NHS says the needs are social care?

If your relative has undergone a full CHC assessment, review the completed Decision Support Tool (DST) and written eligibility decision and compare them with the underlying care and clinical records. Relevant evidence may include: 

• Care plans and daily notes
• Nursing and GP records
• Medication records
• Behaviour and incident charts
• Falls records
• Food and fluid charts
• Wound and continence records 
• Risk assessments. 

Look particularly for: 

• Important needs that are missing or understated 
• Risks recorded without explaining their consequences 
• Well-managed needs being treated as insignificant 
• Interactions between different needs being overlooked 
• Lengthy, frequent or continuous care interventions being minimised 
• Relevant family or professional evidence being omitted 
• Conclusions on nature, intensity, complexity and unpredictability that do not appear to match the evidence 

The key question is whether the DST reflects what actually happens during an ordinary day and night. If it describes behaviour as “settled”, for example, but the daily records show repeated resistance to care, or describes nutrition as “managed” without explaining the input required to achieve that, the assessment may not be presenting the full picture. 

Can you challenge a decision that the needs are social care?

Potentially. A refusal of NHS Continuing Healthcare may warrant challenge where significant needs have been omitted or understated, the DST conflicts with the underlying records, interactions between needs have not been properly considered, well-managed needs have effectively been treated as absent, or the reasoning does not adequately explain why the totality of needs does not amount to a primary health need. 

This does not mean every refusal is wrong. Whether a challenge has merit depends on the individual evidence, the assessment and how the National Framework has been applied. 

How Farley Dwek can help

Farley Dwek’s specialist case managers and experienced Nurse Assessors can review the DST alongside care and clinical records, identify needs that may have been omitted, understated or incorrectly characterised, and reapply the primary health need test. 

If your relative is still going through the assessment process, we can also help review the evidence before the MDT meeting to ensure their needs are properly presented from the outset. 

Where an appeal has merit, we can assist in preparing the case and representing your family through the CHC appeal process. The issue is not simply whether someone has called your relative’s needs “social care”, but whether that conclusion holds up when the actual needs, risks, interventions, and supporting evidence are properly examined.

If you are concerned that a DST or CHC decision has reduced significant health needs to descriptions such as “personal care” or “social care”, Farley Dwek can review the assessment and supporting records and advise whether there are reasonable grounds to challenge the decision.