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The NHS at 70: What's the problem with social care, and why do we need to do better?


  • Ruth Thorlby

  • Anna Starling

  • Catherine Broadbent

  • Toby Watt

To mark the BBC's coverage of the NHS's 70th birthday in July 2018, researchers from the Health Foundation, the Institute for Fiscal Studies, The King’s Fund and the Nuffield Trust have joined forces for the first time, using combined expertise to shed light on some of the big questions on the NHS.

The four organisations have been asked by the BBC to look at five key topics, covering the relative strengths and weaknesses of the health service, the state of social care, NHS funding, the public’s expectations of the NHS and the potential of technology to change things in future. This project and the reports we have produced are intended to inform the national conversation about the past, present and future of the NHS.

Find out more about this series >

The NHS is celebrating its 70th birthday, but the anniversary of an equally important service is not being marked in the same way: adult social care. Unlike the legislation that set up the NHS, the 1948 National Assistance Act did not nationalise social care services and create a familiar public institution, nor did it result in services being free at the point of use. Local authorities were obliged to provide accommodation for people who needed it on the grounds of age or disability, but could charge.

Across the UK, more people work in social care than in the NHS, with social care representing 6% of total UK employment, but the services and support delivered in social care are not well known. The public are increasingly aware of the pressures being faced by the NHS, but much less so about the challenges facing social care, and what that might mean if they or a family member develops social care needs.

This briefing sets out the demand and funding pressures facing social care across the UK. It then looks in detail at the impact of these pressures in England and the barriers to funding reform.

Key findings

  • The social care system is also 70 years old this year but unlike the NHS, its anniversary will pass largely unnoticed. The fault line established 70 years ago between health care which is free at the point of use and social care which is means-tested, remains a fundamental source of inequity and unfairness today.

  • New polling suggests that the majority of the public (56%) think that individuals having to use their housing assets to pay for care is at least somewhat unacceptable, compared to 25% who think it is at least somewhat acceptable.

  • Adult social care spending in the UK has fallen by 9.9% between 2009/10 and 2016/2017.

  • An ageing population and younger adults with disabilities living longer are pushing up the cost of caring for older and disabled people, placing the social care system under huge strain. Based on current spending, a UK funding gap of £18 billion will open up by 2030/31.

Impact of not enough funding for adult social care in England

  • In England the financial thresholds to access social care are 12% lower (in real terms) in 2018/19 than they were in 2010/11, meaning fewer people are now eligible for publicly funded social care.

  • About 400,000 fewer adults received social care services in 2013/14 than in 2009/10, as local authorities have had to prioritise funding for people with the most severe care needs.

  • The care home market is unstable. According to the Competition and Markets Authority (CMA), care homes that have more than 75% of local authority funded residents are most at risk of failure and a quarter of UK-wide care homes fall into this category.

  • There was a 6.6% vacancy rate for the adult social care sector in 2016/17 and particularly high turnover rates for care workers.

  • Informal carers continue to absorb the bulk of the pressure – 75% said they had not received any support or service which allowed them to take a break of between one and 24 hours from caring in the last 12 months.

  • Cuts in local authority social care spending have led to increased use of A&E services by people aged 65 and over.

Where next for social care?

Despite 12 green and white papers and five independent commissions over the last 20 years, successive governments have ducked the challenge of social care reform.

People in need of care will continue to fall through the cracks of a social care system riddled with holes. Attempts to shore up the NHS will be hindered without adequate funding for social care.

Tackling the challenge of social care reform will require decisive political action and an appropriate funding settlement. Unless this happens we will continue to have a system whose inadequacies undermine the NHS and leave many people without the care they need. Transformation is required to make the social care system fair and sustainable in the future.

Download the full report >

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