Fixing public services: Local government

Local government bore a disproportionate share of spending cuts in the 2010s. Local government is one of the few areas of public services where spending remains lower in real terms in 2024/25 than it was in 2010/11. This has had widespread and profound consequences for the quality and accessibility of local authority services, ⁸⁴ Atkins G and Hoddinott S, Neighbourhood Services Under Strain: How a decade of cuts and rising demand for social care affected local services, Institute for Government, 2022, www.instituteforgovernment.org.uk/publication/neighbourhood-services-under-strain  leaving residents across England struggling to access – or receiving poor-quality service from – adult and children’s social care, local road maintenance, libraries, planning departments, recycling and homelessness services, among others.

Local government finances are unsustainable

Pressure on local government finances has never been higher. Since 2018, eight local authorities have issued a total of 12 section 114 notices (section 114 notices are colloquially known as ‘bankruptcy’ notices) compared with two in the preceding 30 years. ⁸⁵ Hoddinott S, ‘Local authority section 114 (bankruptcy) notices’, Institute for Government, 9 October 2023, www.instituteforgovernment.org.uk/explainer/local-authority-section-114-notices

Michael Gove, former Conservative secretary of state for levelling up, housing and communities, claimed that this spate of section 114 notices was due to local authorities’ financial mismanagement, but this is not the whole story. ⁸⁶ Levelling Up, Housing and Communities Committee, ‘Oral evidence: financial distress in local authorities’, Parliament UK, 6 December 2023, Q.222, https://committees.parliament.uk/oralevidence/13964/pdf  The failure of high-profile investments has often been the proximate cause of a number of these section 114 notices, but it was cuts to grant funding that both incentivised local authorities to take greater risk in the search for alternative sources of income and made local authorities less resilient to financial shocks. For mismanagement to have been the entire cause of the uptick in section 114 notices, it would have to have been the case that the quality of management in local authorities declined precipitously throughout the 2010s, and just so happened to coincide with a period of historically deep cuts to councils’ grant funding and rising acute pressures.

Local authorities are worse off now than in 2010

Instead, local authority financial fragility is the result of government policy since 2010. The coalition government chose to make substantial cuts to local authority grant funding from 2010 onwards. Some of these cuts were offset by rising council tax from the middle of the 2010s. But by 2019/20, local authority core spending power* (CSP) was almost a quarter (-22.5%) lower in real terms than it had been in 2010/11.

Since 2019/20, the government has increased central government grant funding in response to rising pressures. Both the 2021 spending review and ^the 2022 autumn statement made more money available for local authorities in cash terms, the latter primarily through additional funding for adult social care. But that additional funding has been consistently eroded by higher-than-expected inflation. The result is that in 2024/25, CSP is still approximately 10% lower than in 2010/11 in real terms. Local authority budgets would need to increase by £7.1 billion to bring funding back to the level it was at in 2010/11, through either central government top-ups or higher council tax income.

^{*Core spending power is a measure of the amount of money available to local authorities to fund service delivery. It is a combination of council tax, central government grants, retained business rates and some smaller income streams such as planning application and parking fees.}

Cuts have fallen hardest on the most deprived parts of England

While CSP has fallen, on average, across England, cuts were not distributed equally. Because of the way the coalition government chose to cut grant funding in 2010, local authorities in the most deprived parts of the country, which were more dependent on central government grants, ended up with lower CSP than councils in less deprived areas. Likewise, when central government chose to allow councils to raise funding through council tax increases, less deprived authorities benefited more because a greater proportion of their funding comes from council tax income.

While this has been partially redressed in recent years, the most deprived local authorities are still substantially worse off compared with 2010/11 than their better-off counterparts. In 2024/25, local authorities in the most deprived decile of the country had seen their CSP fall by 24.4% on average in real terms, compared with 3.1% in the least deprived decile of local authorities.

This is likely to also have been exacerbated by the fact that the funding formula – which the government uses to determine some of the distribution of grant funding to local authorities – is now very out of date. The formula was introduced in the 2000s and the government last updated it in 2013/14. ⁹⁰ Department for Communities and Local Government, Fair Funding Review: A review of relative needs and resources, GOV.UK, 2017, p.8, https://assets.publishing.service.gov.uk/media/5a82c51840f0b62305b943ff/Fair_funding_review_consultation.pdf  As a result, grant allocations do not account for the way that demographics and deprivation have changed in the intervening two decades.

From 2016 onwards, Conservative governments promised to update the funding formula in a process called the ‘fair funding review’. This was supposed to more closely link funding with spending need, based on factors such as population, levels of deprivation and the rurality of local authorities. Despite that promise, implementation was repeatedly delayed, most recently in October 2022, when the Truss government announced that it would not be brought into force until 2025/26 at the earliest. ⁹¹ Kenyon M and Hill J, ‘Government delays fair funding review’, Local Government Chronicle, 5 October 2022, www.lgcplus.com/finance/government-delays-fair-funding-review-05-10-2022  It is vital that the new government updates the funding formula to better reflect need.

Covering shortfalls in day-to-day spending with capital budgets is unsustainable

In response to the crisis in local government finance, the Sunak administration expanded the use of ‘exceptional financial support’ (EFS). This mostly took the form of providing local authorities with ‘capitalisation directions’, in other words allowing local authorities to use their capital resources for day-to-day spending. ⁹² Department for Levelling Up, Housing and Communities, ‘Exceptional financial support for local authorities’, GOV.UK, 29 February 2024, www.gov.uk/government/collections/exceptional-financial-support-for-local-authorities  The government has so far granted 16 single-tier local authorities – more than 10% of the total – and two district authorities exceptional financial support worth £1.4bn in 2024/25, up from £61.7m in 2018/19. Given CSP in 2024/25 is set at £64.7bn, this represents 2.2% of local authority budgets for this financial year. 

But this method of supporting local authorities relies on councils using often one- off capital budgets to fund day-to-day spending. This is a completely unsustainable approach to funding services that are driven by demand, which is only set to increase in the coming years.

Acute pressures force councils to cut spending on other services

Demand for acute, statutory services is outpacing funding

At the same time as central government cut grant funding for local government, demand for acute statutory services – in particular adult and children’s social care, homelessness services and special educational needs and disabilities (SEND) provision – continued to grow. As a result, local authorities have spent an increasingly large proportion of their budgets on those services. In 2009/10, spending on adult and children’s social care accounted for approximately half (53%) of total local authority spending. By 2022/23, this was two thirds (66.9%). 

Several factors are driving the increase in spending. First, the population is both growing and becoming increasingly old. Between 2010 and 2022, the population in England grew by 8.5% while the number of people aged over 65 (who are more likely to draw on adult social care) grew by 24.1%. Second, there are also increasing levels of disability among working-age adults (those aged between 18 and 64), ⁹⁶ Hoddinott S, Davies N, Fright M, Nye P and Richards G, Performance Tracker 2023, ‘Adult social care’, Institute for Government, 2023, www.instituteforgovernment.org.uk/publication/performance-tracker-2023/adult-social-care  many of whom will need adult social care. Even though spending on adult social care has increased since 2009/10, it has not kept pace with demand, and many local authorities have increasingly rationed care. ⁹⁷ Hoddinott S, Davies N, Fright M, Nye P and Richards G, Performance Tracker 2023, ‘Adult social care’, Institute for Government, 2023, www.instituteforgovernment.org.uk/publication/performance-tracker-2023/adult-social-care

Third, child poverty has increased over the past decade. There was a record high of 4.4 million children living in poverty* in 2022/23, up from 3.6 million in 2011/12 – an increase of 20.6%. ⁹⁸ Hoddinott S, Davies N and Kim D, A Preventative Approach to Public Services, Institute for Government, 2024, p.17, www.instituteforgovernment.org.uk/publication/preventative-approach-public-services  That is concerning on its own, but it also puts further pressure on local authorities’ children’s social care budgets.

Finally, local authorities also report increasing demand for homelessness and SEND services,** which is pushing them closer to the brink of having to issue a section 114 notice.

^{*After housing costs.}

^{**For more on this, please refer to the Schools chapter.}

Spending on acute services is squeezing out spending elsewhere

The increasing demand for social care spending has crowded out spending on other local authority-provided services (which we refer to collectively as ‘neighbourhood services’). Local authorities now spend much less on neighbourhood services such as libraries and services for young people. While the magnitude of the drop is smaller than for other services, they also spend less on waste collection, road maintenance and planning services now than in 2009/10. Overall, local authorities spent almost a third (-31.9%) less on neighbourhood services in 2022/23 than in 2009/10.

Interviewees in local authorities reported to us that they feel like all their attention and funding are consumed by firefighting acute demand. One interviewee described their situation as being akin to an adult social care factory, which was focused on providing care packages at the expense of almost everything else.

Caught between rising acute demands and intense budgetary pressures, local authorities have often cut discretionary, preventative services. In interviews, local authorities reported that cutting preventative services leads to rising demand for more acute – and more expensive – services in the future. It also leads to more acute demands in other parts of the public sector, such as the NHS. That creates a vicious cycle: cuts to grant funding mean that local authorities cut preventative services, which raises demand for acute services in the future, which then necessitates further cuts to preventative services. This represents poor value for money for the government.

For example, local authorities cut spending on Sure Start children’s centres – which offer early years education and childcare support for children and families ¹¹⁴ Bouchal P and Norris E, Implementing Sure Start Children’s Centres, Institute for Government, (no date), www.instituteforgovernment.org.uk/sites/default/files/publications/Implementing%20Sure%20Start%20Childrens%20Centres%20-%20final_0.pdf  – by 77.4% in real terms between 2009/10 and 2022/23. ¹¹⁵ Hoddinott S, Davies N and Kim D, A Preventative Approach to Public Services, Institute for Government, 2024, p.16, www.instituteforgovernment.org.uk/publication/preventative-approach-public-services  That led to the closure of 730 Sure Start centres between 2010 and 2023 (a drop of 20.3%) and a paring back of services in the remaining centres, ¹¹⁶ Hoddinott S, Davies N and Kim D, A Preventative Approach to Public Services, Institute for Government, 2024, p.56, www.instituteforgovernment.org.uk/publication/preventative-approach-public-services  despite excellent evidence that Sure Start reduces demand for more acute services and improves children’s long-term health and educational outcomes. ¹¹⁷ Hoddinott S, Davies N and Kim D, A Preventative Approach to Public Services, Institute for Government, 2024, p. 57, www.instituteforgovernment.org.uk/publication/preventative-approach-public-services

The children’s social care market is broken

Private providers are making excessively high profits from rising demand for children’s social care

There has been a steady rise in the number of children looked after by local authorities since 2010, increasing demand for residential care. But as both local authorities and the voluntary sector have reduced their residential provision over the past few decades, ¹¹⁸ Competition and Markets Authority, Children’s Social Care Market Study: Final report, GOV.UK, 2022, p.34, https://assets.publishing.service.gov.uk/media/6228726cd3bf7f158c844f65/Final_report.pdf  councils have increasingly turned to private providers to meet this demand. The Competition and Markets Authority (CMA) found in a 2022 report that 76% of residential care placements in England were with private providers. ¹¹⁹ Competition and Markets Authority, ‘Children’s social care market study final report: England summary’, GOV.UK, 2022, p. 3, https://assets.publishing.service.gov.uk/media/622878cce90e0747aa8eb67e/England_summary_.pdf

While there is little evidence that private provision is of lower quality than local authority provision, it is providing extremely poor value for money, putting strain on council budgets. The CMA has issued strong criticisms of the largest private providers of residential and foster care, stating that they are making significantly higher profits than would be expected under competitive market conditions, with private children’s home operators making consistent profit margins of more than 20%. ¹²⁰ Competition and Markets Authority, ‘Children’s social care market study final report: England summary’, GOV.UK, 2022, p. 5, https://assets.publishing.service.gov.uk/media/622878cce90e0747aa8eb67e/England_summary_.pdf  One council has reported that it was obliged by a lack of alternative placement options to rely on private providers and make cuts to other children’s services as a consequence of rising fees. ¹²¹ Wall T, ‘“Profiteering off children”: care firms in England accused of squeezing cash from councils’, The Observer, 2 March 2024, www.theguardian.com/society/2024/mar/02/profiteering-off-children-care-firms-in-england-accused-of-squeezing-cash-from-councils

The 2022 Independent Review of Children’s Social Care, led by Josh MacAlister, who has just been elected as a Labour MP, also highlights the risks associated with dependence on private sector providers of residential care. The review notes that, when “a majority of homes [are] owned by a few very large providers… many children are at risk of being affected by [a] Southern Cross type collapse”.* ¹²² MacAlister J, The Independent Review of Children’s Social Care: Final report, GOV.UK, 2022, p. 74, https://webarchive.nationalarchives.gov.uk/ukgwa/20230308122535mp_/https://childrenssocialcare.independent-review.uk/wp-content/uploads/2022/05/The-i…

^{*Before 2011, Southern Cross was the largest private provider of care homes in the UK, with a 9% market share. Its collapse that year because of high debt affected 31,000 residents and increased scrutiny of the risks from large social care providers’ failure. For further details, see Public Accounts Committee, ‘1 The oversight of care markets’, (no date) retrieved 3 July 2024, https://publications.parliament.uk/pa/cm201012/cmselect/cmpubacc/1530/153005.htm}

Lack of capacity in residential care is driving a rise in out-of-area placements 

Local authorities are required under the Children Act 1989 to provide placements near a child’s home and within local authority areas “as is reasonably practicable”. ¹²³ Foster D, Looked After Children: Out of area, unregulated and unregistered accommodation (England), House of Commons Library, 2021, p. 8, https://researchbriefings.files.parliament.uk/documents/CBP-7560/CBP-7560.pdf  It is sometimes necessary to place children in homes outside their local authority area due to safeguarding issues; for example, if there are concerns about local criminal or sexual exploitation. ¹²⁴ Children’s Commissioner, Pass the Parcel: Children posted around the care system, 2019, p. 2, https://assets.childrenscommissioner.gov.uk/wpuploads/2019/12/cco-pass-the-parcel-children-posted-around-the-care-system.pdf  But an increasing number of out-of-area placements are due to a lack of available capacity in local children’s homes. ¹²⁵ Jayanetti C, ‘Places in council-run children’s homes in England fall by third as private firms take over’, The Observer, 16 June 2024, www.theguardian.com/society/article/2024/jun/16/places-in-council-run-childrenshomes-in-england-fall-by-third-as-private-firms-take-over

The mismatch between the regional supply of homes and demand is a particular problem in London, which accounts for 11% of children in children’s homes but just 7% of places. ¹²⁶ Ofsted, ‘Many children placed far away from their families amid national sufficiency challenge’, GOV.UK, 8 July 2022, www.gov.uk/government/news/many-children-placed-in-homes-far-away-from-their-families-amid-national-sufficiency-challenge  The average distance between a child’s home address and their placement was 60 miles in 2018, ¹²⁷ Ofsted, ‘Children’s social care in England 2019’, GOV.UK, updated 2020, retrieved 4 July 2024, www.gov.uk/government/statistics/childrens-social-care-data-in-england-2019/childrens-social-care-in-england-2019  up from 52 miles in 2014.**, ¹²⁸ Department for Education, Children’s Homes Data Pack, GOV.UK, 2014, p. 12, https://assets.publishing.service.gov.uk/media/5a7e2d3eed915d74e62249a5/Childrens_Homes_data_pack_Dec_2014.pdf

Since 2009/10, the number of placements within a local authority’s area has remained comparatively stable. In contrast, the number of out-of-area placements increased by 116% between 2009/10 and 2022/23, meaning that by 2022/23 two thirds of all placements in children’s homes were out of area.

In 2019, the children’s commissioner noted that 52% of children in out-of-area placements experienced placement instability, where they experienced at least two changes within two years, compared with 23% of children looked after within their local authority area, negatively affecting their wellbeing. ¹³⁷ Children’s Commissioner, Pass the Parcel: Children posted around the care system, 2019, p. 7, https://assets.childrenscommissioner.gov.uk/wpuploads/2019/12/cco-pass-the-parcel-children-posted-around-the-care-system.pdf

^{**This is the most recent data release, which was not affected by Covid. Restrictions during the pandemic led to children’s homes accepting fewer out-of-area placements, thus reducing the average distance from the capital. For further details, see Association of Directors of Children’s Services, Safeguarding Pressures Phase 7, 2021, p. 53, www.adcs.org.uk/wp-content/uploads/2024/05/ADCS_Safeguarding_Pressures_Phase7_FINAL.pdf}

High-cost care placements are putting further pressures on councils

In addition to growing numbers of residential care placements, children’s needs are becoming more complex, with an increasing number of cases involving multiple risk factors to children’s physical and mental wellbeing. ¹³⁸ Samuel M, ‘Children’s social work caseloads growing increasingly complex, research finds’, Community Care, 26 January 2024, www.communitycare.co.uk/2024/01/26/childrens-social-work-caseloads-growing-increasingly-complex-research-finds ^{, 139} Association of Directors of Children’s Services, Safeguarding Pressures Phase 7, January 2021, p.105, www.adcs.org.uk/wp-content/uploads/2024/05/ADCS_Safeguarding_Pressures_Phase7_FINAL.pdf  Declining capacity in secure children’s homes and inpatient mental health services, which provide specialist support for children with the most complex needs, has led to local authorities spending more on high-cost placements, putting them under further financial strain. ¹⁴⁰ Samuel M, ‘Councils face insolvency without rules curbing children’s care costs warns ADCS head’, Community Care, 30 November 2023, www.communitycare.co.uk/2023/11/30/councils-face-insolvency-without-rules-curbing-childrens-care-costs-warns-adcs-head

A Local Government Association (LGA) survey found that the number of placements costing more than £10,000 a week rose from 120 in 2018/19 to 1,510 in 2022/23 – a 1,250% increase, compared with a 22.5% rise for all placements. The LGA reports the median weekly cost of local authorities’ most expensive care placements as £16,450 and noted substantial variation, with one council spending £63,000 a week on a single placement. ¹⁴¹ Local Government Association, ‘High-cost children’s social care placements survey’, 2023, www.local.gov.uk/publications/high-cost-childrens-social-care-placements-survey

In 2018/19, a quarter of local authorities reported having at least one high-cost placement; this surged to 91% in 2022/23. Almost all councils (98%) stated that a lack of appropriate local placements forced councils to turn to private providers, and more than 90% also cited children’s challenging behaviour or complex mental health needs as reasons for resorting to high-cost placements ¹⁴² Local Government Association, ‘High-cost children’s social care placements survey’, 2023, www.local.gov.uk/publications/high-cost-childrens-social-care-placements-survey  – a factor that interviewees said had worsened since the pandemic.

Children’s social care is now a leading driver of overspending by councils: a study found that it was responsible for half of the £640m overspend forecast by local authorities in 2023/24. ¹⁴³ Samuel N, ‘Rising children’s social care costs deepening councils’ financial woes finds study’, Community Care, 3 March 2023, www.communitycare.co.uk/2023/11/03/rising-childrens-social-care-costs-deepening-councils-financial-woes-finds-study

It is much harder to access adult social care

Despite more requests for support, fewer people can access care due to rationing

Funding for adult social care has increased in recent years and, since 2019/20, has exceeded real-terms spending in 2009/10. Despite that additional funding, there is strong evidence that funding is not keeping pace with demand. Costs in the sector are rising fast, not least due to rapid recent increases in the national living wage. ¹⁴⁴ Hoddinott S, Davies N, Fright M, Nye P and Richards G, Performance Tracker 2023, Institute for Government, 2023, p. 121, www.instituteforgovernment.org.uk/sites/default/files/2024-01/performance-tracker-2023.pdf

Insufficient funding has meant that, since 2015/16 (the earliest year for which we have data), there has been a gradual decline in the number of people receiving publicly funded adult social care, even though the number of people requesting support has increased. By 2022/23, there were 4.3% fewer people receiving long-term care while the number of people requesting support had risen by 10.6%. People are also waiting longer to access care. The Association of Directors of Adult Social Services (ADASS) reports that there were approximately 250,000 people awaiting an assessment for adult social care in August 2023, up from 204,000 in November 2021. ¹⁴⁹ ADASS, Adult Social Care Budgets and Waiting Times, 2024, p. 12, www.adass.org.uk/wp-content/uploads/2024/06/autumn-survey-report-2023-adult-social-care-budgets-waiting-times-2.pdf  There was a greater proportional increase in the number of people waiting more than six months for an assessment, from 41,000 in November 2021 to 85,000 in August 2023. ¹⁵⁰ ADASS, Adult Social Care Budgets and Waiting Times, 2024, p. 12, www.adass.org.uk/wp-content/uploads/2024/06/autumn-survey-report-2023-adult-social-care-budgets-waiting-times-2.pdf

The nature of the problem varies in different parts of the population. In 2022/23, the number of people receiving long-term care was 10% lower among the over-65 population than in 2015/16, while the number of requests for support in this age group grew by 6.1% in that period. In contrast, requests for support from the working-age population grew by 22.2% between 2015/16 and 2022/23, while the number accessing long-term care grew by only 2.1%.

The growing gap between the number of people asking for care and those receiving it is due to rationing. To be eligible for publicly provided adult social care, people have to meet both a means test and a needs test. Rationing has occurred in a couple of ways. First, the means test for adult social care has remained frozen in cash terms since 2010/11, meaning that as people’s wages and incomes have risen with inflation, fewer people are now eligible for publicly funded social care. People may still have requested support from their local authority, unaware that they would not meet the means test, but they would now find themselves ineligible.

Second, while difficult to prove, interviewees agreed that local authorities have also effectively raised the needs threshold for care. This is because the judgment about the need for any individual to receive care rests with local authorities. This means that someone who might have met the needs test in 2010 no longer does so in 2024.

There are alternative possible explanations for the decline in the number of people receiving publicly funded care, such as that local authorities are increasingly relying on a ‘strengths-based’ approach to adult social care – in which people are empowered to live in and contribute to their communities, rather than relying on long-term support. ¹⁵¹ Department of Health and Social Care, Strength-based Approach: Practice framework and practice handbook, GOV.UK, 2019, p. 24, https://assets.publishing.service.gov.uk/media/5c62ae87ed915d04446a5739/stengths-based-approach-practice-framework-and-handbook.pdf  But this explanation is not supported by a change in indicators that would provide evidence that local authorities are pursuing this approach. There has, for example, been little change in the number of people able to access short-term care to maximise independence, and there has been a decline in the amount of support provided to unpaid carers. ¹⁵² Hoddinott S, Davies N, Fright M, Nye P and Richards G, Performance Tracker 2023, Institute for Government, 2023, p. 136, www.instituteforgovernment.org.uk/sites/default/files/2024-01/performance-tracker-2023.pdf

This is not to say that local authorities are acting maliciously. No local authority wants to resort to rationing. But they are caught in an invidious and unenviable position between the needs of their residents, their legal obligation to provide an effective service, and cuts to their funding that prevent them from doing so.

Rising unmet need has wide-ranging implications

It is easy when discussing adult social care to talk in abstract terms about the change in the number of people receiving care and impersonal, technocratic concerns such as frozen thresholds in the means test. But a lack of support can have deep and material impacts on people’s lives. It means someone may struggle to feed, wash and clothe themselves. Or that they are denied help with their mobility, and their condition then rapidly deteriorates. Unmet need contributes to greater suffering and immiseration.

Just because people cannot access publicly funded care, it does not mean that their need for care goes away; rather, the burden of care just shifts elsewhere. Often that burden is carried by friends and family, who step in to help their loved one. According to the census, the number of people providing more than 20 hours a week of unpaid care (as it is impersonally known in policy circles) rose from 2.0 million in 2011 to 2.4 million in 2021. As a proportion of the population, it rose from 3.7% to 4.4% over this period.

This trend has not happened equally across England: the more deprived the area, the more likely it is that someone will have to provide more than 20 hours of unpaid care a week, and this gap widened between 2011 and 2021. In Blackpool, the most deprived upper-tier local authority in 2019, 6.6% of the population provided more than 20 hours of unpaid care a week, compared with 2.8% in Richmond-upon-Thames, the fourth least deprived local authority in 2019. This inequality is likely both because there is higher demand for adult social care among the most deprived parts of the population and because local authorities in deprived areas have also had their funding cut the most since 2010, as previously discussed. Residents in the least deprived parts of the country are also more likely to be able to pay for their own care, meaning that they rely less on unpaid care from relatives and friends.

One of the government’s policies for increasing funding for adult social care is the ‘adult social care precept’ – a percentage-point amount that local authorities may raise council tax by to fund their spending on the sector. But this approach exacerbates inequality of provision. As already discussed, the least deprived authorities receive a greater proportion of their funding from council tax. This means that for every 1 percentage-point increase in council tax, they raise more money than their more deprived counterparts.

A failure to provide adequate social care also affects other public services. Approximately 45% of the people who remain in hospital after being eligible for discharge are there because there is not enough capacity in adult social care. ¹⁵⁷ Nuffield Trust, ‘Delayed discharges from hospital’, 14 December 2023, www.nuffieldtrust.org.uk/resource/delayed-discharges-from-hospital  A lack of adequate care also increases the likelihood that someone will attend A&E ¹⁵⁸ Crawford R, Stoye G and Zaranko B, ‘Long-term care spending and hospital use among the older population in England’, Journal of Health Economics, 2021, vol. 78, www.sciencedirect.com/science/article/pii/S016762962100062X  and need admission to hospital, ¹⁵⁹ Department of Health and Social Care, Evidence Review for Adult Social Care Reform, GOV.UK, 2021, p. 75, https://assets.publishing.service.gov.uk/media/61a7bc688fa8f503780c1c79/evidence-review-for-adult-social-care-reform.pdf  as well as increases their need for GP appointments. ¹⁶⁰ Department of Health and Social Care, Evidence Review for Adult Social Care Reform, GOV.UK, 2021, p. 75, https://assets.publishing.service.gov.uk/media/61a7bc688fa8f503780c1c79/evidence-review-for-adult-social-care-reform.pdf  Therefore, putting aside the improvements in people’s quality of life that would come from increased access to adult social care, it would also help to reduce demand for more acute and expensive services.