The boundary between local authority social care and the NHS is the most constitutionally complex crossing in English healthcare. Two systems built on different premises, for different purposes, under different democratic accountability — sharing responsibility for the same populations with no governed crossing between them.
Critical context for ICS partnerships and place-based teams. See also: Neighbourhood Health
Every year, over 2.5 million people cross the boundary between NHS healthcare and local authority social care. The crossing costs £2 billion annually in delayed discharges alone. The Coughlan judgment (1999) drew the constitutional line between health and social care. The CHC framework determines which side of the line a person falls on. But the moment of crossing — when responsibility transfers, when clinical information enters a social care governance regime, when the legal character of the obligation changes — remains structurally ungoverned.
This series examines the Local Authority–NHS boundary through the lens of Inference Clinical’s Seven Flows framework. It maps where each governance invariant — Identity, Consent, Provenance, Clinical Intent, Responsibility, Service Routing, Outcome — encounters the constitutional gap. It introduces Constitutional Binding: the principle that every action, decision, and data element must be explicitly bound to the constitutional authority under which it was created.
The series covers what happens when both sides of the boundary are redrawn simultaneously through local government reorganisation and ICB mergers, how the Better Care Fund and Section 75 agreements create financial bridges without governance infrastructure, and why “integration” as currently conceived cannot solve a problem that is constitutional, not organisational.
Two constitutional domains, different legislation, different regulators — and no governed crossing between them. This is where the argument begins.
Read Article #1 →All seven governance flows assessed at the Local Authority–NHS boundary. A maturity heatmap showing where infrastructure exists — and the structural gap to Level 3.
Read Article #7 →Eight articles, one argument. Choose your entry point based on your role.
Start with Article #3: Delayed Discharge — £2.6bn annual cost, then #8: BCF Reform
Start with Article #6: Safeguarding & Accountability — 72% of SARs find the same failure, then #7: Seven Flows
Start with Article #4: Data Governance Chasm — why data can’t cross even when both sides want it to
Start with Article #5: Neighbourhood Health — why co-location isn’t integration, then #2: Reorganisation
Start with Article #1: The Constitutional Boundary — the Coughlan legacy, then #8: Six Disruptions
Eight articles, read in order, building one argument from Coughlan to reorganisation
Where the boundary sits, why it was drawn there, and what happens when both sides are redrawn at once
The Coughlan judgment drew the line between health and social care. The CHC framework determines which side a person falls on. Neither governs the crossing itself. Two constitutional domains, £2 billion in delayed discharges, and three distinct failure modes at the boundary nobody is governing.
What happens when both sides of the Local Authority–NHS boundary are redrawn simultaneously. ICB mergers reduce 42 to 26. Local government reorganisation dissolves 21 councils. Every institutional relationship, data sharing agreement, and Section 75 arrangement is invalidated at once.
Delayed hospital discharge costs £2.6 billion per year. 28.2% of delays are classified as “interface processes” — the NHS’s own term for the constitutional boundary crossing. The Seven Flows reveal what fails at every step of the hospital-to-social-care discharge.
Data that cannot cross, neighbourhood health that cannot govern, and safeguarding that cannot hold anyone accountable
Why data cannot flow across the Local Authority–NHS boundary even when both sides want it to. 80% DSCR adoption is necessary but not sufficient. GP Connect is read-only. The Data (Use and Access) Act creates legal authority but not interoperability. Constitutional Binding is the missing governance layer.
The 10 Year Health Plan’s centrepiece reform requires the Local Authority–NHS boundary to work continuously. 43 pilot sites, six professionals per patient, four organisations — and a boundary crossed every week. Co-location is not integration.
Four accountability mechanisms examine the same boundary. 72% of SARs find poor coordination. CHC eligibility varies sixfold. CQC assesses nodes, not edges. Each finds the same failures — none builds the infrastructure to prevent them.
The Seven Flows framework applied at the boundary, and the case for building governed infrastructure before the reorganisation arrives
All seven governance flows assessed at the Local Authority–NHS boundary. A maturity heatmap across six crossing types reveals systemic Level 2 capability — and the structural gap to Level 3 that no current reform addresses.
Six concurrent disruptions are converging on the Local Authority–NHS boundary within twenty-four months. Each demands governed infrastructure that does not yet exist. The organisations that build it now carry it through. The organisations that wait rebuild from scratch.
Architecting Neighbourhood Health
10 articles mapping boundary governance in NHS neighbourhood teams. The Local Authority–NHS boundary is the constitutional version of the problem neighbourhood health centres must solve operationally.
8 articles on boundary governance in insured care. Different vocabulary, same structural problem — organisational boundaries where no framework governs the crossings.
Julian Bradder
Founder & CEO, Inference Clinical
julian@inferenceclinical.com
Inference Clinical’s Boundary Risk Assessment evaluates governance at every organisational boundary — Local Authority–NHS discharge crossings, CHC interfaces, safeguarding referrals, and integrated care partnerships.
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