Performance Tracker 2025: Adult social care

When it came to power in 2024, the Labour government inherited an adult social care system that successive governments had neglected. Cuts to local government grants during the early 2010s under the coalition government meant that local authorities were forced to reduce access to adult social care, particularly for older adults. Those cuts meant that, in 2019/20, spending on adult social care had only just returned to 2010/11 levels. Spending has increased substantially since then, but has struggled to keep pace with rising costs. As a result, it was only in 2022/23 and 2023/24 that access to adult social care increased compared to the previous years (although it still remains below pre-pandemic levels). This is because, ultimately, improving access requires more funding and for that funding to outstrip increases in the cost of delivering care. While funding will likely increase further in this parliament, it is unlikely to be enough to substantially redress the decline in access since 2010.

Multiple governments, from Blair to Sunak, committed themselves to reforming the sector. Brown promised free personal care and Johnson came close to implementing charging reform. But despite many commissions, reviews, command papers and Acts of Parliament, ¹ The King’s Fund, ‘A history of social care funding reform in England: 1948 to 2023’, blog, 4 May 2023, retrieved 12 September 2025, www.kingsfund.org.uk/insight-and-analysis/data-and-charts/short-history-social-care-funding  all those governments largely failed. That is partly because of the political damage ² Dunning J, ‘Labour rules out £20,000 death tax’, Community Care, 9 February 2010, retrieved 12 September 2025, www.communitycare.co.uk/2010/02/09/labour-rules-out-20000-death-tax ^{, 3} Asthana A and Elgot J, ‘Theresa May ditches manifesto plan with “dementia tax” U-turn’, The Guardian, 22 May 2017, retrieved 12 September 2025, www.theguardian.com/society/2017/may/22/theresa-may-u-turn-on-dementia-tax-cap-social-care-conservative-manifesto  that comes from trying to change the system. The current Labour government has internalised the lesson that reforming adult social care carries a heavy political cost. Despite a flurry of reforms across other services, it has effectively ruled out large-scale reform of adult social care during this parliament by launching an independent commission that will not deliver its final report until 2028.

Other decisions may actively harm the sector. For example, the government has decided to end the visa route for international care workers based outside the UK, cutting off a vital source of staff. While international staff are still entering the sector through other routes and the government has plans to boost domestic recruitment through ‘fair pay agreements’, these may not come soon enough or deliver the increases in staff that the sector needs.

The government’s inaction on adult social care is disappointing. Hundreds of thousands of people rely on care to help them live independent lives. More than one and a half million people work in the sector in England – more than in the NHS. ⁴ Skills for Care, The State of the Adult Social Care Sector and Workforce in England: 2024, 2024, www.skillsforcare.org.uk/Adult-Social-Care-Workforce-Data/Workforce-intelligence/documents/State-of-the-adult-social-care-sector/The-state-of-the-adu…  And almost six million people in the UK provide some level of unpaid care to friends and loved ones. ⁵ Carers UK, ‘Facts about carers’, (no date), www.carersuk.org/media/xajkldmo/facts-about-carers-june-2025final.pdf  In short, adult social care touches the lives of a large proportion of the population. Failing to improve the sector will be visible to those millions.

Putting aside an argument to improve the system on its own merits, adult social care has an impact on many other services and rationing care imposes costs elsewhere, either forcing people towards more expensive acute services or putting pressure on friends and relatives to leave the workforce to provide unpaid care. Failing to improve social care in this parliament would be a notable failure of the government and will hinder the progress of multiple reform programmes.
 

Spending on adult social care

Spending has risen considerably in recent years

The first half of the 10-year period from 2009/10 was difficult for adult social care. Under the coalition government, spending on the sector fell by 9.5% in real terms between 2009/10 and 2014/15. This accelerated the reduction in access to publicly funded care that we describe in more detail below, particularly for older adults.

Spending rose gradually during the second half of the decade and in 2019/20 was roughly in line with the level it had been a decade earlier. After that, the funding picture changed, and in 2024 Labour inherited a system that had experienced relatively large injections of funding in the previous few years. At £27.6 billion (bn) (2025/26 prices), spending in 2023/24 was 15.5% higher in real terms than in 2019/20, an average annual increase of 3.7% in real terms, compared to 2.1% between 2014/15 and 2019/20. In total, spending on publicly funded adult social care rose by 16.0% in real terms between 2009/10 and 2023/24.^*

That trend is set to continue. If total spending on the sector rises in line with local authorities’ spending in 2024/25, ⁶ Ministry of Housing, Communities and Local Government, ‘Local authority revenue expenditure and financing England: 2024 to 2025 budget individual local authority data’, GOV.UK, 3 October 2024, retrieved 12 September 2025, www.gov.uk/government/statistics/local-authority-revenue-expenditure-and-financing-england-2024-to-2025-budget-individual-local-authority-data  it will have risen again, by 3.6%. For 2025/26, we can estimate the increase in spending on adult social care by using the increase in local authorities’ funding. Using that data – and assuming that adult social care receives a proportional increase in funding – we would expect spending to rise again in 2025/26, by 4.6% in real terms.^** This would bring spending on adult social care to just under £30bn in 2025/26.

In recent years, much of the additional spending on adult social care has been funded from local authorities’ decision to raise Council Tax. Between 2019/20 and 2024/25, local authorities’ funding from Council Tax increased by 29.6% in real terms compared to 24.4% for grant funding.

This relatively large amount of additional funding has not translated into a commensurate increase in people being able to access care. As laid out in more depth below, most of this additional spending has been driven by above-inflation rises in fees for providers. Successive governments’ decision to raise the real-terms value of the National Living Wage has been one of the key drivers of these rises.

_{*    From now on, all social care discussed in this report will be publicly funded care, unless stated otherwise.
**    More precisely, this uses the increase in upper- and single-tier local authorities’ core spending power between 2024/25 and 2025/26. Please see the Methodology for more detail on how this was calculated.}

Much of the additional spending on adult social care in 2023/24 paid for increased fees for providers

Cancelled charging reforms funded additional spending in 2023/24

The Johnson government made progress on charging reforms where previous governments had failed. That government announced that it would implement a version of Andrew Dilnot’s charging reforms – first recommended in 2011 ⁷ The King’s Fund, ‘A history of social care funding reform in England: 1948 to 2023’, blog, 4 May 2023, retrieved 12 September 2025, www.kingsfund.org.uk/insight-and-analysis/data-and-charts/short-history-social-care-funding  – from October 2023. ⁸ Department of Health and Social Care, ‘Adult social care charging reform: further details’, GOV.UK, 12 September 2024, retrieved 12 September 2015, www.gov.uk/government/publications/build-back-better-our-plan-for-health-and-social-care/adult-social-care-charging-reform-further-details  In the 2022 autumn statement, the Sunak government delayed implementation to October 2025 (after the general election), putting the money that had been set aside for the reforms into new grants for social care in 2023/24. ⁹ HM Treasury, Autumn Statement 2022, CP 751, The Stationery Office, 2022, https://assets.publishing.service.gov.uk/media/63761099d3bf7f720cfc0040/CCS1022065440-001_SECURE_HMT_Autumn_Statement_November_2022_Web_accessible1_…  The incoming Labour government then cancelled the implementation of charging reforms after winning the election, with the chancellor, Rachel Reeves, stating that it was not possible to implement reforms that “were not funded”. ¹⁰ House of Commons, Hansard, ‘Public Spending: Inheritance’, 29 July 2024, col 1037, retrieved 18 September 2025, https://hansard.parliament.uk/commons/2024-07-29/debates/45E1221B-F210-4132-8A8E-711B96F4D503/PublicSpendingInheritance

If they had been implemented, the reforms would have limited the risk of “catastrophic costs” ¹¹ Independent Age, ‘Free personal care: how to eliminate catastrophic costs’, April 2019, www.housinglin.org.uk/_assets/Resources/Housing/OtherOrganisation/Catastrophic-costs-report.pdf  for some people who rely on adult social care and would have made the means test for the receipt of publicly funded social care more generous. But they would not have brought additional funding into the system or likely have improved the quality of care. Rather, the major effect would have been to shift some of the burden of funding the existing system from private individuals to the state.

While spending on adult social care has risen substantially in recent years, the rising costs of care have driven most of that increased spending. Since 2015/16, the unit cost of delivering care has risen faster than economy-wide inflation in all settings and for both working age adults (aged 18 to 64) and older adults (aged 65 and over). This means that local authorities have to spend more for the same level of care. Between 2019/20 and 2023/24, local authorities’ spending^* on long-term care rose by 17.1% in real terms. But if provider fees for home care (when carers travel to someone’s home to care for them), residential care and nursing care had stayed the same as in 2019/20, local authorities’ spending would have fallen by 8.0%, implying that local authorities are spending more for less activity.

Costs have risen particularly fast for older adults in nursing and residential care: between 2015/16 and 2023/24, the unit costs for care for those adults rose by 29.5% and 41.3% in real terms respectively.

The costs of providing residential care and nursing care to working-age adults rose by less: 13.9% and 18.4% respectively between 2015/16 and 2023/34. The cost of providing home care (for all adults, there is no split by age group) rose by 18.1% in real terms in that time.

_{*    This is in terms of gross current spending, to get a better view of the impact of fee changes, as it does not account for local authorities’ income. It is therefore not directly comparable to the net current spending totals shown earlier in this chapter.}

While fees have risen nationally, there was a substantial range in the average cost that different local authorities paid for home care in 2023/24. For example, Waltham Forest paid an average of £17.00 per hour, while Windsor and Maidenhead paid the most at £40.38 per hour.

At the end of 2022, the Homecare Association (a representative body for home care providers) recommended that the NHS and local authorities should pay a minimum of £25.95 per hour for home care in 2023/24 (the ‘minimum price’^*). ¹² Lloyd G, ‘Homecare Association announces new minimum price for homecare 2023-2024’, Home Care Insight, 14 December 2022, retrieved 12 September 2025, www.homecareinsight.co.uk/homecare-association-announces-new-minimum-price-for-homecare-2023-2024  Only 10 of the 149 local authorities (6.7%) for which we have data paid more than that amount on average, with almost half (49.0%) paying between £20.00 and £22.50 per hour.

_{*    The Homecare Association describes the minimum price as “the amount required to ensure the minimum legally compliant pay rate for care workers (excluding any enhancements for unsocial hours working), their travel time, mileage, and wage-related on-costs. The rate also includes the minimum contribution towards the costs of running a care business, which complies with quality and other legal requirements”; see Homecare Association, A Minimum Price for Homecare: April 2024 to March 2025, 2023.}

A rising National Living Wage is partly driving increasing costs

One of the main drivers of the increase in provider fees is the rising National Living Wage (NLW). Between 2015/16 and 2025/26, the NLW grew by 82.2% in cash terms. This means that it outstripped both growth in average earnings in the entire economy (45.1%) and economy-wide inflation^* (37.3%). There were only two years in that time (2021/22 and 2022/23) when the NLW grew less than economy-wide inflation. In real terms, the NLW grew by 32.7% between 2015/16 and 2025/26.

The NLW increases affect local authorities in two ways:

•    through the direct cost of having to pay their own staff more

•    through the indirect cost of having to pay independent providers more for care packages.

The adult social care sector is particularly exposed to the NLW. Skills for Care (the organisation that collates and publishes adult social care workforce data, alongside other responsibilities) estimates that, in March 2024, more than half (59%) of staff employed in the independent sector earned below the NLW level that was due to be introduced in April 2024. ¹³ Skills for Care, The State of the Adult Social Care Sector and Workforce in England: 2024, 2024, p. 103, www.skillsforcare.org.uk/Adult-Social-Care-Workforce-Data/Workforce-intelligence/documents/State-of-the-adult-social-care-sector/The-state-of-the-adu…  Because of this, an increase in the NLW generally means that providers’ wage bills increase substantially. Providers, in turn, pass those higher costs on to local authorities in the form of higher fees.

The Nuffield Trust estimates that, in 2025/26, the indirect cost of the NLW increase to local authorities will be £1.3bn. ¹⁴ Nuffield Trust, ‘Social care providers at risk of collapse as analysis reveals cost to sector of employer national insurance hike’, press release, 22 November 2024, retrieved 12 September 2025, www.nuffieldtrust.org.uk/news-item/social-care-providers-at-risk-of-collapse-as-analysis-reveals-cost-to-sector-of-employer-national-insurance-hike

_{*    In this instance, we mean the GDP deflator, as this is the index that measures the inflation that a local authority faces.}

Cost pressures risk wiping out any increase in spending in 2025/26

The Labour government raised employers’ National Insurance Contributions (employer NICs) at the 2024 autumn budget. ¹⁵ HM Government, Autumn Budget 2024: Fixing the foundations to deliver change, HC 295, The Stationery Office, 2024, https://assets.publishing.service.gov.uk/media/672b98bb40f7da695c921c61/Autumn_Budget_2024_Print.pdf  Like NLW rises, this will raise local authorities’ costs.

Labour provided local authorities with £502 million at the 2025/26 local government finance settlement to offset the cost of higher employer NICs for the staff they employ directly (across all services, not just adult social care). But that funding did not compensate local authorities for the higher NIC costs that independent providers will face. ¹⁶ Ministry of Housing, Communities and Local Government, ‘Guidance: updated explanatory note on the Employer National Insurance Contribution Grant 2025 to 2026’, GOV.UK, 3 February 2025, retrieved 12 September 2025, www.gov.uk/government/publications/updated-explanatory-note-on-the-employer-national-insurance-contribution-grant-2025-to-2026  As providers pass on those costs to local authorities in the form of higher fees, these are ‘indirect costs’ of the employers’ NICs to local authorities. The Nuffield Trust estimates that the impact of these indirect NICs costs will be £665m in 2025/26 to local authorities. ¹⁷ Nuffield Trust, ‘Social care providers at risk of collapse as analysis reveals cost to sector of employer national insurance hike’, press release, 22 November 2024, retrieved 12 September 2025, www.nuffieldtrust.org.uk/news-item/social-care-providers-at-risk-of-collapse-as-analysis-reveals-cost-to-sector-of-employer-national-insurance-hike

The cost of the NLW and employer NICs, combined with economy-wide inflation, mean that local authorities will spend £2.2bn on adult social in 2025/26 for the same level care as in 2023/24. At the same time, we estimate that the cash increase in funding for adult social care will be just over £2bn.

That means that the entirety of the uplift in spending on adult social care in 2025/26 could go on meeting the higher cost of delivering care. This is before accounting for pressure from rising demographic demand and the increasing complexity of need, which will require even more spending.

There is no straightforward relationship between spending and activity

It might be expected that local authorities that increased their spending on adult social care the most between 2022/23 and 2023/24 also saw the largest increase in activity. But this is not the case. There is no straightforward relationship between the change in spending on long-term adult social care and the change in the number of long-term care packages that local authorities provided between 2022/23 and 2023/24.^* This is true even after adjusting for changes in fees.

_{*    This is using gross current spending as the measure of spending, instead of net current spending, which accounts for income from sales, fees and charges. We use this measure because it is more likely to be linked to activity than net current spending.}

There are various factors that could explain why there is no direct relationship between spending and activity. There could, for example, be changes in the types and intensity of care that local authorities provide from year to year, with some choosing to shift spending towards prevention, while others put additional funding into more expensive long-term care packages. It is also possible that local authorities are choosing to increase the intensity of care for some of those with the highest needs who are already receiving care, which would result in higher spending but no apparent change in activity.

Interviewees speculated that this pattern could also be because reporting practices vary across local authorities and between years. As an example, they pointed out that local authorities record approximately a fifth of their spending as ‘other’, which would therefore not be included in our metric of spending on long-term care used above, but which may well have an impact on access to long-term care. ¹⁸ Institute for Government interview

There are positive recent signs for the provider market

The Sunak government set an ambition of stabilising the care provider market. One mechanism it used to achieve this goal was to encourage local authorities to increase provider fees above the rate of inflation in 2023/24. ¹⁹ Department of Health and Social Care, ‘Guidance: Market Sustainability and Improvement Fund 2023 to 2024’, GOV.UK, 2 June 2023, retrieved 12 September 2025, www.gov.uk/government/publications/market-sustainability-and-improvement-fund-2023-to-2024/market-sustainability-and-improvement-fund-2023-to-2024  To support local authorities to do this, it provided funding through the Market Sustainability and Improvement Fund (at least part of which was money for charging reform that the government reallocated ²⁰ Oung C, ‘What has happened to the funding earmarked for social care reform?’, Nuffield Trust, 24 July 2024, retrieved 12 September 2025, www.nuffieldtrust.org.uk/resource/what-has-happened-to-the-funding-earmarked-for-social-care-reform ).

It is difficult to know how effective this approach was. On the one hand, all 153 local authorities increased home care fees in 2023/24 and all but a small handful increased nursing and residential care fees – achieving at least part of the government’s stated aim. ²¹ Department of Health and Social Care, ‘Market Sustainability and Improvement Fund (MSIF): provider fee reporting 2023 to 2024’, GOV.UK, 28 July 2023, retrieved 12 September 2025, www.gov.uk/government/publications/market-sustainability-and-improvement-fund-2023-to-2024-care-provider-fees/market-sustainability-and-improvement-f…  But it is much harder to determine whether this achieved the desired effect of increasing stability in the provider market – due to a lack of data. One source of information about the provider market is the Association of Directors of Adult Social Services’ (ADASS)^* annual survey of its members. One measure that ADASS uses to track stability in the provider market is the proportion of local authorities in which providers have handed back contracts in the previous year. Providers hand back contracts for a range of reasons, including closure or a change in their business model, and the measure is therefore an “inexact” barometer of market health, as ADASS itself says. ²² Association of Directors of Adult Social Services, 2025 ADASS Spring Survey, 2025, p. 19, www.adass.org.uk/wp-content/uploads/2025/07/ADASS-Spring-Survey-Final-15-July-2025.pdf

Regardless of the reason, when a provider hands back their contract, it can create distress for service users who have to move to a new provider. ²³ Glasby J, Allen K, Bennett M, Douglass T, Iqbal A and others, ‘Achieving closure: improving outcomes when care homes close’, University of Birmingham and the National Institute for Health and Care Research, 2025, p. 6, www.birmingham.ac.uk/documents/college-social-sciences/social-policy/achieving-closure/ac-policyguide.digital.pdf  The 2025 ADASS survey shows that the proportion of local authorities that had providers hand back contracts in 2023/24 was the same as in 2022/23 (66%) and slightly higher than in 2021/22 (64%). But there was a large decline in 2024/25, to 56%. ²⁴ Association of Directors of Adult Social Services, 2025 ADASS Spring Survey, 2025, p. 19, www.adass.org.uk/wp-content/uploads/2025/07/ADASS-Spring-Survey-Final-15-July-2025.pdf  Unfortunately there is no data on earlier years to make further comparisons.

Another source of information is the Care Quality Commission, which inspects providers. It estimates that care home providers’ profit margin^** (before netting off interest costs, taxes and non-cash expenses) for residents aged 65+ rose from 22.5% in March 2022 to 26.9% in March 2024. ²⁵ Care Quality Commission, The State of Health Care and Adult Social Care in England 2023/24, HC 274, The Stationery Office, 2024, p. 51, www.cqc.org.uk/sites/default/files/2024-10/20241025_stateofcare2324_print_0.pdf  It attributes this to a mixture of rising occupancy rates, increasing fees and relatively flat costs (the Care Quality Commission attributes these flat costs, despite rising wages, to reduced use of agency staff). LaingBuisson analysis on the state of the independent sector shows that this increase in profitability comes after a long-term decline in provider profitability, going back to the start of the 2010s. ²⁶ LaingBuisson, Adult Social Care in the UK: Scale, structure, funding and financial performance of the independent sector, 2024, p. 18, retrieved 18 September 2025, www.homecareassociation.org.uk/asset/F26B2E4B-C183-45E8-ABC6274E97EE24AC

Despite these measures, successive governments have placed the failure of a major provider on the national risk register, estimating that there is a 5% to 25% chance that it will happen in the next five years. ²⁷ Cabinet Office, National Risk Register: 2025 edition, GOV.UK, 2025, p. 65, https://assets.publishing.service.gov.uk/media/67b5f85732b2aab18314bbe4/National_Risk_Register_2025.pdf  But one interviewee pointed out that there has not been a major failure for a long time (arguably the last was Southern Cross in 2011 ²⁸ BBC, ‘Southern Cross set to shut down and stop running homes’, BBC News, 11 July 2011, retrieved 12 September 2025, www.bbc.co.uk/news/business-14102750 ) or a swathe of smaller failures, implying that “the market is far more stable than the sector states”. ²⁹ Institute for Government interview.

_{*    Directors of adult social services (DASS) are responsible for delivering adult social care in a local authority
**    Technically, this is providers’ earnings before interest, taxation, depreciation, amortisation, rent and management fees.}
 

Adult social care staffing

Workforce growth continued in 2024/25

When the Labour government came to power in 2024, it inherited the largest adult social care workforce on record. There were 1.55 million filled posts in the adult social care sector (whether employed by local authorities, independent sector providers or direct payment recipients) in 2023/24, 7.5% up on 2022/23 and 11.9% higher than in 2016/17, the first year for which there is data on the workforce.

Workforce growth slowed in 2024/25. In that year, there were 3.2% more filled posts in the adult social care sector compared to 2023/24, bringing the total to 1.60 million. This happened at the same time as vacancy rates fell, as discussed in more depth below.

Skills for Care estimates that for the workforce to match the growth of the population aged 65 and over, there will need to be an increase of 470,000 posts between 2024/25 and 2040, a rise of 26.9%. ³⁰ Skills for Care, The Size and Structure of the Adult Social Care Sector and Workforce in England 2024/25, 2025, p. 16, www.skillsforcare.org.uk/Adult-Social-Care-Workforce-Data/Workforce-intelligence/documents/Size-and-structure/The-size-and-structure-of-the-adult-soc…  This would be an average annual increase of 1.6%. If the number of filled posts grows at the annual average growth rate between 2016/17 and 2024/25 (1.9%), this would be an achievable target. But this was a period in which there was a large influx of staff recruited from outside the UK, as discussed in more detail below. The current government has made it more difficult to recruit internationally, which might slow the rate of workforce growth in the coming years.

Most of the filled posts in 2024/25 were in the independent sector: 1.35 million out of the 1.60 million (84.3%), with 7.5% employed by local authorities and the remaining 7.5% employed by direct payment recipients.

A rise in international recruitment has driven workforce growth

The Labour government also inherited a system that was increasingly reliant on international staff. This followed the Johnson government’s decision to liberalise the immigration system in February 2022, making it easier for health and care staff who would earn low wages to come to the UK. This came after a recommendation from the Migration Advisory Committee (an independent public body that advises the government on migration issues) to add senior care workers to the Shortage Occupation List. ³¹ Migration Advisory Committee, Review of the Shortage Occupation List: 2020, GOV.UK, 2020, p. 281, https://assets.publishing.service.gov.uk/media/5f8d49748fa8f56ad551249a/SOL_2020_Report_Final.pdf

There was steady and then rapid growth in the number of staff from outside the UK and the European Economic Area (EEA) working in the adult social care sector between 2019/20 and 2023/24. In 2019/20, there were approximately 115,000 staff from outside the UK and EEA working in the local authority and independent sectors. That more than doubled to 295,000 in 2023/24, an increase of 156.5%.

In contrast, the number of British staff working in the adult social care sector fell every year between 2019/20 and 2023/24: from 1.19 million at the start of the period to 1.16 million at the end, a drop of 2.1%. This means that, in 2023/24, 19.1% of the adult social care workforce came from outside the UK and EEA, compared to 8.2% in 2019/20.

This trend did not stop after the Sunak government tightened visa requirements or after the Labour Party won the general election in 2024. By the end of 2024/25, there were 375,000 staff from outside the UK and EEA working in the independent and local authority adult social care sectors, an increase of 27.1% from 2023/24 and 226.1% higher than in 2019/20. It was the second highest single-year increase in staff, behind only 2023/24. There were also 30,000 fewer British staff in those sectors in 2024/25, compared to 2023/24. This means that, by the end of 2024/25, almost one in four (23.5%) people working in the adult social care sector were from outside the UK and EEA compared to roughly one in twelve (8.2%) in 2019/20.

This growth in the workforce was vital for improving access to adult social care in 2023/24. As one interviewee put it to us: “We would have been lost without international staff.” The Care Quality Commission also attributes the drop in providers’ use of agency staff between 2021/22 and 2023/24 to increased international recruitment. As it is generally more expensive for providers to fill vacancies with agency staff than with permanent staff, this has also helped to keep costs lower than they might be otherwise. But the Care Quality Commission stated that the benefits of this visa route shrank in 2023/24 as providers improved their recruitment and retention of British staff, although its report does not explain why this has happened. ³² Care Quality Commission, The State of Health Care and Adult Social Care in England 2023/24, HC 274, The Stationery Office, 2024, p. 52, www.cqc.org.uk/sites/default/files/2024-10/20241025_stateofcare2324_print_0.pdf

Reliance on international staff varies by region of England and staff group

In 2023/24 (the most recent year for which there is subnational data), more than a third (36.1%) of adult social care posts in London were filled by staff from outside the UK and EEA. In contrast, the North East had by far the smallest proportion of its workforce from outside the UK and EEA, at 8.2%.

Both in England as a whole and in all of its regions, the proportion of the adult social care workforce who are from outside the UK and EEA is greater than the proportion of the overall working-age population who are from outside the UK and EEA.^* For England, 20.5% of the adult social care workforce were from outside the UK and EEA in 2023/24, compared to 5.5% for the entire working-age population.

_{*    Unfortunately, the Office for National Statistics last published data on the working-age population from outside the UK and EEA in 2021 and therefore this does not capture more recent immigration to the UK.}

There are also differences between staff groups. In 2023/24, more than a quarter (27.7%) of registered nurses working in the adult social care sector were from outside the UK and EEA. In comparison, only 6.0% of managers were.

Vacancy and turnover rates fell in 2024/25

The Labour government inherited an adult social care workforce that is much more stable than it has been in recent years. For the fourth consecutive year, turnover rates in the adult social care workforce fell in 2023/24, to 24.8%, down from a high of 31.4% in 2019/20.

Turnover fell again in 2024/25, the Labour government’s first year in some control of the sector, to 23.7%. That is lower than any year since 2013/14. This is positive for the effectiveness of the workforce – staff who stay in the sector longer become more experienced and learn to work more effectively. There are also benefits from staff staying in one role for longer, as it increases the likelihood that they care for the same person.

Skills for Care believes that the reduction in the turnover rate is in part due to the increasing proportion of the workforce from outside the UK and EEA, who it says “have around half the turnover rate of people recruited from within the UK”. ³³ Skills for Care, The State of the Adult Social Care Sector and Workforce in England 2023, 2023, p. 72, www.skillsforcare.org.uk/Adult-Social-Care-Workforce-Data/Workforce-intelligence/documents/State-of-the-adult-social-care-sector/The-State-of-the-Adu…  Its report does not offer any explanation for why this is the case, but one interviewee suggested that it is because international staff are more likely to have fixed-term contracts that are tied to their visas, making it harder for them to leave their job.

Likewise, interviewees attributed the recent decline in the vacancy rate to higher international recruitment. The vacancy rate fell consistently between 2021/22 and 2024/25, from 10.5% to 7.0%. That now means that vacancies in adult social care are roughly in line with pre-pandemic levels (7.1% in 2019/20). However, this is still far above the vacancy rate of 2.2% across the wider UK economy in 2024/25.

As the number of total posts (which is the sum of filled and vacant posts) rose between 2023/24 and 2024/25, from 1.67 million to 1.71 million, providers reducing their hiring does not explain the falling vacancy rate. There a few factors that do. First, the leaver rate declined between 2023/24 and 2024/25, meaning that providers would not have to hire new staff as often. Second, employers may be finding it easier to recruit staff, although further research would be needed to establish whether this is the case. Third, the declining vacancy rate reflects the broad pattern in the wider economy. Across the economy, vacancies peaked in 2022/23 (a year after adult social care vacancies peaked and at a much lower rate than in the adult social care sector – only 3.2% compared to the peak in adult social care of 10.5%) and have since gradually declined. As with the adult social care sector, the economy-wide vacancy rate in 2024/25 was back to pre-pandemic levels.

Adult social care vacancy rates vary substantially by region and staff group, although data on this is only available for 2023/24, not 2024/25.

The national vacancy rate for all adult social care job roles in 2023/24 was 8.3%. This is not directly comparable to the national adult social care vacancy rate of 7.0% highlighted above, which was for 2024/25. Vacancy rates were highest in London – 10.5% of posts for all job roles were unfilled, two thirds higher than in the North East, where the figure stood at 6.3%.

In terms of staff groups, the highest proportion of unfilled posts in 2023/24 were for care workers, at 9.9%. Once again, the greatest shortfall was in London, where one in eight care worker posts were unfilled. Vacancy rates were consistently low in management positions in the sector: only 3.7% of managers and 1.7% of senior management roles were unoccupied and there was no region in England in which the vacancy rate for senior management roles exceeded 2.8%.

While this implies that there are few issues in terms of managerial staff groups at the moment, interviewees said that there are concerns in the sector about the pipeline of staff for future management roles. This is primarily because the wage scale for most staff groups has been compressed over the past few years as the National Living Wage (NLW) has risen. This has pushed up wages at the bottom of the pay scale, while wages further up have remained much more similar. This reduces the incentive for staff to progress into roles that have more responsibility, such as management.

The government’s decision to further tighten immigration rules for care workers could cause staff shortages

The Johnson government’s decision to add care workers to the Shortage Occupation List in February 2022 contributed to an increase in visa applications. In 2023/24, there were 93,329 applicants for health and care visas who would then work in ‘caring personal services’ (the closest proxy for care workers). Of these applications, the government granted 84,715 visas. This was an increase from 59,553 in 2022/23 and 7,354 in 2021/22.

However, there were fears that people who had no intention of working in the sector were abusing this visa route. In its 2023 review of the immigration system as it relates to the adult social care sector, the independent chief inspector of borders and immigration reported instances of fraud, such as people applying under the name of a residential care provider for 275 certificates of sponsorship (the document that the Home Office grants an employer, which allows them to hire someone from outside the UK ³⁴ HM Government, ‘UK visa sponsorship for employers’, GOV.UK, (no date), retrieved 12 September 2025, www.gov.uk/uk-visa-sponsorship-employers/certificates-of-sponsorship ), without the knowledge of the provider. ³⁵ Independent Chief Inspector of Borders and Immigration, An Inspection of the Immigration System as it Relates to the Social Care Sector: August 2023 – November 2023, GOV.UK, 2024, p. 5, https://assets.publishing.service.gov.uk/media/6602a6b765ca2fa78e7da854/An_inspection_of_the_immigration_system_as_it_relates_to_the_social_care_sect…  In response, the Sunak government increased the scrutiny of employers’ applications from October 2023, ³⁶ Ibid., p. 6.  resulting in a large decline in applications between then and mid-2024. ³⁷ Home Office, ‘Monthly entry clearance applications, June 2025’, GOV.UK, 10 July 2025, retrieved 12 September 2025, www.gov.uk/government/statistics/monthly-entry-clearance-visa-applications-june-2025/monthly-entry-clearance-visa-applications-june-2025

That intervention seems to have been the main cause of the sharp fall in applications rather than the later change the Sunak government made in spring 2024, ³⁸ Home Office, Department of Health and Social Care, Department for Work and Pensions, ‘New laws to cut migration and tackle care worker visa abuse’, GOV.UK, 11 March 2024, www.gov.uk/government/news/new-laws-to-cut-migration-and-tackle-care-worker-visa-abuse  after which the number of applications stayed broadly flat. The new reforms meant that care workers and senior care workers were no longer eligible to bring “dependants” (by which they mean carers’ family members) with them on their care visa and raised the salary threshold for applicants. ³⁹ Ibid.

The current government decided to further tighten visa rules for care workers. In its white paper, Restoring Control over the Immigration System, published in May 2025, it announced that it intends to “end overseas recruitment for social care visas”. ⁴⁰ HM Government, Restoring Control over the Immigration System, CP 1326, The Stationery Office, 2025, p. 27, https://assets.publishing.service.gov.uk/media/6821f334ced319d02c906103/restoring-control-over-the-immigration-system-web-optimised.pdf  The government subsequently ended the health and care visa on 22 July 2025 (although continues to allow people who are already in the country on another visa to apply for a health and care visa until 2028). ⁴¹ Home Office, ‘Explanatory memorandum to the statement of changes to the Immigration Rules: HC 997, 1 July 2025’, GOV.UK, 1 July 2025, retrieved 18 September 2025, www.gov.uk/government/publications/statement-of-changes-to-the-immigration-rules-hc-997-1-july-2025/explanatory-memorandum-to-the-statement-of-change…  Instead, the government hopes to encourage more British people to work in the sector through the creation of fair pay agreements (a manifesto commitment designed to increase the wages of care staff), as discussed in more depth below. ⁴² The Labour Party, Build an NHS Fit for the Future, manifesto, 2024, retrieved 18 September 2025, https://labour.org.uk/change/build-an-nhs-fit-for-the-future

There is now data for two years that the tightening of visa restrictions may have affected: 2023/24 and 2024/25. In both years, the number of staff from outside the UK and EEA working in adult social care increased despite the visa restrictions, albeit by less in 2024/25 than it had in 2023/24. Combined with lower vacancy rates, this might make it appear as though the visa restrictions have not had much of an effect on the sector.

But when we look at the number of people who started working in the sector having arrived in the UK that year, there was a large drop between 2023/24 and 2024/25 – 105,000 in the former compared to 44,000 in the latter. Of the 44,000 people in 2024/25, only 7,891 came to the UK on a health and care visa (17.9%). Skills for Care says that the remaining 34,000 must have come to the UK on other visa routes, such as student visas, or as dependants of people arriving in the UK through other visa routes. ⁴³ Skills for Care, The Size and Structure of the Adult Social Care Sector and Workforce in England: Workforce supply and demand trends 2024/25, 2025, p. 13, www.skillsforcare.org.uk/Adult-Social-Care-Workforce-Data/Workforce-intelligence/documents/Size-and-structure/The-size-and-structure-of-the-adult-soc…  A far higher proportion of international starters in the sector came through the health and care visa route in 2022/23 and 2023/24: 74.4% and 80.7% respectively.

Given other sources of international staff, it could be that the reduction in the number of health and care worker visas may either take a while to have an impact on the system or have no impact at all. But there is some evidence that the restrictions are making it harder for providers to recruit enough staff. In ADASS’s 2025 spring survey, directors of adult social services reported that some (although it is unclear how many) providers had handed back contracts due to “concerns… about the pipeline of international recruits [being] closed”. ⁴⁴ Association of Directors of Adult Social Services, 2025 ADASS Spring Survey, 2025, p. 20, www.adass.org.uk/wp-content/uploads/2025/07/ADASS-Spring-Survey-Final-15-July-2025.pdf

Regardless of the merits of shifting the source of recruitment from international to domestic staff, it is undoubtedly true that the constant to-ing and fro-ing on immigration policy since early 2021 makes it difficult for providers and local authorities to plan effectively. The government should aim for stability and pragmatism in its policy regarding the international recruitment of care staff for the rest of this parliament.

It is unclear how the government plans to implement fair pay agreements or what effect they will have

Introducing fair pay agreements (FPAs) is the government’s policy response to an anticipated reduction in international staff. These agreements are intended, among other aims, to make the sector more attractive to British staff. The government is legislating for the introduction of FPAs through the Employment Rights Bill, which is currently passing through parliament. ⁴⁵ Department for Business and Trade, ‘Factsheet: Employment Rights Bill – overview’, GOV.UK, 18 October 2024, https://assets.publishing.service.gov.uk/media/67f6711f555773bbf109e21a/employment-rights-bill-overview.pdf  This will create a single negotiating body that represents the sector nationally.

An FPA “provides a means to negotiate for better pay and conditions in the ASC [adult social care] sector as a whole and provides levers to ensure the negotiated outcome is honoured”. ⁴⁶ Department for Business and Trade, ‘Final stage impact assessment: establish a fair pay agreements process in the adult social care sector’, GOV.UK, 21 October 2024, p. 3, https://assets.publishing.service.gov.uk/media/671259d59cd657734653d7e5/impact-assessment-establish-a-fair-pay-agreements-process-in-the-adult-social…  The government’s own impact assessment provides only a vague indication of costs and benefits, although it says that it expects FPAs to translate into higher costs for self-funders and local authorities. ⁴⁷ Ibid., p. 21

There is still little detail on how the FPAs will work in practice or what form they will take. Some of that is by design. The government’s legislation requires that providers and unions decide the scope of the negotiations themselves.

Even if there was clarity around these matters, there are several barriers to the effective implementation of FPAs. FPAs require agreement between representative bodies of both employees and employers. This is easier said than done. The provider market is heavily fragmented, with more than 18,000 providers operating across England. There are membership organisations – for example the Homecare Association and Care England – but negotiating FPAs would go beyond their current responsibilities. And while they all represent providers, these representative organisations often have overlapping but not completely aligned interests, making agreement difficult.

In addition, direct payment recipients employ approximately 123,000 people, further adding to the complexity of the employment landscape. Finally, there is no collective body representing workers in the sector – the Resolution Foundation estimates that only 15% of staff that private sector providers employ are members of a union. ⁴⁸ Cominetti N, Who Cares? The experience of social workers, and the enforcement of employment rights in the sector, Resolution Foundation, 2023, p. 34, www.resolutionfoundation.org/app/uploads/2023/01/Who-cares.pdf

Experience from the New Zealand government’s attempt to implement a similar FPA system indicates that building consensus among employers is crucial, and even then, there is no guarantee of co-operation. ⁴⁹ Davison N, ‘Labour’s fair pay agreements: lessons for Keir Starmer from New Zealand’, blog, Institute for Government, 24 July 2024, retrieved 12 September 2025, www.instituteforgovernment.org.uk/comment/labours-fair-pay-agreements-new-zealand

Starting in 2020, the French government has managed to increase pay for care workers through a set of agreements collectively bargained between unions and providers. This includes a national pay scale that rewards things such as length of time in the sector and levels of qualifications. ⁵⁰ Hemmings N, Allen L, Lobont C, Burale H, Thorlby R, Alderwick H and Curry N, From Ambition to Reality: National policy options to improve care worker pay in England, Nuffield Trust, 2024, p. 30, www.nuffieldtrust.org.uk/sites/default/files/2024-07/Nuffield%20Trust%20and%20Health%20Fdn%20-%20Care%20worker%20pay_WEB.pdf

Previous Institute for Government work has recommended some alternative, simpler models that could deliver similar results. These include:

•    introducing a sector-specific minimum wage

•    setting up a social care pay review body (along the lines of pay review bodies in the NHS, schools and other public sector areas), which could recommend pay for the sector in each year

•    creating an institution modelled on Australia’s Fair Work Commission, which sets the pay and terms for the sector based on submissions from employers and unions, without having to rely on the government to approve recommendations. ⁵¹ Davison N, ‘Labour’s fair pay agreements: lessons for Keir Starmer from New Zealand’, blog, Institute for Government, 24 July 2024, retrieved 12 September 2025, www.instituteforgovernment.org.uk/comment/labours-fair-pay-agreements-new-zealand

A less controversial step would be for the government to enforce the payment of existing National Living Wage levels, given widespread underpayment across the sector. As an example, the Nuffield Trust points out that many home care workers are not paid for the time that they spend travelling between appointments. ⁵² Hemmings N, Allen L, Lobont C, Burale H, Thorlby R, Alderwick H and Curry N, From Ambition to Reality: National policy options to improve care worker pay in England, Nuffield Trust, 2024, p. 21, www.nuffieldtrust.org.uk/sites/default/files/2024-07/Nuffield%20Trust%20and%20Health%20Fdn%20-%20Care%20worker%20pay_WEB.pdf

Crucially, the implementation of any FPA that set a sector-specific wage for social care would, by definition, result in providers having to pay staff more. This would require local authorities to pay more for care in the form of higher provider fees. Work from the Fabian Society estimates that setting pay equivalent to an NHS health care assistant would cost local authorities an additional £1.5bn per year, ⁵³ Dromey J and Cooper B, Seizing the Opportunity: The fair pay agreement in social care, Fabian Society, 2025, p. 2, https://fabians.org.uk/wp-content/uploads/2025/05/FPA-Report-FINAL-iw-formatted.pdf  an increase of 5.8% of 2023/24 social care spending and 2.2% of local authorities’ core spending power in 2025/26. In October 2025, the government announced that it will establish the ‘Adult Social Care Negotiating Body’ in 2026, with the first fair pay agreement ‘coming into force in 2028’.^* The government has allocated £500m for funding that agreement, roughly 2% of the amount spent on the service in 2023/24.

_{*    Department of Health and Social Care, ‘£500 million for first ever fair pay agreement for care workers’, GOV.UK, press release, 30 September 2025, retrieved 7 October 2025, www.gov.uk/government/news/500m-for-first- ever-fair-pay-agreement-for-care-workers}

A far larger proportion of staff in adult social care are employed on zero-hours contracts than in the wider economy

In 2023/24,^* local authorities and independent sector providers employed 21.5% of their staff on zero-hours contracts. These contracts allow employers to employ staff for short periods of time, with no obligation to give them a minimum number of hours. Conversely, staff can refuse to work when asked. ⁵⁴ HM Government, ‘Contract types and employer responsibilities’, GOV.UK, (no date), retrieved 12 September 2025, www.gov.uk/contract-types-and-employer-responsibilities/zero-hour-contracts  There is a large difference in the use of zero-hours contracts between different types of employer. In 2023/24, only 5.4% of local authority staff were employed on zero-hours contracts, compared to 22.9% of independent provider staff. In comparison, only 3.2% of people in employment in England were employed on zero-hours contracts between January and March 2024. ⁵⁵ Office for National Statistics, ‘EMP17: People in employment on zero hours contracts’, GOV.UK, 12 August 2025, retrieved 12 September 2025, www.ons.gov.uk/employmentandlabourmarket/peopleinwork/employmentandemployeetypes/datasets/emp17peopleinemploymentonzerohourscontracts

The year 2023/24 saw the lowest level of zero-hours contract usage (21.5%) since at least 2016/17, when Skills for Care began publishing data. But there has been little variation in that time. The highest level of employers’ use of zero-hours contracts was in 2020/21, when 24.7% of staff were employed on these contracts in the independent and local authority sectors.

There is much more variation in the use of zero-hours contracts between the regions of England and local authorities. In 2023/24, London had the highest proportion of zero-hours contract usage, at 38.6%, while the North East had the lowest, at 15.6%. The local authority with the lowest rate of usage was North East Lincolnshire, at 7.6%, and the local authority with the highest level was Redbridge, in London, at 58.8%.

_{*    This is the most recent year for which there is published data.}

The government’s employment reforms should reduce the use of zero-hours contracts and may increase the cost of providing care

As part of the government’s Employment Rights Bill, staff employed on zero-hours contracts will be able to move onto guaranteed hours contracts, if they wish. ⁵⁶ Department for Business and Trade, ‘Factsheet: Zero hours contracts’, GOV.UK, (no date), https://assets.publishing.service.gov.uk/media/67e429cf2621ba30ed9776d1/zero-hours-contracts.pdf  This will increase the certainty and stability of work for those employees, but it will also likely raise costs for employers.

As a sector with a large proportion of staff working on zero-hours contracts, adult social care providers will likely see their costs rise, in some cases substantially. As with other measures – such as an increase in the National Living Wage, which pushes up the cost of employing staff – this will likely mean that local authorities will have to pay higher fees to providers for the same level of work.

As with the implementation of fair pay agreements, central government must ensure that local authorities are appropriately compensated for changes in national policy that drive up the cost of providing care. If not, there is a risk that these changes will result in a reduction in access to care.
 

Demand for adult social care

Requests for social care support grew sharply among younger adults (aged 18–64) in 2023/24

In 2023/24, 1.4 million total adults in England requested support^* from their local authority, an increase of 4.9% from 2022/23. Between 2022/23 and 2023/24, there was growth among both working-age adults and older adults, by 8.5% and 3.2% respectively. This represented a small increase in the proportion of the adult population overall requesting support: in 2022/23, 3.0% of the adult population requested support, compared to 3.1% in 2023/24.

There was growth in requests, even when accounting for changes in population size. 1.3% of working-age adults requested support in 2022/23, rising to 1.4% in 2023/24 – an increase of 6.7%.

Unsurprisingly, a far higher proportion of the population aged 65 and over request support from their local authority than the working-age population. In 2022/23, 8.7% of people aged 65 and over requested support, rising to 8.8% in 2023/24, an increase of 1.6%. The year 2023/24 was the first year that the proportion of adults of all ages requesting support exceeded pre-pandemic levels. The year also saw the highest number of requests for support on record.

Over the longer-term, however, patterns of demand for the two age groups have diverged. The proportion of working age adults requesting support increased 18.6% between 2017/18 and 2023/25. In contrast, there was a decline in the proportion of over-65s requesting support between 2017/18 and 2023/24, by 7.5%. Both of these trends mirror changes in disability rates, as we have previously shown, ⁵⁷ Hoddinott S, Adult Social Care Across England: Performance Tracker Local, Institute for Government, 2025, retrieved 18 September 2025, www.instituteforgovernment.org.uk/publication/performance-tracker-local/adult-social-care  and which we discuss further below.

_{*    This may not be a perfect indication of need for care. People may not come forward for care when they are eligible as they might be receiving unpaid care from friends or family. And some may apply for an assessment when they are not eligible.}

There is considerable variation in requests for support around England,^* with London a particular outlier. Compared to the England average of 3.1% of all adults requesting support in 2023/24, requests for support in London were approximately a third lower: 2.1%. London also had the lowest and second lowest proportion of adults requesting support in the 18–64 and 65+ age groups, respectively.

At the other end of the spectrum, in 2023/24, a far larger proportion of working-age adults requested support in the North East than either London or England as a whole: 1.9% compared to 1.0% and 1.4%, respectively.

_{*    Some reviewers argued that local authorities record requests for support differently, meaning that some of the data presented here is not directly comparable. We still believe there is benefit in comparing broad trends as different recording practices do not seem to explain, on their own, the scale of some of the differences seen.}

Access to adult social care is not keeping pace with demand

Need for care is difficult to determine. We can look at changes in requests for support, as previously discussed. But this is only a partial view. We therefore need to look at other measures of demand.

In the 2011 census, 13.4% of adults aged 20–64 reported living with a disability. This rose to 15.6% in the 2021 census. The increase was even larger among those aged 20–34, where self-reported disability grew from 6.1% in 2011 to 12.0% in 2021. In contrast, the rates of reported disability among adults aged 65+ shrank, from 53.1% in 2011 to 35.2% in 2021.

But despite increasing levels of demand, the rate of access has not kept pace. Among adults aged 18–64, there was a slight decline in access between 2010/11 and 2020/21, while self-reported disability rates increased. And while both disability rates and access declined for older adults, the rate of the fall in access was greater than the rate of decline in disability rates. If both were indexed at 100 in 2011, then disability rates fell to 66.3 while access fell to 58.1.
 

Activity and access

A greater proportion of adults received care in 2023/24

The Labour government inherited a system where access to adult social care was at near historic lows. From a high of 2.31% of the total adult population receiving publicly funded long-term care in 2003/04, access fell gradually throughout the rest of the 2000s, declined precipitously in the first half of the 2010s^* and then reached a low of 1.37% in 2021/22 (although this was partly due to a reluctance to draw on adult social care during the Covid pandemic). By 2023/24, access to long-term care had rebounded slightly, to 1.42% of the adult population, in line with the level in 2019/20.

_{*    There are two caveats to this trend. First, the government collected slightly different data from 2014/15 onwards (although it published this time series as being broadly comparable to previous years). And second, the introduction of the Care Act in 2014 placed new duties on local authorities, which may have changed the type and amount of care that they provided.}

The decline was steepest among those aged 65+. The proportion of older adults accessing long-term care was 8.19% in 2003/04 and 3.57% in 2023/24, slightly above the low of 3.44% in 2021/22. Access to care among working-age adults (those aged 18–64) also fell between 2003/04 and 2023/24, albeit much less dramatically, from 0.79% to a low of 0.74% in 2015/16, before increasing marginally to 0.76% in 2023/24.

A smaller proportion of people accessed care in most settings in 2023/24 than in 2003/04. This includes working-age and older adults in nursing and residential settings, as well as older adults in community care. The only setting in which there was growth in the proportion of adults accessing long-term care was community care for working-age adults, where 0.65% of adults were accessing care in 2023/24, up from 0.60% in 2003/04. That is the result of successive governments pushing for increased use of community settings. However, our analysis finds that there is a strong negative relationship between the proportion of care users receiving community care and users’ self-reported quality of life scores.

The number and proportion of working-age adults in residential care continued its steady, long-term decline in 2023/24, reaching a historic low of 0.1% – about half the rate in 2003/04 – due to long-running policy to shift care away from residential settings. This is the only age group and setting where the proportion of people accessing care was lower in 2023/24 than it was in 2022/23.
 

Reduced access is partly due to rationing and a less generous means test

As previous Institute for Government work has shown, falling rates of access to long- term care over the past few decades – particularly among older adults – are the result of local authorities being forced to ration care due to restricted finances. ⁸⁸ Hoddinott S, Adult Social Care Across England: Performance Tracker Local, Institute for Government, 2025, retrieved 18 September 2025, www.instituteforgovernment.org.uk/publication/performance-tracker-local/adult-social-care

There is a strong negative relationship between the size of a local authority’s older population and the proportion of the population receiving long-term care. As an older adult population acts as a proxy for demand for care, local authorities that have high levels of demand respond by reducing the amount of care that is provided. As our previous work showed, the result holds when controlling for other determinants of demand for adult social care, such as deprivation and living arrangements. ⁵⁹ Ibid., p. 28.

This is a phenomenon that pre-dated the coalition government taking office in 2010 but was turbocharged during the first half of the 2010s as central government cut councils’ grant funding. Rates of access to long-term care fell more quickly for both older and younger adults between 2009/10 and 2016/17 than in the years before or since.

Our previous analysis has also shown that more people provide unpaid care in the local authorities that provide less long-term care to residents aged 65 and over. An additional percentage point of the 65+ population receiving long-term care is associated with a 0.6 percentage-point reduction in the proportion of the population providing any amount of unpaid care. ⁶⁰ Hoddinott S, Adult Social Care Across England: Performance Tracker Local, Institute for Government, 2025, retrieved 18 September 2025, www.instituteforgovernment.org.uk/publication/performance-tracker-local/adult-social-care  It is difficult to know which way causality flows in this relationship, but interviewees suggested that it was likely that when local authorities ration care, friends and family members are required to provide more unpaid care.

Another reason that a lower proportion of people accessed care in 2023/24 than in the past is because the means test for care has become less generous over time. Not everyone is eligible for publicly funded care. To receive it, a person has to meet both the needs test (which becomes less likely as disability rates and other drivers of demand decline) and the means test. The latter of these assesses an individual’s income and assets to determine whether they are wealthy enough to pay for their own care. ⁶¹ NHS England, ‘Financial assessment (means test) for social care’, (no date), retrieved 12 September 2025, www.nhs.uk/social-care-and-support/help-from-social-services-and-charities/financial-assessment-means-test

But successive governments have kept the thresholds of the means tests frozen in cash terms since 2010/11. This means that the upper and lower capital limits are, respectively, 36.6% and 36.1% lower in 2025/26 than they were in 2010/11, after adjusting for inflation. ⁹⁰ Hoddinott S, Adult Social Care Across England: Performance Tracker Local, Institute for Government, 2025, p. 17, www.instituteforgovernment.org.uk/sites/default/files/2025-06/adult-social-care-across-england_1.pdf

Local authorities provided far more short-term care in 2023/24

An alternative explanation for falling levels of access to long-term care is that local authorities are instead substituting long-term care with activity that prevents people from requiring that care in the first place. This is difficult to prove. But one proxy for this type of preventative care is the provision of short-term care. The chart below shows the number of short-term care packages designed to maximise independence (otherwise known as ‘ST-Max’ packages) that local authorities provided between 2014/15 and 2023/24.
 

Between 2014/15 and 2022/23, there was not much evidence that local authorities were substituting long-term care packages with increasing numbers of ST-Max packages. But the number of ST-Max care packages rose from 251,260 in 2022/23 to 281,855 in 2023/24 – an increase of 12.2%. The increase happened for both working- age and older adults, although the growth was larger for the former: 15.6% compared to 11.7% for older adults.

Local authorities delivered a record number of ST-Max care packages in 2023/24, with the largest single-year increase on record. That level was 10.8% higher than in 2014/15 – the first year for which there is data on these packages.

Interviewees said that this could be due to the hospital discharge fund, which the previous government launched in 2023/24. ⁶³ Institute for Government interview.  This made £200m available to NHS integrated care boards to provide people who have been discharged from hospital with “up to four weeks of a new or extended package of care”. ⁶⁴ NHS England, ‘Hospital discharge fund guidance’, 23 January 2023, retrieved 12 September 2025, www.england.nhs.uk/long-read/hospital-discharge-fund-guidance  This reflects a wider trend in health and care of shifting more care into the community – one of the current government’s aims for the NHS. But this also highlights the incoherence of reforming the NHS without simultaneously reforming the care sector; making a success of NHS reforms requires a well-functioning social care system.

The pattern of reduced access to long-term care in local authorities that have larger older adult populations does not hold in the case of short-term care. There is no relationship between the proportion of adults aged 65 and over and the number of short-term care packages per person aged 65+.

Support for carers returned to pre-pandemic levels in 2023/24

Other than contracting with providers to provide someone with care, or providing it directly themselves, local authorities can also provide support to unpaid carers if they meet certain eligibility criteria, as set out in the Care Act 2014. ⁶⁵ Legislation.gov.uk, ‘The Care and Support (Eligibility Criteria) Regulations 2015’, Regulation 3, 2015, retrieved 12 September 2025, www.legislation.gov.uk/uksi/2015/313/regulation/3/made  This support can be in the form of direct payments (when the local authority provides cash payments to the carer or the person requiring care ⁶⁶ Carers UK, ‘Understanding direct payments’, (no date), retrieved 12 September 2025, www.carersuk.org/help-and-advice/practical-support/arranging-care-and-support-for-someone/direct-payments ) or as respite care (whereby the carer is able to take a break while someone else cares for their friend or family member ⁶⁷ NHS England, ‘Carers’ breaks and respite care’, (no date), retrieved 12 September 2025, www.nhs.uk/social-care-and-support/support-and-benefits-for-carers/carer-breaks-and-respite-care ).

After a dip during the pandemic, reaching a low in 2022/23, local authorities increased the amount of direct support^* they provided to carers in 2023/24.
_{*    This is the sum of direct payments, part direct payments, managed personal budgets and commissioned support. It excludes the provision of information and signposting.}

Local authorities provided approximately 108,000 carers with direct support in 2023/24 compared to 97,000 in 2022/23 – an increase of 10.9%. But this was still 22.4% lower than the level provided in 2014/15, and roughly in line with the level provided in 2020/21. One interviewee suggested that the increase in 2023/24 could be the result of local authorities having slightly more financial headroom and thus being better able to fund a service that had previously been deprioritised in the face of funding pressures. ⁶⁸ Institute for Government interview.

There was also a decline in the number of carers coming forward for assistance: by 15.2% between 2014/15 and 2023/24. But this means that even though the direct support provided to carers increased in 2023/24 compared to 2022/23, the amount of direct support provided fell further than requests for support between 2014/15 and 2023/24.

Part of the reduction in the number of carers coming forward for support could reflect a genuine reduction in demand for support. The census showed that the number of people providing unpaid care fell from 5.4 million in 2011 to 4.7 million in 2021, a drop of 13.8%. ⁶⁹ Office for National Statistics, ‘Unpaid care, England and Wales: Census 2021’, 19 January 2023, retrieved 12 September 2025, www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandwellbeing/bulletins/unpaidcareenglandandwales/census2021

While not perfectly comparable due to different time periods, this is roughly similar to the reduction in the proportion of requests for support. It could also be that people realised that they were less likely to receive support, so elected not to come forward in the first place.

Most requests for support still result in the local authority providing the unpaid carer with ‘information and advice’ – one of the lowest cost responses available to a local authority. This was the outcome for 55.4% of requests in 2023/24, compared to 43.5% in 2014/15.

Local authorities report that they scaled back preventative spending in 2024/25

Local authorities have a duty to undertake preventative activity that they think will reduce the need for care in their area, among other objectives. ⁷⁰ Legislation.gov.uk, ‘The Care Act 2014’, part 1, section 2, 2014, retrieved 12 September 2025, www.legislation.gov.uk/ukpga/2014/23/section/2  The range of activity that can be classified as preventative is broad. In its statutory guidance for delivering care and support, the Department of Health and Social Care says that there “is no single definition for what constitutes preventative activity” and lists a range of activities, including population-level interventions to improve health and interventions to improve unpaid carers’ wellbeing. ⁷¹ Department of Health and Social Care, ‘Care and support statutory guidance’, GOV.UK, 22 July 2025, retrieved 12 September 2025, www.gov.uk/government/publications/care-act-statutory-guidance/care-and-support-statutory-guidance  The Social Care Institute for Excellence has attempted to provide a tighter definition of what constitutes prevention in adult social care: “services which prevent or delay the need for care in higher-cost, more intensive settings” and “strategies and approaches that promote the quality of life of older people and their engagement with the community”. ⁷² Social Care Institute for Excellence, ‘Prevention in social care’, May 2021, retrieved 18 September 2025, www.scie.org.uk/integrated-care/prevention-in-social-care  But even these cover a wide range of potential interventions.

This vagueness allows local authorities to define preventative activity quite widely. Despite that, ADASS’s 2025 spring survey shows that directors of adult social services anticipate that spending on prevention^* will fall in 2024/25 and 2025/26, after an uptick in both estimated spending and activity in 2023/24. This decline is in both cash terms, but also as a proportion of net spending on adult social care in their local authorities. They estimate that the proportion of net spending on adult social care that goes on prevention will fall from 8.2% in 2023/24 to 7.0% in 2024/25 and 5.6% in 2025/26. ⁷³ Association of Directors of Adult Social Services, 2025 ADASS Spring Survey, 2025, p. 34, www.adass.org.uk/wp-content/uploads/2025/07/ADASS-Spring-Survey-Final-15-July-2025.pdf

_{*    The question that ADASS asked local authorities in its 2025 spring survey was: “What is your planned spend for 2025/26 on wider prevention services that can be accessed by people whose needs do not cross the national eligibility threshold?” This means the spending would exclude any activity such as the short-term care packages, long-term care and support for carers that we discuss in this section. This is a helpful measure of preventative spending because it includes spending that is more discretionary than spending incurred after someone meets the eligibility threshold.}

There are a range of reasons for this low and declining spend on preventative activity. In March 2025, Melanie Williams (then president of ADASS and director of adult social services for Nottinghamshire County Council) described the difficulties to the House of Commons Health and Social Care Committee:

“[Local authorities] have a very in year focus. It is all about managing the restrictions now and, in all honesty, trying to work with somebody in a way that minimises their draw on adult social care and the cost [to the local authority].” ⁷⁴ House of Commons Health and Social Care Committee, Oral Evidence: Adult social care reform: The cost of inaction, HC 368, The Stationery Office, 2025, Q 135, https://committees.parliament.uk/oralevidence/15468/pdf

She then went on to describe how the rising costs of providing care mean that local authorities are less able to spend money on the upstream services that reduce demand in the longer run.

There are good examples of local authorities taking preventative approaches to provision. In its report on Camden council (one of only two local authorities to thus far receive an ‘outstanding’ score after an inspection), the Care Quality Commission said that “a prevention approach was evident at all levels of the local authority”. ⁷⁵ Care Quality Commission, ‘London Borough of Camden: local authority assessment’, 7 August 2025, retrieved 12 September 2025, www.cqc.org.uk/care-services/local-authority-assessment-reports/camden-0225-theme1-support  Crucially, Camden relies on working across multiple services within the local authority – housing services and drug and alcohol services, for example – to help reduce the reliance on adult social care. Despite lauding Camden’s approach, the report notes that there is little evidence from published data about the impact of this approach, showing a key difficulty that local authorities have in justifying greater spending on prevention.

Many of the reasons for underinvesting in prevention in adult social care are the same as previous Institute for Government work has described across all public services:

•    a need to provide and fund acute services in a constrained funding environment

•    a lack of strong evidence

•    poor political incentives to create long-term benefits

•    difficulties agreeing on what outcomes to pursue. ⁷⁶ Hoddinott S, Davies N and Kim D, A Preventative Approach to Public Services, Institute for Government, 2024, retrieved 18 September 2025, www.instituteforgovernment.org.uk/publication/preventative-approach-public-services

One interviewee stressed that some preventative work that would benefit adult social care sits outside of local authorities’ remit. The example they gave was the use of district nurses (who are employed by the NHS) to help reduce avoidable admissions to hospital, as admissions tend to contribute to higher demand for adult social care. ⁷⁷ Institute for Government interview.  But a lack of district nurses is also the result of the NHS failing to properly invest in preventative interventions and a consistently poor track record of co-operation between adult social care and the NHS.
 

Performance

The number of people waiting for adult social care assessments is slowly falling 

After the pandemic, ADASS surveys suggested that there was a large increase in the number of people who were waiting for a local authority assessment of their care needs.

This reached a peak of 294,000 people waiting for an assessment in April 2022, despite requests for support in 2021/22 being lower than they were before the pandemic. The number of people waiting more than six months peaked later, at 85,000 in August 2023. Both levels have fallen recently. There were 196,000 people waiting for an assessment in March 2025, down from 227,000 a year earlier, a fall of 13.9%.

Long waits for an assessment mean that people who are waiting and would be eligible for publicly funded care spend longer living without the support necessary to improve their standard of living. It can also mean that people deteriorate further and might, in some situations, require admission to hospital.

It was reasonable for there to be a spike in people waiting for an assessment during the pandemic as face-to-face contact was restricted. But interviewees claimed that the reason for the consistent backlog after the pandemic was due to a lack of staff – such as social workers – who carry out assessments of an individual’s care needs. ⁷⁸ Institute for Government interview.  At a national level, the number of social workers was flat at 19,000 between 2019/20 and 2021/22. But there was a slight increase to 19,500 in 2022/23 and a larger increase to 21,000 – a record level – in 2023/24. ⁹² Skills for Care, ‘Workforce data estimates’, (no date), 12 September 2025, retrieved 18 September 2025, www.skillsforcare.org.uk/Adult-Social-Care-Workforce-Data/Workforce-intelligence/publications/Workforce-estimates.aspx  This might explain why there has been progress in clearing some of the backlog of assessments.

The Care Quality Commission has inspected just over a third of local authorities

The previous government introduced assessments of local authorities’ adult social care services in April 2023. ⁸⁰ Samuel M, ‘CQC checks on council adult services still set for April 2023 start’, Community Care, 12 February 2023, retrieved 12 September 2025, www.communitycare.co.uk/2023/02/12/cqc-checks-on-council-adult-services-still-set-for-april-2023-start  Those assessments are intended to evaluate whether local authorities are meeting their duties as laid out under the Care Act 2014. ⁸¹ Care Quality Commission, ‘An introduction to our assessments of local authorities’, 30 June 2025, retrieved 12 September 2025, www.cqc.org.uk/guidance-regulation/local-authorities/introduction-to-assessments  These include responsibilities such as:

•    “promoting individual wellbeing”

•    “preventing needs for care and support”

•    “promoting integration of care and support with health services”. ⁸² Legislation.gov.uk, ‘The Care Act 2014’, part 1, 2014, retrieved 12 September 2025, www.legislation.gov.uk/ukpga/2014/23/part/1

Since April 2023, the Care Quality Commission has conducted assessments of all upper- and single-tier local authorities. At the time of writing, it has published the results of 68 inspections – just under 45% of the total number of local authorities. It aims to have conducted first assessments of all local authorities by December 2025. ⁸³ Local Government Association, ‘CQC’s assurance framework’, (no date), retrieved 12 September 2025, www.local.gov.uk/our-support/partners-care-and-health/cqcs-assurance-framework

Of those 68 local authorities, the Care Quality Commission rated one local authority as ‘inadequate’, 20 local authorities (29.4%) as ‘requires improvement’, 45 (66.2%) as ‘good’ and only two (1.9%) as ‘outstanding’. Camden, and Kensington and Chelsea – the only two local authorities that received an outstanding rating – were awarded a substantially higher score (89 out of 100) ⁸⁴ Care Quality Commission, ‘London Borough of Camden: local authority assessment’, 7 August 2025, retrieved 12 September 2025, www.cqc.org.uk/care-services/local-authority-assessment-reports/camden-0225-summary , ⁸⁵ Care Quality Commission, ‘Royal Borough of Kensington and Chelsea: local authority assessment’, 25 July 2025, retrieved 12 September 2025, www.cqc.org.uk/care-services/local-authority-assessment-reports/kensingtonchelsea-0725/summary  than Hertfordshire, the next best performing council (81 out of 100). ⁸⁶ Care Quality Commission, ‘Hertfordshire County Council: local authority assessment’, 29 July 2025, retrieved 12 September 2025, www.cqc.org.uk/care-services/local-authority-assessment-reports/Hertfordshire2

Although the sample size is still relatively small, there is no obvious relationship between a local authority’s score on their Care Quality Commission assessment and metrics including:

•    levels of access to adult social care

•    satisfaction scores from the adult social care outcomes framework

•    spending per adult in the local authority

•    staffing levels.