Despite an ageing population, spending on adult social care has fallen by 5% since 2009. The number of people receiving services (particularly community care) has fallen, while providers are facing increasing financial strains. User satisfaction is being maintained, but the general election revealed significant public concern about how future demand will be funded and provided.
Spending on adult social care has fallen by around 5% in real terms since 2009/10.
Adult social care – the provision of support and personal care (as opposed to treatment) to meet needs arising from illness, disability or old age – is funded by the Department for Communities and Local Government (DCLG) and managed through local authorities.
Day-to-day spending on adult social care fell by nearly 10% in real terms between 2009/10 and 2014/15, but since then it has begun to grow; our estimate suggests that in 2016/17 spending was around 5% below 2009/10 levels.* The recent increase in funding has been supported by the 2015/16 Better Care Fund (a programme to join up health and care services) and the commitment in the 2017 March Budget of an additional £2bn in funding between 2017 and 2020 (with £1bn front-loaded in 2017/18).
However, financial pressures persist, with The Health Foundation, The King’s Fund and Nuffield Trust jointly estimating in November 2016 a funding gap of £1.9bn in 2017/18. While the national picture obscures local variation across different demographic and socio-economic profiles (with greater challenges in authorities with more deprivation and older people), pressures do appear to be widespread.
Local authorities have sought to protect their adult social care budgets as their overall spending has shrunk. In the 2017 Association of Directors of Adult Social Services (ADASS) Budget Survey, it was estimated that adult social care made up 35.6% of 2016/17 council-controlled budgets** (compared with 30% in 2010/11) and that it would rise again to 36.9% in 2017/18. Furthermore, 100 councils reported overspending their adult social care budget, to a cost of £448m, with the most common means of financing coming from council reserves (67%) and underspending in other services (66%). These implications for local authorities are detailed in Chapter 5.
Demand is set to keep growing.
The majority of people who receive state-funded long-term social care are aged 65 or over: two thirds in 2015/16. The growth of the older population is therefore set to put significant strain on social care services. Between 2009 and 2016 the number of people in England aged over 65 grew by 17.7%, to 9.9 million. Furthermore, the Office for National Statistics (ONS) forecasts that between 2014 and 2039 the number of over 65s will grow by 60% to 15.2 million. While not all over 65s require care, healthy and disability-free life expectancy is not keeping pace with total life expectancy. At 65, most people have at least one long-term health condition; at 75 most people have two.
As better health care has improved the life expectancy of people with certain conditions, the number of working-age adults with long-term care needs has also increased. For example, between 2009/10 and 2013/14 the number of adults with learning disabilities rose by around 20%. Demand is rising not just because of ageing, but also as more adults with physical or mental health needs are living longer.
However, the number of people receiving state-funded care has fallen by a quarter.
Unlike health care, there is no universal access to social care. The provision of state- funded care to an individual is based on two things: the severity of their need, and their ability to pay for it. Between 2009/10 and 2013/14, the total number of people receiving state services fell by 25%. This decline is recent, as the number of people receiving state-funded social care increased by 2.3% between 2005/06 and 2008/09.
Intensive and expensive types of care are being prioritised, while community care has been squeezed. Between 2009/10 and 2013/14, the total number of community care clients fell from 1,464,140 to 1,051,540. This included a 249,700 drop in clients receiving long-term support or professional treatment and a 154,400 drop in clients provided with equipment. A reduction in service levels is not necessarily a sign of service failure. Local authority spending might be more efficient and prioritising short-term care; in 2015/16, 12% of requests for support were answered with intensive periods of ‘re-ablement’, helping clients to be more independent.
On the other hand, more people may be having to rely on unpaid care. It is estimated that across the UK there was a 9.5% increase in hours of unpaid care between 2009 and 2014, from 7.4bn to 8.1bn, with 14.3% growth in people receiving unpaid continuous care (that is, receiving 168 hours per week). Another possibility is that as services are reduced, unmet need increases. This would be difficult to determine: only 26.8% of councils in the 2017 ADASS Budget Survey stated they had arrangements to monitor unmet need. Research by Ipsos MORI and NatCen has argued that need is often hidden, with half of those with care needs possessing at least one unmet need. Conversely, Health Survey England found that from 2011 to 2015 the percentage of over 65s with unmet need for Activities of Daily Living (ADLs) fell from 26% to 22%, despite a 15% to 11% drop in those receiving care.
Whether reduced services represent a rationing or efficiency story is not apparent with current levels of data. Regardless, pressures are clear: only 29% of councils in the 2017 ADASS survey were ‘fully confident’ they could meet their statutory duties for 2017/18 (dropping to 3% for 2019/20).
There has been an increase in unnecessary hospital stays because of social care, although recently it appears to have slowed.
Delayed transfers of care (DTOC) occur when someone is clinically fit to be discharged from their care setting, but they remain there longer than they need to. DTOCs are costly (the NHS spends around £820m a year treating older patients who no longer need to be in hospital) and inefficient, reducing the availability of beds for other patients. There is also an impact on patient health; a 2014 report estimated that a wait of more than two days negates the additional benefit of intermediate care, and seven days is associated with a 10% decline in muscle strength.
Between August 2010 and July 2017, the total number of delayed days across all organisations rose by 65%. Delayed days due to social care rose the most, a 77% increase from 38,324 to 67,969 (peaking at 74,288 in March 2017 before stabilising). The most common reason for social care delayed days was the patient waiting for a care package in their own home; this rose from 8,547 days in August 2010 to 22,100 days in July 2017, nearly a 160% increase.
The sector is growing, but providing care has become increasingly difficult.
Skills for Care estimates that between 2009 and 2016, there was a 19.7% increase in adult social care jobs, to around 1.58 million. This was made up of notable shifts, including a 37% decline in local authority jobs through service closures and outsourcing. The number of FTE jobs also increased, from 1.025 million in 2012 to 1.11 million in 2016.
However, as the sector has grown there have been difficulties with retaining workers; between 2012/13 and 2015/16, turnover rose from 22.6% to 27.8%. Furthermore, the CQC has stated that “staffing levels were a key factor in providers being rated as inadequate or requires improvement for safety”, especially when providers did not effectively make use of staff time. Another issue reported by the CQC was a lack of knowledge by providers about what skills their workers already possessed or would need training on, in order to manage complex patient needs.
The greater concern is the financial sustainability of providers. The average fee they are paid by local authorities fell by 6.2% between 2011 and 2016. According to the UK Home Care Association, in 2016 the average hourly price paid by councils for domiciliary care was £14.58, with only 10% paying the £16.70 estimated as the minimum sustainable price for home care services. Furthermore, it is estimated that meeting the National Living Wage will cost providers £2.3bn in wages by 2020 and could crowd out some of the additional funding promised to social care. In light of these pressures, 77% of councils in the ADASS Budget Survey said providers were facing financial difficulty currently (and this rose to 84% for 2018–20). There are concerns that providers might cut their losses and provide services for privately funded clients only (for example, in 2016/17, 36.8% of councils reported home care contracts being ‘handed back’ in the previous six months). At worst, financial pressures may shut down providers; between January and June 2013, 260 care homes closed, but between January and June 2016, this rose to 380.
The people who do receive state-funded care remain satisfied, but public concern with social care is high.
Despite changes to service provision, the satisfaction of recipients has been consistent. In 2015/16, 90.3% said they were satisfied with their care and support, comparable to previous years. Yet public concern is high; social care became a focal point of the 2017 general election and a British Social Attitudes survey found that only 26% of people were satisfied with it, down from 30% in 2012 (although it should be noted that fewer people experience social care directly, compared with other elements of health care).
Recent CQC evaluations have provided new insight into the clinical quality of social care. They are quite positive, with 79% of all services rated as good or outstanding. Providers also showed some capacity for improvement: upon re-inspection, 56% of providers rated as ‘requires improvement’ were upgraded to ‘good’. However, there were variations between quality indicators, which reflect the pressures on services: 95% of services were good or outstanding at ‘being caring’ but this was only true of 75% for ‘being safe’ and 76% for ‘being well led’. Moreover, 74% of councils in the ADASS Budget Survey said more providers were facing quality challenges (and this rose to 83% for 2018–20).
* 2016/17 numbers are an estimate derived from a different source – actual figures may be different.
** This is not a percentage of total local authority spending.