Distinguishing between health and social aspects of institutional care for frail elderly people remains confusing and contentious in the UK, even though health and community care reforms specifically sought to avoid such problems. Nursing home care in the UK has developed rapidly to 170 000 nursing home beds. Nursing home care now costs significantly more than the total committed to primary care. Some health authorities maintain a large commitment to long-term care provision in hospitals and contract nursing home beds; others have divested themselves of providing long-term care, becoming dependent on means-tested nursing home care provided by social services. Where 'free' health service contract nursing home beds are adjacent to social services means-tested placements the inconsistencies become even more perverse. Distinguishing between health and social patients/clients/supplicants on the basis of health or social care need is often impossible. Health Service responsibilities to support care home residents will become more onerous as cost pressures define the limits of social care for individuals and social services producers alike. There is, in addition, an unresolved tension between the professions associated with the care of elderly patients, who are seeking clear standards, and the hostile purchasing environment which fails to value the cost benefit, let alone the health gain of planned care management in deference to the Mammonism of treatment episodes.