All-Age Continuing Care: The Quiet Test for Integrated Care

For more than two decades the health policy community has talked about the need to integrate health and social care. Successive reforms have been built around this idea. Partnerships were created, then systems were created, and most recently Integrated Care Boards were given responsibility for planning services across whole populations.

Yet despite all of this structural effort, the boundary between the NHS and local government remains one of the most difficult relationships in the public sector. Funding flows differently, accountability operates through entirely separate democratic and governance frameworks, and the two sectors often find themselves managing the same individuals but through completely different systems.

Few services illustrate that tension more clearly than All-Age Continuing Care (AACC).

In fact, AACC may be the place where the strengths and weaknesses of integrated care become most visible. It is also the place where the system might finally learn how to make integration work properly.

A service that sits between two worlds

AACC exists because some people live with complex and ongoing needs that cannot easily be separated into neat categories of health or social care. Children with lifelong conditions, adults living with neurological disorders, people whose health deteriorates rapidly following illness or injury, and older people with highly complex needs all fall within its scope.

The NHS funds AACC where an individual is judged to have a primary health need, but much of the care itself takes place in people’s homes or in community settings that look very similar to social care provision.

This means AACC sits directly at the intersection between the NHS and local government. Eligibility decisions determine which organisation ultimately carries the financial responsibility, and those decisions can involve extremely large sums of money over the lifetime of a care package. It is therefore hardly surprising that the process has evolved into something that can sometimes feel less like collaborative care planning and more like a complex boundary negotiation.

Recent commentary has made this tension increasingly visible. Speaking at the Nuffield Trust Summit earlier this month, Baroness Casey described the relationship between the NHS and local government as fundamentally unbalanced, arguing that local authorities frequently find themselves operating in a system dominated by NHS priorities and funding rules. Her observation will resonate with anyone who has spent time in this part of the system.

At the same time the NHS has always been cautious about transferring large amounts of funding into structures that it does not directly control. As Roy Lilley noted in a recent commentary on the wider health and care landscape, trust between the two sectors has never fully settled into something stable or comfortable. Health leaders worry about losing financial grip, while local government leaders often feel they are being asked to solve problems without the authority or resources required to do so.

The result is that AACC has largely remained within NHS governance structures, sitting inside Integrated Care Boards even though the services themselves frequently operate well beyond traditional healthcare settings.

Governance in the wrong place

This creates a further contradiction. Integrated Care Boards are increasingly being positioned as lean commissioning organisations whose primary responsibilities revolve around planning, contracting and financial control. Much less emphasis is now placed on the collaborative system leadership role that originally defined the integrated care agenda. Yet AACC requires exactly the opposite kind of operating model. It depends on sustained partnership between NHS organisations, local authorities, community providers and families. The assessment process itself is multidisciplinary and often involves clinicians, social workers and care coordinators working together to understand an individual’s needs. It therefore requires a level of collaboration that the current system architecture does not always encourage.

Recent reporting in the health policy press has suggested that AACC has effectively remained within ICBs largely because there is no obvious alternative home for it. Moving the function entirely into local government would raise concerns about funding responsibility and financial oversight. Pulling it back into acute providers would be even less logical, since the whole purpose of the service is to support people outside hospital settings. So the service sits where it currently sits, in a governance structure that sometimes struggles to provide the collaborative environment that the work itself requires.

A market shaped by incentives

Alongside the governance challenges sits another issue that is attracting increasing attention. Capacity pressures within ICBs have led many systems to outsource elements of the AACC pathway, particularly eligibility assessments and backlog clearance.

Several commercial providers have entered this space offering services designed to help systems manage demand and reduce costs. Some of these models link commercial reward to efficiency gains or savings achieved through the assessment process. Others operate on a pay-per-case basis that focuses primarily on clearing large numbers of assessments quickly.

It is easy to see why these arrangements appeal to organisations under financial pressure. AACC expenditure is substantial and growing, and any opportunity to manage that cost more effectively will attract interest. However, the structure of these contracts can sometimes raise uncomfortable questions about incentives. When revenue depends on the savings that an organisation helps generate, or when throughput becomes the primary performance measure, the system inevitably begins to worry about whether the balance between cost control and patient centred decision making is being struck in the right place.

None of this implies bad intent on the part of the organisations involved. It simply reflects the reality that incentive structures shape behaviour. In her recent speech, Baroness Casey hinted at precisely this concern when she suggested that the current system can sometimes appear to reward limiting care rather than ensuring that people receive the support they genuinely need.

The workforce question that no one talks about

Perhaps the most under-explored aspect of AACC is the workforce itself. The professionals responsible for undertaking assessments, coordinating care packages and supporting complex decision making are typically experienced nurses, social workers and clinical coordinators working in Band 6 or Band 7 roles. Many are highly skilled practitioners who have developed deep expertise in navigating the complexities of the national framework.

Yet the career structure around these roles remains surprisingly thin. There is no nationally recognised accreditation pathway for AACC assessors and no clearly defined professional progression that signals the importance of this work as a specialist field.

The result is that AACC roles can sometimes feel like a professional side road rather than a recognised destination within a clinical career.

This matters because the work itself is intellectually demanding and ethically complex. Decisions involve detailed clinical judgement, an understanding of the legal framework that underpins eligibility, and the ability to balance compassion with responsible stewardship of public resources. Encouragingly there are signs that this is beginning to change. Initiatives such as Liaison’s training programme for AACC practitioners represent an important step towards recognising the need for structured professional development in this area. Creating clearer training pathways helps legitimise AACC as a specialist discipline rather than simply an administrative function.

At the same time, initiatives like this inevitably raise broader questions about how training and service delivery intersect. Organisations that are also involved in delivering assessment services face a delicate balance between building professional capability and maintaining the perception of independence that the assessment process requires.

These tensions are not unique to AACC. They arise in many areas of healthcare where expertise and service provision develop alongside one another. The key challenge is ensuring that governance and transparency are strong enough to maintain confidence in the integrity of the process.

AACC as the real proving ground for integrated care

Despite these challenges, AACC may represent the most realistic opportunity to demonstrate what genuinely integrated care could look like. The service already contains many of the elements that policymakers say they want the system to prioritise. It focuses on people with complex long-term needs rather than episodic treatment. Care is delivered primarily in community settings rather than hospitals. Decision making requires collaboration across organisational boundaries. The quality of outcomes depends heavily on continuity of care and the stability of the workforce.

In other words, AACC already operates in the world that the wider health system is trying to move towards. The difficulty is that the surrounding structures have not yet evolved in a way that fully supports that ambition.

Rethinking how the system approaches AACC

If AACC were treated as a flagship area for integrated care rather than an administrative necessity, several shifts might begin to emerge. The first would involve rethinking how services are commissioned. Contracts that focus exclusively on cost reduction or case throughput inevitably distort priorities. A more balanced approach would link financial incentives to outcomes such as quality of care, stability of support packages, patient experience and long term cost optimisation.

The second shift would involve building a recognised professional pathway for the workforce. Structured accreditation, rotational placements across health and social care environments, and clear career progression would help establish AACC as a respected clinical specialism.

A third area of focus would be the way care packages are reviewed over time. Current investment tends to concentrate heavily on the initial eligibility decision, yet people’s needs evolve and complex care packages require continuous oversight. Strengthening the review process would not only improve quality of care but also help ensure that resources are used effectively as needs change.

Finally there is the question of workforce stability. Much of the current care delivery model relies on fragmented agency supply, with highly skilled nurses and support workers moving between providers in search of the best available rates. Developing more stable workforce pools trained for specific complex care needs would significantly improve continuity for patients and families.

A quiet but important policy frontier

All-Age Continuing Care rarely dominates political debate. It does not generate the headlines associated with hospital waiting lists or GP access, yet it sits quietly at the centre of some of the most difficult policy questions facing the health and care system.

It is where the boundary between the NHS and local government becomes real. It is where the challenge of delivering complex care in people’s homes becomes most visible. And it is where the success or failure of integrated care ultimately becomes tangible for the individuals who depend on the system. For that reason alone, AACC deserves far more attention than it typically receives.

If policymakers genuinely want to understand whether integrated care can move beyond rhetoric and structural reform, this may be the place to start. Handled thoughtfully, AACC could become the area where the NHS and local government finally learn how to work together around the needs of people rather than around the boundaries of institutions.

Handled badly, it risks remaining another example of how well intentioned reforms struggle when incentives, governance and workforce design pull in different directions.

The question is whether the system is prepared to treat AACC as the laboratory where integrated care is finally made real.