Social workers could join neighbourhood teams for people with complex needs

Social workers could form part of neighbourhood-based multidisciplinary teams (MDTs) providing support for people with complex health and social care needs.

The Department of Health and Social Care (DHSC) called on NHS and local authority leaders to establish the teams in guidance on their use of the Better Care Fund (BCF), under which they are required to pool resources to tackle government priorities.

The BCF policy framework for 2025-26 said such teams were designed to provide “more integrated and proactive care for people with complex needs”, to help them “stay independent for as long as possible” and reduce the likelihood of them being admitted to hospital or care homes.

This is part of the government’s ambition to create a “neighbourhood health service”, further details of which were set out in guidance issued by NHS England this week, which said the MDTs were one of six “core components” of the approach.

NHS England said a neighbourhood service involved delivering “more care at home or closer to home” and creating “healthier communities, helping people of all ages live healthy, active and independent lives for as long as possible while improving their experience of health and social care”.

‘Too many experience fragmentation and suboptimal care’

While this required an integrated response from health and social care bodies, “too many” people experienced “fragmentation, poor communication and siloed working, resulting in delays, duplication, waste and suboptimal care”, NHS England added.

Echoing the BCF framework, it said that NHS integrated care boards (ICBs) and local authorities’ focus in 2025-26 should be on people with “complex health and social care needs who require support from multiple services and organisations”. This should include:

• adults with moderate or severe physical or cognitive frailty;
• people of all ages with palliative care or end of life care needs;
• adults with complex physical disabilities or multiple long-term health conditions;
• children and young people who need specialist paediatric expertise regarding their physical or mental health;
• people of all ages with high intensity use of emergency departments.

It said ICBs and councils should jointly draw up a plan for a neighbourhood health and care model including the six core components, which NHS England said were based on existing good practice.

Integrated teams potentially involving social workers

Along with improving population health management, general practice, community health and urgent care, this should involve establishing neighbourhood MDTs to carry out holistic assessments and reviews and plan and co-ordinate care for people with complex needs.

Best practice would be for the team to include a core group of staff responsible for complex case management, with a care co-ordinator assigned to each person, and an extended team who could be drawn upon for specialist support.

NHS England said teams could include social workers, home care staff and care home staff, as well as district nurses, GPs, occupational therapists, hospital staff and social prescribing link workers whose role is to connect people with community-based activities.

NHS England indicated that these teams would support adults, adding that guidance on neighbourhood MDTs for children and young people would be published shortly.

The final core component of the model was the provision of short-term rehabilitation, reablement and recovery services, overseen by a registered therapist, to people at home, it added.

Better Care Fund targets

The DHSC said the BCF’s aim in 2025-26 should be to support shifts in care from “sickness to prevention” – by helping people remain independent for longer and preventing escalation of need – and from “hospital to home”, by preventing hospital and long-term care home admissions and tackling delayed discharges.

These are broadly similar to this year’s objectives of “helping people stay well, safe and independent at home for longer” and “providing people with the right care, at the right place, at the right time”.

However, the DHSC has reduced the seven previous metrics that local areas will be measured against to three:

• emergency admissions to hospital for people aged over 65 per 100,000 population​;
• average length of discharge delay for all acute hospital adult patients, derived from a combination of:​
  • the proportion of adult patients discharged from acute hospitals on their discharge ready date (DRD);
  • for those adult patients not discharged on their DRD, the average number of days from the DRD to discharge;
• long-term admissions to residential and nursing homes for people aged 65 and over per 100,000 population.

Increase in NHS funding for adult social care

The DHSC has provided councils with £2.64bn in BCF funding for 2025-26, the same as in 2024-25; this must be combined with NHS resources into locally pooled funds.

ICBs must make a minimum contribution of £5.614bn to the BCF, up 1.7% on the 2024-25 level. As in previous years, some of this NHS money must be used to fund adult social care, with the DHSC stipulating that this component increase by at least 3.9% in 2025-26.

According to NHS England figures, ICB funding for adult social care through the BCF was £2.92bn in 2023-24.

The BCF also includes the disabled facilities grant (DFG), which funds housing adaptations for disabled people, and is worth £711m in 2025-26, the same level as 2024-25 following in-year increases in resource.

The DFG must be spent in accordance with an agreed BCF plan, the DHSC said.

Requirements to submit plans to NHS England

Health and wellbeing boards (HWBs) – local partnerships of health and social care leaders – must submit their plans to NHS England’s national BCF team for approval by 31 March.

These will then be reviewed, with HWBs informed by May whether their plans have been approved, approved with conditions or not approved, which applies when the plan does not meet national conditions for use of the BCF.

In the latter case, the partnership will likely receive “enhanced support and oversight”, including advice and, potentially, funded support to meet national objectives.