Social care 360: access

This content relates to the following topics:

1. More adults are asking for help

The number and rate of requests for support – from both working age adults and those over-65 – has increased

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There were more than 70,000 new requests for support in 2018/19, a 3.8 per cent increase, bringing the total to more than 1.9 million requests.

The number of requests for support is not the same as the number of people requesting support since there are, on average, 1.4 requests per person. The 1.9 million new requests therefore came from 1.3 million people, and the increase in requests during 2018/19 was from around 50,000 people. 

Some of this increase can be explained by a growing population. Between 2017/18 and 2018/19 alone, the working-age population of England (those aged 18–64) grew by more than 121,000 (0.4 per cent) while the number of older adults (those aged 65 and over) increased by nearly 150,000 (1.5 per cent). On average, therefore, local authorities had around 800 more working-age adults and 1,000 more older adults in their populations than the previous year.

Of the 70,610 additional requests, more than 44,000 were from older people – an increase of 3.3 per cent over the previous year. There was a bigger percentage increase in requests from working-age adults – 5.1 per cent – continuing a trend seen since 2015/16. However, because fewer working-age adults ask for help than older people, the number of new requests (26,515) was smaller.

However, population growth alone does not explain the increase in requests because there was also an increase in the ‘rate of requests’ – ie, the number per 100,000 of the relevant, age-banded part of the population.

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One reason for this might be increased need, particularly among working-age adults. Medical advances mean that more children and young people are surviving into adulthood and beyond with complex, lifelong conditions that may nonetheless require ongoing social care support. There is also evidence that more working-age adults are reporting mental health conditions (see indicator 4).

There was also very significant local variation in the number of requests for support. Even taking into account size of population, the 10 local authorities with the most requests from working-age adults on average recorded more than 12 times the number of requests than the 10 local authorities with the fewest. For older people, the figure is 6 times more. There is no simple explanation for this; there are likely to be many reasons, from levels of deprivation to administrative differences in contact-handling and recording practice.

Most requests for support (77 per cent) came from people in the community, with only 22 per cent originating in diversion or discharge from hospital. This is an important rider to the national debate about care, which often focuses on the need for care services to support hospitals to discharge people more quickly. Inability to do this leads to ‘delayed transfer of care’ (see indicator 17).

The remaining one percent of requests for support came from prisons and from people who had been paying for their own care, typically in care homes, but ran out of savings and approached local authorities for support. This is a relatively small but increasing number (5,385 people in 2018/19, up from 3,905 in 2017/18) and a potentially challenging issue, since local authorities may not be able to pay the same rates for care as some self-funders will have been paying. In these instances, providing there has been a proper assessment of need, the care home may have to reduce its fees, families may have to top up the rate the person has been paying, or the person may have to move to a cheaper care home.

 

2. Overall, fewer people are receiving support

Fewer older people – but more working-age adults – are receiving publicly-funded care

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Although more working-age adults and older people requested support in 2018/19 (see indicator 1), only the former actually received more support. In total, around 12,500 fewer older people received support, compared to around 5,500 more working-age adults. 

What is long-term care?

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.

What is short-term care to maximise independence (ST-Max)?

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. The numbers for ST-Max refer to the numbers of packages of support provided and there are an average of 1.2 completed episodes of ST-Max per person during the year.  

The key trend was a continuing fall in the number of older people receiving long-term care – down nearly 17,000 (3 per cent) – bringing the total fall to 7 per cent since 2015/16. In that year, more than 587,000 older people were receiving formal long-term care, but by 2018/19, this had fallen to less than 550,000, despite an increase in the older population of nearly 468,000 over that period. For every 100,000 older people, there has been a fall of 662 people receiving long-term support since 2015/16. There were however just over 5,000 more packages of ST-Max delivered to older people in 2018/19.

The trend for working-age adults is different: just over 1,000 more received long-term care in 2018/19 – essentially unchanged as a percentage – but just over 5,000 more packages of ST-Max, up 22 per cent. Compared to 2015/16, the change among this age group is even more notable: long-term care has increased by 3 per cent but ST-Max has increased by 44 per cent, albeit from a very low base.

These different trends for older people and working-age adults may reflect differing trends in underlying disability (see indicator 4). They may also reflect changes in the financial eligibility criteria (see indicator 3), which are likely to affect older people more than working-age adults. But there is one other factor that is likely to be contributing significantly to these trends: faced with continued pressure on expenditure (see indicator 6), local authorities are having to restrict their services to those with the greatest need. In addition, many councils are citing the adoption of asset-based and self-help approaches (see below), which can involve less uptake of formal services and greater use of the voluntary and community sector. However, it is currently impossible to measure how extensive – or indeed effective – such approaches are in practice, and there are concerns that the voluntary and community sector may not have the capacity to provide support in all areas. 

Asset-based approaches aim to signpost people to less formal types of support, often provided by the voluntary and community sector, while strength-based approaches aim to support an individual’s independence, resilience and ability to make choices. The two terms are often used interchangeably.

The increase in short-term care to maximise independence may also reflect an increased focus on some types of preventive approaches by local authorities. Certainly, many local authorities have indicated that this was a feature of their plans to cope with budget restrictions, while also noting the tension between meeting their statutory duties and investing in such services.

An apparent paradox is that the overall number of long-term care packages has declined, yet in 2018/19, spending on long-term care actually increased by £674 million (4.8 per cent). One explanation for this is costs: the fees that local authorities pay for residential, nursing and home care have been rising more quickly than inflation, as councils try to shore up a fragile provider market (see indicator 7). Also, use of the most expensive element of residential care (for working-age adults) has increased while the less costly element (for older people) has fallen. Finally, this data only captures the number of care packages being provided, not their intensity or complexity, and it may be that these aspects have changed in response to increased need of those receiving care.

 

3. The means test has got even meaner

The freezing of financial thresholds has excluded more people from publicly funded social care

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Unlike the NHS, social care services are means tested (see below): only people with low levels of savings and other assets are entitled to publicly funded services. Since 2010/11, central government has not increased the means test thresholds to take account of inflation; if it had, the upper threshold would have been nearly £3,500 more (at £26,711) in 2018/19 than it actually was. The freeze in the threshold has been maintained up to and including 2020/21, so by 31 March 2021, the gap will have risen even further to more than £4,500.

The £23,250 limit in England is different from that in other UK nations. Scotland has increased its upper threshold to £28,000 and Wales has increased its threshold to £50,000 for residential care.

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 ('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 have to contribute to the costs 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 thresholds, individuals have to contribute on a sliding scale using a formula which assumes that individuals have £1 of income for every £250 of assets.

For more information on the financial assessment, see the Age UK website.

So in England, people who had assets in 2018/19 of between £23,250 and £26,711 had effectively lost their entitlement to publicly funded social care support, compared to 2010/11, and by the end of March 2021, those with assets of up to £27,759 will have done so. They will 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 more than working-age adults, as they have had more lifetime opportunity to build up the level of savings or property that would put them above the threshold.

Working-age adults may be affected by the similar failure to raise the minimum income guarantee - the amount of weekly income with which home care users must be left after local authorities have charged them for social care services. It has not increased since 2015 and, to make matters worse, many local authorities who used to apply a more generous income guarantee than was legally necessary are now reducing it to the statutory minimum.

 

4. Reported levels of disability have changed little

Overall levels of disability have stayed flat, though there has been a small rise in working-age disability

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*Note: From 2012/13 disabled people have been identified as those who report any physical or mental health condition or illness that lasts or is expected to last 12 months or more, and which limits their ability to carry out day-to-day activities. This is consistent with the 2010 Equality Act. Figures from 2004/05 to 2011/12 are based on those reporting barriers across nine areas of life. In April 2018, the State Pension age was over 64 years 5 months for women and 65 years for men. On 6 March 2019, the State Pension age for both men and women increased to over 65 years 2 months. The State Pension age for both men and women will continue to increase at the same rate, reaching 66 by October 2020.

The level of disability in the population is a good indicator of the need for social care. The Family Resources Survey asks 19,000 households1 about levels of disability (defined very broadly as a long-term physical or mental health condition or illness which limits ability to carry out day-to-day activities). It suggests that the level of disability stayed the same in 2018/19 as in 2017/18 and remains broadly the same as in 2010/11. However, there are important differences in trends between older people and working-age adults, which are mirrored in benefit receipt (see indicator 5).

In 2018/19, the Family Resources Survey found that 44 per cent of pension-age adults2 reported a disability, unchanged from 2017/18 and similar to the 2010/11 level (45 per cent). However, the percentage of working-age adults reporting disability rose slightly in 2018/19 to 19 per cent, compared to 15 per cent in 2011/12.

Types of disability may be changing. In each of the three years to 2018/19, mobility was the most common impairment reported but this has fallen slightly from 51 per cent in 2016/17 to 48 per cent in 2018/19. The proportion of people reporting a mental health impairment increased from 24 per cent in 2016/17 to 27 per cent.

This rise in disability among working-age adults may help explain concerns expressed by the Association of Directors of Adult Social Services (ADASS): 39 per cent are most concerned about financial pressures arising from working-age adults, while 51 per cent are equally concerned about the pressures on services from working-age adults and older people.

The smaller Health Survey for England finds that the overall prevalence of disability among over-65s in England (it does not measure need among under-65s) has fallen in recent years, though it rose slightly in 2018/19. 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 27 per cent in 2018.

The Health Survey for England does, however, find that levels of unmet need remain significant: among those who needed help, 24 per cent did not receive any, compared to 26 per cent in 2011. Furthermore, the measure of unmet need used by the survey does not capture those who say they receive some support but not enough. Age UK has alternative, higher, estimates of unmet need, using the English Longitudinal Study of Ageing.

Reported disability is not an exact proxy for the numbers of people entitled to state-provided social care which, in practice, sets the barrier for receiving help quite high. Nor is disability and need necessarily the same across all age cohorts of older people. 
And, of course, the number of people with a disability depends not just on the prevalence of disability but also on the size of the population. The older population has been rising, which will increase the number of people with a disability. The rate of population growth in England is shown in the graph below.

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  • 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 survey notes that the state pension age for women has been gradually increasing since 2010, though the age for men has remained the same.

5. More people are receiving disability benefits

More working-age adults are claiming disability benefits but among older people the number of claimants is flat

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The number of people claiming disability benefits such as Disability Living Allowance (DLA), Personal Independence Payment (PIP) and Attendance Allowance should be a useful 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). 
Just over 2 million older adults and 1.8 million working-age adults1 were receiving disability benefits in August 2019. As with other indicators, there are significant differences between working-age adults and older people in terms of uptake. A greater proportion of working-age adults are now receiving disability benefits than in 2002, and the upturn has been greatest since the DLA was replaced by PIP in April 2013. This growth is consistent with the increasing proportion of working-age adults reporting disability in the Family Resources Survey (see indicator 4).

The number of older people receiving disability benefits has remained broadly static, despite a large rise in that population group. The Office for Budget Responsibility also 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.

This trend could be explained by a reduction in the prevalence of disability, as suggested by the Health Survey for England. However, it might also reflect other factors such as awareness of entitlement to benefits.

  • 1. In November 2018 the state pension age started to rise for men and women and the upper age for claiming PIP rose in line with this. Disability benefit receipts from May 2019 onwards are therefore for people who have reached state pension age rather than 65 years of age.

There are important similarities as well as 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.

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 for social care. 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 who do not qualify for social care support can receive disability benefits. 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).

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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