A fragile sector
The data shows us that the social care sector had been fragile for several years and that the unprecedented challenges for the sector in responding to Covid-19 started from this unsteady foundation.
The data shows that spending by councils on social care has risen since the low of 2014/15 (though in real terms it remains below the 2010/11 level). Much of that money has been spent on trying to shore up a fragile provider market, with a consistent, above-inflation increase in the fees paid for residential, nursing and home care. While overall expenditure by councils on social care is now £942 million more in real terms than in 2015/16 (see indicator 6), spending on commissioned services from external providers has risen by £1.4 billion.
However, this spending has had only limited impact: local authorities continue to report companies handing back contracts or going out of business, and service users report difficulties in finding the care they need. And while some of the extra money has been used to provide a welcome boost to care workers’ pay, this has not stopped vacancies from rising. Tackling these problems will be at least as important a challenge after the coronavirus epidemic as it was before.
As well as shining a harsh light on the fragility of the sector, the epidemic is already causing changes to the delivery of social care and its connections to other services, most obviously the NHS. It will certainly have effects – even if short term – on some of the key indicators in this report, such as requests for support, receipt of care, expenditure, and on specific measures such as delayed transfer of care from hospital. Some of next year’s indicators may therefore look quite different from this year’s.
However, alongside understanding these, it will also be important to remember some of the key longer-term trends in social care that reform will need to address. These may not have been as obvious during the Covid-19 crisis. They are described below.
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- The number and rate of requests for support – from both working age adults and those over-65 – has increased
- Fewer older people – but more working-age adults – are receiving publicly-funded care
- The freezing of financial thresholds has excluded more people from publicly funded social care
- Overall levels of disability have stayed flat, though there has been a small rise in working-age disability
- More working-age adults are claiming disability benefits but among older people the number of claimants is static
- Spending on social care is increasing but remains lower than it was nearly a decade ago
- The cost of services rose again last year, especially residential care for older people and home care
- The number of care home beds is falling while the number of nursing beds is more stable, but with wide regional variation in both
Workforce and carers
- Jobs growth is almost at a standstill and vacancies are harder to fill
- In 2018/19, care workers were paid less than shopworkers and cleaners
- More people receive the national benefit for carers but fewer get support from local authorities
- More services are now rated ‘good’ or ‘outstanding’ but 1 in 6 are still below standard
- Two-thirds of people receiving publicly funded services say they are ‘very’ or ‘extremely’ satisfied
- The public is less satisfied with social care than the NHS but has less experience of it
- The proportion of service users receiving direct payments fell again in 2018/19
- More older people entered care homes in 2018/19 but the overall trend remains downward
Connections to other services
- Delayed transfers from hospital due to social care are well below their peak but have increased
- The trend for reablement services contrasts with that for short term care generally
- Fewer people are receiving long-term NHS Continuing Healthcare (CHC) but more get fast-track funding
- Increased central government funding has led to more Disabled Facilities Grants
Key longer-term trends
Fewer people are receiving publicly funded care...
A key trend in adult social care continues to be an increase in demand for care (see indicator 1) but a fall in the numbers of people accessing it (see indicator 2). Since 2015/16, local authorities have received over 100,000 more requests for social care support (a 5.7 per cent increase) but more than 18,000 fewer people1 have received it (a 1.7 per cent decrease).
...but there is a big difference between age groups
The overall picture obscures a big difference between the numbers of under-65s and over-65s receiving care. More working-age adults (under-65s) are getting support, but that increase is wiped out by a much larger fall in the number of older people (over-65s) getting support. Increasing demand for care from working-age adults does not just raise questions about meeting need but also challenges many people’s assumptions that the pressures on adult social care are simply the result of an ageing population. It also raises questions about the models of care we want, the type of system we may need in future, and how we should fund it.
There is a shift from long-term to short-term support
The type of care being received is also changing, in that more people are receiving short-term care and fewer are receiving long-term care. This is seen most obviously in long-term care packages for older people, which have fallen by 7 per cent since 2015/16, while short-term care packages designed to maximise independence (ST-Max) have increased by 2 per cent. This trend can also be seen in provision of NHS Continuing Healthcare, where the numbers receiving short-term ‘fast track’ care have increased by 40 per cent but the numbers receiving standard, long-term care have fallen by 16 per cent. Short-term care can be the most appropriate form: in social care, it may involve helping people get back on their feet rather than going into long-term care. But it is not clear whether this is really what is driving the shift or whether other factors – including service availability and funding – are playing more of a role.
There remain too many knowledge gaps to explain all these trends
There are too many gaps in our knowledge to paint a full picture of trends in adult social care. We can identify those gaps even if we cannot yet fill them. A critical gap concerns data about self-funders, where in most cases we are reliant on estimates of service use, expenditure and satisfaction. An even more fundamental gap, however, concerns the outcomes of receiving care; we know far too little about the impact of using adult social care services on the lives of those accessing care, their families, and on the wider health and care system. A further issue is local variation: here, we have the data but remain largely in the dark about the reasons for the differences it reveals. Addressing these gaps should be a fundamental part of the wider reform of social care.
- 1. This figure combines the number of people receiving long-term support and the number of packages of short-term support to maximise independence (ST-Max). There will be some overlap between these two numbers because some people receive both types of support in a year and some people receive more than one package of short-term support. Nonetheless, it is the best available figure of overall care system output. have received it (a 1.7 per cent decrease).
- Our methodology outlined
Definition Methodology Source Demand Number of requests for support received from new clients As reported, and calculated as a per 100,000 population rate and indexed to 2015/16 Adult Social Care Activity and Finance Report, NHS Digital Service users
New clients with a package of short-term support to maximise care (ST-Max) care and a known sequel
Long-term support during the year
As reported Adult Social Care Activity and Finance Report, NHS Digital Financial eligibility Means test threshold upper limit Adjusted to 2018/19 prices using March 2020 GDP deflators Need Disability prevalence by age group As reported Family Resources Survey, Department for Work and Pensions
Mid-year population estimate
As reported Mid-year population estimates, Office for National Statistics Disability benefits
Attendance Allowance: cases in payment
Disability Living Allowance: cases in payment
Personal Independence Payments: claims in payment
As reported DWP Stats-Xplore, Department for Work and Pensions Local authority expenditure Expenditure (including capital) – total Adjusted to 2017/18 prices using December 2018 GDP deflators Adult Social Care Activity and Finance Report, NHS Digital Expenditure by primary support reason As reported Adult Social Care Activity and Finance Report, NHS Digital Cost of buying care Unit costs for clients accessing long-term support – residential and nursing Adjusted to 2018/19 prices using March 2020 GDP deflators Adult Social Care Activity and Finance Report, NHS Digital Unit costs, average weighted standard hourly rate for the provision of home care by activity provision Adjusted to 2018/19 prices using March 2020 GDP deflators Adult Social Care Activity and Finance Report, NHS Digital Number of nursing and care home beds
Care home beds per 100 people 75+
Nursing home beds per 100 people 75+
Care home beds by region
Nursing home beds by region
Calculated year-on-year change Data from the CQC Jobs Estimated number of full-time equivalent (FTE) adult social care jobs Calculated year-on-year change Vacancies Vacancy rate – all job roles As reported State of adult social care, Skills for Care Pay Median hourly pay for care workers and other low paid jobs State of adult social care, Skills for Care Carers Support provided to carers during the year, by type of support provided As reported Adult Social Care Activity and Finance Report, NHS Digital Carer’s Allowance: cases in payment Number in payment as at Q4 DWP Stats-Xplore, Department for Work and Pensions Care quality The percentage of care services rated outstanding or good As reported Chart published in State of Care, numbers provided directly by CQC User satisfaction Question 1 combined - overall, how satisfied or dissatisfied are you with the care and support services you receive? As reported Public satisfaction
How satisfied or dissatisfied are you with social care provided by local authorities for people who cannot look after themselves because of illness, disability or old age?
All in all, how satisfied or dissatisfied would you say you are with the way in which the National Health Service runs nowadays?
From your own experience, or from what you have heard, please say how satisfied or dissatisfied you are with the way in which each of these parts of the National Health Service runs nowadays: for each service in turn
As reported Direct payments Number of service users receiving direct payments and part-direct payments at the year-end 31 March As reported Adult Social Care Activity and Finance Report, NHS Digital Care home admissions The number of council-supported younger/older adults whose long-term support needs were met by a change of setting to residential and nursing care during the year (excluding transfers between residential and nursing care) Data calculated as a per 100,000 population rate Adult Social Care Activity and Finance Report, NHS Digital Delayed transfers of care Number of delayed days during the reporting period, acute and non-acute, for NHS organisations in England by the responsible organisation Data calculated as 12-month rolling average Reablement Number/proportion of older people (aged 65 and over) discharged from acute or community hospitals to their own home or to a residential or nursing care home or extra care housing for rehabilitation, with a clear intention that they will move on/back to their own home (including a place in extra care housing or an adult placement scheme setting) As reported Adult Social Care Activity and Finance Report, NHS Digital NHS Continuing Healthcare NHS Continuing Healthcare cumulative activity year to date from 1 April, England As reported NHS Continuing Healthcare expenditure As reported Time series data provided directly by NHS England Disabled facilities grant Average number of disabled facilities grants completed per authority As reported DFG Activity Report, Foundations
With thanks to
With help at The King's Fund from Richard Humphries, Dan Wellings, Siva Anandaciva, David Maguire, Jake Beech, Megan Price, Nicholas Willsher, Helen Joubert and Jennifer Thorley.
Many people in many other organisations provided support for this work by discussing the indicators and the trends behind them and by reviewing copy, often more than once. Their help was invaluable, though the final text, the analysis behind it and any errors or omissions remain the responsibility of the authors. Thank you to:
- Sue Adams, Care and Repair England
- Graham Atkins, Institute for Government
- Adrian Crook, Bury Council
- Will Fenton, Skills for Care
- Dave Griffiths, Skills for Care
- Chris Hatton, Lancaster University
- Nina Hemmings, Nuffield Trust
- Matt Hibberd, Local Government Association
- Liz Hodgkinson, NHS England and NHS Improvement
- Emily Holzhausen, Carers UK
- Jim Ledwidge, independent consultant
- Sarah Liley, NHS Digital
- Sheila Mackintosh, University of the West of England
- Tim Parkin, Think Local Act Personal
- Paul Smith, Foundations
- Duncan Stacey, Care Quality Commission
- Tim Walker, Think Local Act Personal
- Elizabeth Webb, Age UK
- Sally West, Age UK
- Cathie Williams, Association of Directors of Adult Social Services
- Robyn Wilson, NHS Digital