Social care 360: access

This content relates to the following topics:

1. Working-age adults increasingly ask for help

The rate of new requests is increasing from working-age adults but falling from older people

The proportion of working-age adults approaching local authorities for support (even if they do not necessarily receive it) has grown by nearly 4 per cent since 2015/161 while the proportion of older people has fallen by more than 2 per cent.

However, because the population has been growing, the actual numbers requesting help has grown over that period from 1.31 million to 1.32 million older people and from just over 500,000 to nearly 524,000 working-age adults.

In total, local authorities received 1.84 million requests for social care support from new clients in 2017/18, an increase of 2 per cent since 2015/16.

The different trends between demand from working-age adults and older people may, at least in part, be explained by different rates of growth in disability (see indicator 4).

There is also significant local variation in demand across England. In 2017/18 for England as a whole there were 1,554 requests for support for every 100,000 18–64-year-olds, but the range was from 5,655 to 287. For over 65s, the England average is 13,160 per 100,000 older people but the published rate is as high as 77,220 and as low as 3,306. There are likely to be a range of reasons for these differences from large-scale demographic differences between local authorities and levels of deprivation to administrative differences in contact handling and recording practice.

How do we account for the broader, national trends in requests for support? Possible explanations for the decrease in the proportion of older people requesting support include:

  • less financial eligibility: financial thresholds have not changed since 2010 so fewer people will be eligible for local authority support (see indicator 3) and may not approach local authorities at all but instead purchase care directly (or go without) 
  • signposting away: many local authorities are developing 'asset-based' and self-help approaches to reduce the numbers of people receiving long-term care so some may be signposted away before a formal request is made 
  • public perception: some may be put off applying for support because of perceptions about the quality or availability of social care (two-thirds of the public are not confident social care services will be available when they need them) or concerns about their eligibility
  • less need: the older population may have less disability (see indicator 4), which may in turn reduce need for social care services, though this is by no means clear.

Possible explanations for more working-age people approaching local authorities include:

  • increased need: due to medical advances, people are surviving into adulthood with complex, lifelong conditions that may nonetheless require ongoing social care support
  • increased awareness: there is more public discussion of disability, especially 'hidden' disabilities such as autism, and of mental health conditions, which may lead more people to approach local authorities for support.

 

  • 1. Though data for this indicator are available from 2014/15, local authorities advised NHS Digital of issues with its collection for that year. As a result, this and other analysis in this review only uses data from 2015/16 onwards.

2. Older people are less likely to be getting support

A smaller proportion of older people – but a higher proportion of working-age adults – is now receiving long-term care

While the proportion of working-age adults receiving long-term support has risen slightly, the proportion of older people getting long-term help has fallen by 6 per cent. This may be related to the trends in requests for support.

Long-term care is any ongoing service or support provided by a local authority to a person to maintain quality of life. It is provided after a formal assessment and is subject to regular review.

Over 7,000 more working-age people are receiving long-term support compared to 2015/16, but there has been a fall of over 20,000 older people receiving it. 

The trend for short-term support offered to promote independence – for example reablement (see indicator 18) – is more static, with the increase in working-age recipients slightly outnumbering the fall in older recipients.

Short-term care is an episode of time-limited support – for example, reablement (see indicator 18) – intended to reduce or eliminate the need for ongoing support.

There had also been a large decrease between 2009/10 and 2013/14 when the total number of adults receiving publicly funded care fell by around 400,000. However, the system of recording changed in 2013/14 so numbers may not be exactly comparable with those since 2015/16.

One reason for the more recent decrease may be changes in the financial eligibility criteria (covered in indicator 3). In addition, faced with curbs on spending, local authorities are restricting delivery of formal services (even though they have typically protected adult social care budgets more than other budgets, except for children's social care, which has had a real-terms increase).

At least partly as a result of curbs on spending, councils are also changing their approach to social care. In the ADASS budget survey 2018, 75 per cent of adult social services directors said that reducing the number of people in receipt of care was important or very important to their planned savings in 2018/19. And 82 per cent of directors said the adoption of asset-based and self-help approaches, which can involve less provision of formal service, were very important.

Asset-based approaches aim to signpost people to the types of support provided by the voluntary and community sectors while strength-based approaches aim to support an individual’s independence, resilience and ability to make choices.

It is also important to note that these figures show only the numbers who receive care and support, not the intensity of support that those service users receive or, indeed, the cost of providing it (see indicator 7). Both factors will affect the overall amount local authorities spend on care (indicator 6).

 

3. The means test has got meaner

Fewer people now qualify for council social care support because financial thresholds haven't increased since 2010/11

Publicly-funded social care is only available to people with low levels of financial assets, assessed through a means test.

Financial assets are typically people's savings and – if a person is moving into a care home – their property. The means test sets two important cut-off points (called 'thresholds') for these assets. 

The lower threshold – currently £14,250 – is the point below which an individual does not have to contribute anything towards their care from their assets (though will most likely still contribute to the cost of their care from their income). 

The upper threshold – currently £23,250 – is the point above which an individual will have to fund all their social care costs.

Between these two points, individuals contribute on a sliding scale using a formula which assumes individuals have £1 of income for every £250 of assets. 

More information and detail about the financial assessment is available on the Age UK website.

Since 2010/11, these means test thresholds have not been increased in line with inflation; if they had, the upper threshold would now be £2,811 higher at £26,061.

So people whose assets today are between £23,250 and £26,061 have effectively lost their eligibility for publicly funded social care support. They will either have to pay for their care themselves, rely on informal care from friends and family – or go without.

This is likely to affect older people rather than working-age adults, as they have had more lifetime opportunity to build up the level of savings or property that would leave them above the threshold.

Working-age adults may be affected by the similar failure to raise the minimum income guarantee since 2015. This is the amount of weekly income with which home care users must be left after local authorities have charged them for social care services. However – unlike for residential care – individual local authorities can adopt more generous charging policies for home care if they choose.

 

4. There's conflicting evidence on need

The prevalence of disability is increasing among working-age adults, but not among older people

Publicly funded social care is available only to people with high enough needs. But identifying the incidence of need in the population is far from straightforward.

The Family Resources Survey1 asks 19,000 households about levels of disability – defined as 'a long-standing illness, disability or impairment which causes substantial difficulty with day-to-day activities'. In 2017/18, 44 per cent of pension-age adults2 reported a disability, slightly down from 45 per cent in 2010/11. However, the percentage of working-age adults has increased over the same period from 15 per cent to 18 per cent. The Office of Budgetary Responsibility analysis of this data finds that the proportion of disabled working-age adults reporting mental health conditions increased from 24 per cent to 36 per cent in the five years to 2016/17.

This rise in working-age disability may explain concerns expressed by directors of adult social services: 32 per cent are most concerned about financial pressures arising from working-age adults while a further 56 per cent are equally concerned about working-age adults and older people. The smaller Health Survey for England finds that the overall prevalence of disability among the over-65 population in England (it does not measure need among under 65s) has fallen in recent years. The percentage of over-65s needing help with at least one activity of daily living – for example, washing or dressing – has fallen from 32 per cent in 2011 to 26 per cent in 2017.

This survey does, however, find that levels of unmet need remain at very significant levels – 22 per cent compared to 26 per cent in 2011. Furthermore, the measure of unmet need used by the Health Survey for England does not capture those saying they receive some support but not enough. Age UK has alternative, higher, estimates of unmet need, using a third survey, the English Longitudinal Survey of Ageing (ELSA).

Even if we could get the numbers in these different surveys to correspond, disability – particularly where self-identified – is not an exact proxy for the numbers of people entitled to state-provided social care. Entitlement for this is set out in the 2014 Care Act and, in practice, the barrier is quite high – approximately the level of requiring help with three or more activities of daily living. Forthcoming Age UK analysis of ELSA suggests that prevalence of need at that level is static at around 6 per cent of people over 65.

A further complication is that measuring activities of daily living may not in itself indicate people's degree of dependency and therefore need for support – for example, a major study using an alternative measure found that between 1991 and 2011 there were significant increases in years lived with both low and high dependency from age 65 years for men and women.

Finally, the actual number with a disability will be determined not just by the proportion of the population with a disability but also the size of that population. The actual and projected rate of population growth in England is shown in the graph below.

Projections of increasing future need for publicly-funded adult social care are set out by the Personal Social Services Research Unit.

As we say in our introduction, it therefore seems likely that – irrespective of whether need for older people is growing – the trends of rising disability among the working-age population, growing numbers of older people and existing unmet need are presenting significant challenges for our care and support system.

 

  • 1. Unlike the other indicators in this review, the Family Resources Survey data is for the UK as a whole, not just England.
  • 2. The FRS notes that the state pension age for women, though not for men, has been gradually increasing since 2010.

5. Overall, a higher proportion of people are receiving disability benefits

Long-term, receipt of disability benefits has increased among working-age adults, though it has now fallen among older people

The proportion of people who claim disability benefits1 such as Disability Living Allowance, Personal Independence Payment and Attendance Allowance is a useful further indicator of the rate of disability in the population and therefore of the need for social care(though it can also, of course, be influenced by other factors such as changes to eligibility criteria).

  • 1. We follow the Office for Budgetary Responsibility in distinguishing between disability benefits, which are intended to pay for additional costs for people with disabilities, and incapacity benefits such as Employment Support Allowance, which aim to replace income for those unable to work.

There are important similarities – but also important differences – between the social care support system and the disability benefits system.

Disability benefits are intended to pay for additional costs of everyday life for someone with an illness, disability or mental health condition, rather than specifically for their statutory care needs, which are assessed, paid for and administered separately by local authorities. One report estimates these additional costs average £583 a month, an amount that would far exceed additional benefits payments received.

Unlike social care support, disability benefits are not means tested. However, local authorities can take some income from disability benefits into account when carrying out their means test. In practice, therefore, some disability benefit income moves from individuals to local authorities to pay for care and support.

The level of need required to qualify for disability benefits is lower than that for receiving social care support from local authorities – people will receive benefits who do not qualify for social care support.

Similarities between the two systems had become stronger in recent years because the trend had been for social care to be provided in the form of direct payments - a cash sum, like a disability benefit. However, this trend has now stalled (see indicator 15). 

The graphs above show that a greater proportion of working-age people are now receiving disability benefits than in 2002, and the upturn has been greatest since the phased replacement of Disability Living Allowance by Personal Independence Payment in 2013 (though there have been some changes in the types of conditions most likely to be supported and this analysis focuses on the numbers of people receiving benefits, not the expenditure on them). This growth is consistent with the increasing proportion of working-age people reporting disability in the Family Resources Survey (indicator 4). 

The trend with older people is harder to explain. The Office for Budgetary Responsibility notes that the proportion of pension-age adults receiving disability benefits peaked at 26.8 per cent in 2009/10 and has since declined by more than enough to offset the effect of the rising pension-age population on the caseload. In 2017/18 there were 2.4 million people receiving disability benefit compared to 2.6 million in 2009/10. 

This trend could be explained by a reduction in the prevalence of disability, as suggested by the Health Survey for England. However the Office for Budgetary Responsibility observes it may also reflect a recent absence of benefit take-up promotion, as was done for pension credit after its introduction in 2003, for example.      

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Comments

Nigel Spalding

Position
Trustee,
Organisation
Healthwatch Kingston
Comment date
27 April 2019

Where is it possible to download social care data (of the kind provided in this report) for individual local authorities?

Fleur Perry

Comment date
30 April 2019

Check out the National Adult Social Care Intelligence Service (NASCIS)

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