Despite – or possibly because of – the breadth of this review, some clear themes emerge.
The growth in support required by working-age adults is perhaps the single biggest trend. The Family Resources Survey (indicator 4) shows a consistent rise over the last decade in the number of working-age adults identifying themselves as having a disability. More working-age people are approaching local authorities for support, and more are getting it. And more working-age adults are claiming disability benefits (indicator 5).
The trend in the level of need for older people is less straightforward. The indicators suggest that need for social care measured as the proportion of the population is stable, or even falling. However, the numbers of older people have grown significantly (and are projected to increase more sharply in the coming decades). There is also evidence that a significant amount of need among older people is not currently being met.
Together these three factors – rising disability among the working age population, growing numbers of older people and existing unmet need – suggest there are significant challenges for our care and support system now and in the future.
Evidence from the NHS suggests this too, with sharp rises in the number of emergency admissions for patients aged 85 years or older and in admissions for patients with multiple health conditions. That in turn identifies a second theme: the underinvestment in preventive services. The investment is not decreasing, but began from a low point. For example, the number of people receiving Disabled Facilities Grants increased significantly in 2016/17, but from a very low level. Similarly, the number of people receiving reablement services has increased in 2017/18 but, despite the strong evidence for its effectiveness, to nowhere near the potential number that might benefit.
A third, related, theme – perhaps a more contentious one – is the tendency for indicators that relate to local authority spending to remain the same or decline while those driven by central government are more likely to increase. The most obvious example is that the number of carers supported by local government has fallen over the past four years while the number receiving Carer’s Allowance, a national benefit, has nearly doubled. Since 2015/16, the take-up of disability benefits by under-65s has also risen more than the take-up of long-term care provided by local authorities, and take-up of disability benefits among over-65s has fallen less.
There are some complicating factors. For example, there is wide local variation that we were not able to explore. We also note that the rate of take-up of NHS Continuing Healthcare (as well as NHS Funded Nursing Care) is declining but the reason is heavily disputed. Similarly, there has been a small increase in the number of young people going into residential care but the reasons, or whether we should be concerned about them, are not clear.
It is also important to point out that we are generally reporting measures of output rather than outcome. In terms of service delivery, this means we are reporting on the numbers receiving social care services at a time when – as we show – many local authorities are moving towards a model which tries to limit receipt of formal services.
In the section on quality, some of our indicators can be seen as 'outcomes'; however, there are other gaps in this section. We report the Care Quality Commision’s (CQC) ratings of care providers but not indicators of concern about quality, such as safeguarding alerts or complaints to the ombudsman. This is mainly because both are likely to be significantly affected by awareness of how to complain and who to complain to (we do not use complaints to the Local Government and Social Care Ombudsman as an indicator, for the same reason).
There is also a gap around the volume and type of services provided to self-funders. There are very few, if any, indicators that meet our criteria of being publicly available, annual and representative. This is a particular concern in relation to the 400,000 fewer people who receive publicly-funded social care now compared to 2009/10. These people are now outside the system and, if they are receiving formal care, are paying for it themselves, yet we know very little about them.
Taking a broad approach does limit our ability to explore issues in depth: our analysis can often only scratch the surface, raising rather than answering questions about the trends the data shows.
To provide as much insight as possible, however, we have used two basic principles in reporting and analysing the indicators, we use:
- real-terms financial amounts – ie, adjusting for inflation
- activity and other measures in relation to the size of the population – typically per 50,000 or 100,000 people (though we do report actual numbers where useful).
We intend to update – and explore – the indicators periodically to explore future trends.
- Our methodology outlined
Definition Methodology Source Demand Number of requests for support received from new clients Data 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 an episode of short-term support to maximise care (ST-Max) care and a known sequel
Long-term support during the year
Data calculated as a per 100,000 population rate and indexed to 2015/16 Adult Social Care Activity and Finance Report, NHS Digital Financial eligibility Means test threshold upper limit Adjusted to 2017/18 prices using December 2018 GDP deflators Approaches to social care funding, Health Foundation and The King’s Fund Need Disability prevalence by age group As reported Family Resources Survey
Mid-year population estimate
As reported Office for National Statistics Disability benefits
Attendance Allowance: cases in payment
Disability Living Allowance: cases in payment
Personal Independence Payments: claims in payment
Data calculated as a per 100,000 18+ population rate Department for Work and Pensions (DWP Stats-Xplore) 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 Income – client contributions, joint arrangements, income from NHS, other income Adjusted to 2017/18 prices using December 2018 GDP deflators 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 2017/18 prices using December 2018 GDP deflators and calculated year-on-year change 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 2017/18 prices using December 2018 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+
As reported Public Health England Fingertips Tool – End of Life Profile Jobs Estimated number of full-time equivalent (FTE) adult social care jobs Calculated year-on-year change The size and structure of the adult social care workforce, Skills for Care Vacancies Vacancy rate – all job roles As reported The state of the adult social care sector and workforce in England, 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 Department for Work and Pensions (DWP Stats-Xplore) 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 Personal Social Services Adult Social Care Survey, NHS Digital 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?
As reported British Social Attitudes Survey, King’s Fund analysis of NatCen Social Research’s BSA survey data Direct payments Number of service users receiving direct payments and part-direct payments at the year-end 31 March As reported Adult Social Care Outcomes Framework, 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 Outcomes Framework, 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 NHS England 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 Outcomes Framework, NHS Digital CQC NHS Continuing Healthcare cumulative activity year to date from 1 April, England As reported Time series data provided directly by NHS England, most recent years available publicly Disabled facilities grant Average number of disabled facilities grants completed per authority As reported Disabled facilities grant (DFG) and other adaptations – external review Funding for disabled facilities grants – central government funding As reported Disabled facilities grants for home adaptations, House of Commons Library
With thanks to
With help at The King's Fund from Richard Humphries, Ruth Robertson, Dan Wellings, Siva Anandaciva, David Maguire, Dave Buck.
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
- Sharon Allen, Skills for Care
- Phillip Anderson, MS Society
- Laura Arrowsmith, NatCen Social Research
- Graham Atkins, Institute for Government
- Tim Atkins, Care Quality Commission
- Fredi Cavander-Atwood, MS Society
- Clenton Farquarson, Think Local Act Personal
- Dave Griffiths, Skills for Care
- Dan Harbour, Beacon CHC
- Chris Hatton, University of Lancaster
- Matt Hibberd, Local Government Association
- Liz Hodgkinson, NHS England
- David James, Care Quality Commission
- John Jackson, Local Government Association and Association of Directors of Adult Social Services
- Jim Ledwidge, Independent Continuing Healthcare advisor to Association of Directors of Adult Social Services
- Sarah Liley, NHS Digital
- Sheila Mackintosh, University of Western England
- Brian O’Shea, Spinal Injuries Association
- Tim Parkin, Think Local Act Personal
- Caroline Speirs, Think Local Act Personal
- Duncan Stacey, Care Quality Commission
- Andy Tookey, NHS England
- Michael Varrow, consultant, Health Foundation
- Martin Walker, Think Local Act Personal
- Elizabeth Webb, Age UK
- Sally West, Age UK
- Robyn Wilson, NHS Digital
- Members of the Association of Directors of Adult Social NHS Continuing Healthcare National Reference Group