Defining the problem
Social care services in England face longstanding pressures. With consistent underfunding, access to publicly funded care for older adults1 is now limited to those with the lowest means and highest needs. Provision across the country has become fragile and fragmented, and workforce shortages limit the supply of care. With 165,000 vacancies in 2021/22, the vacancy rate in the sector has reached a new high, and the workforce has shrunk for the first time since records began. Navigating the social care system is highly complex and confusing. Major bottlenecks occur when people try to access services, leading to needs often going unmet.2 And the pandemic has clearly exacerbated these long-term issues.
This short briefing draws together different measures of access to social care for older adults. Presenting a range of key numbers and statistics in order to build a picture from varied sources, it shows, despite complexities in interpreting the data, how the ability of the state to provide quality care that older people can access is changing for the worse: the number of older people getting state-funded long-term support has decreased by 10% since 2015/16.
Access to publicly funded care
In England, access to publicly-funded social care is both means and needs tested. Individuals with care needs are entitled to an assessment by their local authority irrespective of their financial situation. Anyone with means in excess of £23,250 (including income, assets and savings) is required to self-fund their social care. Individuals with assets between £14,250 and £23,250 may be able to access some funding, and anyone with assets below £14,250 are able to access full funding, depending on level of need. National eligibility criteria for need were set out under the Care Act (2014). However, there remains a certain degree of local authority discretion and access and provision vary across the country. Even people who have access to publicly funded care may be required to contribute towards their care costs where the care package offered by the local authority does not fully meet their needs, either through top-up payments or unpaid care, resulting in a substantial number of people whose needs remain unmet or under-met by the system. For a more comprehensive overview of the social care system, see our explainer series.
How many older people have social care needs?
Between 2015/16 and 2021/22, the number of people aged 65 and above grew by 7.8%, and the number over 80 by 8.8%.
But the latest data on total numbers of people over 65 with care needs at home have remained relatively stable, with an estimated 2.2 million people requiring support with at least one task of everyday life, such as eating or dressing.3 The proportion of the total older population living at home who need help has actually fallen slightly: from 23% in 2014 to 22% in 2018. Improvements in living standards and health mean people are often able to live independently much later into life and are less likely to require help with tasks of everyday life. This trend is especially true for people aged 80 and over: a person aged 80 today is less likely to need care than a person aged 80 a decade ago.
Understanding levels of demand is a multifaceted issue – not only determined by numbers of people with care needs, but also by people’s ability to pay for care, the informal support network around them, and by their condition and how much help they need. People’s needs are becoming increasingly complex in old age as more and more live with multiple long-term conditions. This may increase demand for formal care over unpaid care provided by family or friends.
And need is not equally distributed across the population but increases with level of deprivation. The overall picture may also have changed considerably since 2018 when the last estimate was available: the pandemic is likely to have increased need for social care as lockdowns meant a more rapid decline in older people’s functioning, for instance in people with dementia.
How many people get any kind of help?
In 2018, under half (45%) of people aged 65 and over with at least one care need drew on any kind of support, whether publicly funded, self-funded, provided by unpaid carers, or a mixture of all three. And while there has been limited change on this measure since 2014, there does appear to be a shift towards unpaid carers providing more intense care in the most recent Census results.
In 2021, an estimated 1.4 million people in England provided care for 50 hours or more, up from an estimated 1.3 million in 2011. A further 969,800 people provided care for 20 to 49 hours, up from 721,100 in 2011. This is a significant amount of caregiving and indicates a shift towards unpaid carers supporting people with high care needs who may well have drawn on formal care in the past.
A regional breakdown of Census data shows a concentration of high levels of unpaid care provision in poorer areas, which tend to be the areas with higher demand for publicly funded care. Moreover, the Personal Social Services Survey reported a sharp drop in the number of unpaid carers saying that the person they care for has used formal services which would allow them to take a break from caring, such as home care or day care activities, from 2 in 5 in 2014/15 to 1 in 3 in 2021/22.
The pandemic undoubtedly contributed to significant additional pressures on unpaid carers as the provision of services decreased and patients were rapidly discharged from hospital starting in March 2020. Directors of Social Services have also reported rising numbers of referrals and requests because of breakdowns in unpaid care arrangements.
Amidst all these pressures, it is worth noting that access to good-quality care is not necessarily easier or better for people who self-fund their care. Self-funders typically seek and organise their own care, which can be a daunting and complicated process, and they are often charged more for their care to compensate for reduced local-authority fees. The ONS estimates that in 2021/22, 28% of recipients of community-based care services for older people and/or those providing dementia care were self-funders, and 39% of care home residents in England.
How have requests for support changed over time?
Individuals with social care needs can approach their local authority for a needs and financial assessment, regardless of level of need or financial means.
In 2021/22, there were 1.37 million requests for support made by people aged 65 and over to local authorities, up from 1.31 million in 2015/16. This is only a modest increase of 4.6% compared to the increasing number of older people in the population, and when taking into account the ageing population represents a 3.1% decrease in rate of requests.
There are a couple of factors explaining this: first, the population is ageing, which means the older population has higher needs overall, but the younger ages within that total are likely to have lower levels of need at a given age than people who are older would have done at that earlier point in their life. Furthermore, the number of requests has gone down during the pandemic as people may have struggled to access local authorities, opted not to come forward for fear of infection, or relied more on unpaid care. While 2021/22 has seen a return to the previous trend of increasing requests, some of which may be the result of pent-up demand during the pandemic, this may underestimate growth in demand as barriers to access may result in people not requesting care altogether.
The nature of requests is changing, and people are presenting with more severe and urgent needs. In 2021/2022, Directors of Social Services reported a significant increase in urgent requests for care due to mental health, safeguarding concerns, breakdown in unpaid care arrangements, and challenges facing the NHS, as well as an increase in the size of care packages due to increased complexity of need.
Are more people waiting for care and assessment?
The waiting list in social care is significant. Some 245,820 adults were waiting for an assessment as of August 2022, with an additional 29,570 people waiting for care and support or direct payments to begin.5 Waiting times for a social care assessment are lengthy, with an estimated 33% of adults waiting over 6 months in August 2022, up from 20% in November 2021. Part of the reason for this bottleneck could be pent-up demand due to a decline in social care activity during the pandemic, alongside a decline in local authority staff giving advice and information or carrying out assessments combined with a lack of capacity within providers to take on new clients.
A lack of sufficient social care capacity also means that people admitted to hospital are waiting for social care support to become available which would enable them to be discharged, such as to a care home, home with support, or short-term rehabilitation in a community hospital. Delayed discharges are becoming an increasingly significant issue with adverse consequences for patient outcomes and NHS capacity. In December 2022, 18% of patients delayed6 in hospital were waiting for a care or nursing home bed, 22% were waiting for a short-term bed, such as rehabilitation, and 25% of patients were waiting for a home care package7.
How has access to publicly funded care changed over time?
Long-term support8 is intended to maintain quality of life on an ongoing basis. It includes both care home support (residential and nursing) and support within the community, such as direct payments, home care or supported living.
Since 2015/16, there has been a 10% overall decrease in the number of older people accessing long-term support – an 8% decrease in numbers accessing publicly funded community care and a 13% decrease in over 65s getting care home support (both nursing and residential). This might reflect fewer people qualifying for publicly funded care due to a tighter eligibility test as local authorities seek to ration care, and a ‘meaner’ means test as the thresholds of assets and savings have not risen in line with inflation.
Conversely, taking a closer look at the trends shows that while access to care homes has declined since the beginning of the pandemic, access to local community support saw a small increase of 4% in 2020/21. This is representative of a shift in preferences during Covid fuelled by concerns over infection and visiting restrictions, and an increase in demand for community services as many unpaid carers were unable to provide support and some care homes were not admitting new clients due to workforce shortages. Access to community support has since fallen back to pre-pandemic levels.
Short-term support to maximise independence
Short-term support to maximise independence is time-limited rehabilitative support aimed at fostering people’s independence in carrying out daily tasks of living. The number of people accessing this form of support has increased by 3.3% since 2015/16. In 2021/22, over a third of people who drew on short-term support no longer needed support, but 19% required long-term support.
Self-directed support, such as direct payments, is aimed at giving recipients more choice and control over the type of care they draw on. Direct payments are cash payments given to individuals to purchase their own care to better meet their needs. The proportion of older people who access long-term support who receive direct payments has decreased by 1.8 percentage points, from 17.3% in 2015/16 to 15.5% in 2021/22.
Are people’s needs being met within the adult social care system?
An increasing number of requests for social care support result in no care being provided at all (27% in 2021/22 compared to 23% in 2017/18). This may be because people do not meet the needs threshold or because of a lack of services available to meet their needs due to workforce or cost pressures. Increasingly tight council budgets have resulted in a less generous system, and the means thresholds have not risen in line with inflation, so fewer people qualify for publicly funded care.
In addition, evidence suggests that local authorities are shifting to asset-based approaches9 to make savings. This leaves individuals having to rely on families, neighbours and volunteering services, or without their care needs being met at all. Even where people draw on some level of publicly funded care, their needs may not be fully or appropriately met: they may still need to top up their state-funded care, the services that are on offer may not meet need, or may be unavailable.
For instance, between April and June 2022, an estimated 1.1 million home care hours were not delivered due to insufficient staffing capacity. There are also reports of some local authorities reducing the number of time allocated to recipients of home care services, resulting in rushed or poor care.
The overall picture
Despite relatively stable levels of need for social care relative to the older population, the number of older people approaching their local authority for publicly funded support is increasing and the social care system is struggling to keep up with demand. A growing number of older people in the population means that the number of people requiring support is increasing, even though today's older people live without care needs for longer than previous generations. Access to and provision of publicly funded care has become worse over the past seven years, with thousands waiting for assessments and waiting for the care they need to begin.
As a result, people get stuck in hospital waiting for care packages to be arranged. Unpaid carers are increasingly called upon, and many are left with unmet needs entirely. Even when people draw on care, their needs may only be partially met. While the impact of the pandemic remains yet to be fully understood and makes some of the recent trends more difficult to interpret, the corrosive effects of the pandemic on social care and the people who draw on it and their carers has likely led to pent-up demand for services and a lockdown-induced decline in older people’s (mental) health and functioning.
Staffing shortages have reached a level of severity that impedes the ability of care providers to return to the same level of services seen before the pandemic, or to accept new packages of care or care home residents. In addition, the cost of living crisis puts additional financial pressure on providers. Providers are increasingly going out of business or handing back contracts to local authorities, with knock-on effects on the NHS.
Despite promises over many years, plans to address social care funding and provision remain as distant as ever. Recently promised reform has been put on hold over concerns that allocated funding was not sufficient for local authorities to deliver it. And, while the recent Autumn Statement diverted some of the reform money into running the system, once inflationary pressures are taken into account, this is not sufficient to expand provision to meet needs.
The failure to put in place long-term sustained funding is having severe knock-on consequences for people with care needs and across the NHS.
Schlepper L and Dodsworth E (2023): The decline of publicly funded social care for older adults. QualityWatch annual statement, Nuffield Trust and Health Foundation.