The (Real) State of Social Care

The Care Quality Commission produces an annual report of the State of Social Care for Parliament. It tells MPs what the Commission believes they need to know. The most recent report has 7 key findings. Three address delayed discharges from hospital, others address workforce issues. But none address what is arguably the most important political issue for MPs to understand:

• are councils using the resources at their disposal to best effect?

• if not, what are the consequences for the people who rely on social care and for the efficient use of public money?

Perhaps the Commission feels no need to address the popular public narrative promoted by social care’s leaders. Councils are doing the best they can but with insufficient resources. They simply require more money.

But there is copious data, publicly available, that fundamentally challenges this view. Councils make annual returns on spend, activity and outcomes stored by the NHS. Careful analysis reveals a very different story. It points to a system institutionally incapable of;

• allowing people the agency in how their own lives are lived that is necessary for them to have the best possible wellbeing and independence

• working in the way social care’s leaders have long known is required for the win-win of maximising individuals’ independence and so minimise demand on public funds

The system induces dependency and so creates demand. Further, the system simply disappears needs for which it has no resource. In combination, these two factors mean the level of funding actually required cannot be known.

Only the small number who have what it takes to escape the system by taking a cash payment to employ their own care and support workers can be confident of knowing how to use public resources to be as independent as their impairment allows.

The following relates to the year 2023/24.

What needs are being met?

Councils’ distinguish between needs that are ‘eligible’ for public funding from those that are not. Fairness, transparency and priority are assured by councils all working to the same national eligibility criteria.

All councils say this is exactly what they do. But the data tells a very different story.

Historically, all councils spend much more on working age than older people. There is a long standing but unresolved question about ageism being a factor. Leaving that aside for the moment (and also leaving aside what that in itself says about the operation of eligibility criteria that are meant to apply equally to all ages) the different levels of spending between the two age groups makes it important to separate out the two age groups to understand what is going on.

In 2023/24, councils spent between them £10.4BN on 299,500 working age people and £11BN on 559,220^[1] older people to meet on-going eligible needs. So the averages are £19.7K per older person, and £34.7K for working age people. If national policy is working, we would expect to see individual councils clustering around those two averages for each of the age groups.

But this not the case. In both age groups, the differences are astonishing:

• For working age people, the lowest spending 10% of councils – 15 councils in total - spent £23.8K and the highest 10% double at £47.1K (2)

• For older people, the pattern is similar. The lowest 10% of councils spent £13.9K per older person and the highest nearly double at £26.4K.

This spending pattern must be understood in the context of all councils meeting all needs they have deemed to be eligible and only needs they have deemed eligible. There is no reason to believe that the people served by the highest spending councils have greater levels of need than those served by the lower spending councils. In 2011, the Dilnot Commission, set up to report on the funding of social care, noted how people with similar levels of need received 'very different' levels of support. Dilnot did not put a figure on the differences. The above figures do.

Councils and their staff use the language of the national eligibility criteria to describe individual case decisions. This gives the appearance of following the national criteria. But it is an appearance that is entirely misleading.

Eligibility of need is not determined by the national eligibility criteria.

So how does eligibility work?

Councils must meet two legal obligations – they must meet all needs they have deemed ‘eligible’ and they must spend within whatever budget they happen to have.

The evidence shows they succeed in both. According to the Association of Directors of Adult Social Service annual budget survey ^[3], over the past 6 years, the aggregate of net budgets was £104.9BN and aggregate spend £106.4BN.  An overspend just above 1% in an area of public policy seen to be of such high financial risk will give the Chancellor nationally and Finance Directors locally little cause for concern.

Councils are required to create budgets that are ‘balanced’, meaning they are sufficient to meet demand. Government says councils must do so by setting budgets sufficient to meet all needs. But this is an undeliverable demand. Firstly they do not know how much 'sufficient' would be. Secondly, even if they did, budgets are set in a highly combative if not messy and brutal process where all services compete for finite public funds. 

If budgets cannot be set to meet need, then need must be set to match budgets.

Eligibility is determined to match whatever the local budget happens to be

Why is the resulting variance between councils so remarkably high?

It is necessary to look at the two sides of the coin – numbers of people served and levels of spend. To make comparisons meaningful, both must be pegged to the local populations.

There are huge differences in numbers of people served. This is determined largely by levels of affluence/deprivation. In addition to more affluent people having better health and so lower levels of need through being able to lead healthier lifestyles, the means test ensures only people without sufficient income or wealth are financially eligible. Their numbers decrease as overall level of affluence of communities increases.

• The 10% of councils serving the most affluent communities served 42.2 older people per 1,000 population over 65 while the 10% serving the most deprived served 75.3 older people per 1,000 population over 65 – nearly 80% more

• For working age people, the most affluent communities served 7.1 people per 1,000 population 18-64 and the most deprived 10.6, which is 50% more

These differences would, of course, not matter if spending followed suit. But it does not. The councils that spent the least per person did so because they are hit with a double whammy.

• The 10% of councils that spent the least per older person served 41% more people per their populations - 49.8 per 1,000 population against 69.3. But far from being able to spend commensurately more per population, they actually spent 5% less - £1,202 against £958

• The 10% of councils that spent the least per working age person not only served 61% more people per 1,000 population 18-64 than the 10% who spent the least – 11.4 per 1,000 population against 7.1 - but they also spent 19% less - £260 per 1,000 population against £320.

The mis-match of demand and budgets makes the level

of needs met between councils little better than random.

The situation for older people

The impact on people

There is an assumption that spending more results in better outcomes. But does the data bear this out?

One broadly accepted key measure of better outcomes is whether people are being supported to remain in their own home. The converse, therefore, is the number of people in residential or nursing care.

• The 10% of councils that spent the least per person served between them 54,905 older people. Of those, 16,915 were in residential or nursing care – 29.5%. The 10% of councils that spend the most per person served 49,600 people. Of those, 22,425 were in residential or nursing care – 45%.

• People served by councils who spend the most per person are 50% more likely to find themselves in residential or nursing care

• The patten is similar for working age people. 17% of people served by the highest spending councils were in institutional care and 14% if served by the lowest.

Against a key measure of success in making

lives better, the more money a council has the worse it makes lives.

Another source of information about impact on lives is the annual survey of service users and unpaid carers. Doubts have been raised about the reliability of these survey results. When people are asked by a service itself for their opinions about a service upon which they depend on so heavily, they will fear being critical. However, whatever bias exists will be the same across the country. Comparisons between councils are therefore valid.

The following table shows the scores for three of the most relevant questions in relation to older people.

	The range of scores nationally	The 10% highest spending councils	The 10% lowest spending councils
Quality of life	16.8 to 20.1	18.7	18.7
User satisfaction	43.5 to 86.9	63.6	61.3
Carer satisfaction	20.5 to 63.8	39.9	40.1

The level of spend makes scarcely any difference. Both sets of councils are clustered around the national middle ground.

The same is the case with regard to working age people.

	The range of scores nationally	The 10% highest spending councils	The 10% lowest spending councils
Quality of life	16.2-20.9	19.5	19.7
User satisfaction	46.9-90.9	70.7	69.2
Carer satisfaction	18.6-60.4	42	39.7

Where is the money going?

If the extra money is not improving lives, where is it going?

One answer is that not only does residential and nursing care represent the least independent option for people, it is also much more costly. For older people the average cost of residential and nursing care is £32.1K per person, nearly three times the £12.1K average cost to support a person in their own home. For working age people, the figures are £72.1K and £28.4K (4).

There is also an issue of how much councils pay for what is essentially the same service. The price varies hugely. Residential and nursing care is measured by the weekly ‘unit’ cost.

• The 10% of councils that spend the most per person paid £1,094 per week, 32% more than the 10% who spent the least per person at just £826.

• The equivalent figures for working age people are £1,617 and £1,812.

Councils pay whatever price their local budgets make possible.

Fair price for care

With virtually all provision provided independently, there has long been an issue of how much councils should pay providers. The data shows huge differences in the prices paid that account for a significant amount of the differences in spend per person.

• The 10% of councils that pay the most pay £1,202 a week for residential and nursing for older people. The 10% of councils that pay the least paid 68% less at £716 a week

• The figures for working age people are even more stark with a difference of 108%. The councils that paid the most paid £2,299 a week and councils that paid the least £1,103.

The price required to fund the care needed for each individual can vary considerably according to complexity of need. However, there is no reason to believe that across whole populations served by councils there will be any differences in those variations. All councils will have to address all levels of complexity. The required price should average out. 

The question is where within those huge ranges lies the price that is sufficient for providers to resource their service sufficiently to meet the needs of the people they serve whilst allowing a fair return on their capital and labour – a fair price.

The answer is nobody knows. But what we do know is that a price below the fair price leaves service users at risk of poor service and providers at risk of financial collapse. Above the fair price lies financial opportunism.

The price social care’s leaders put on bad social care

Social care’s leaders are conscious of a great difference between social care at its best and social care at its worst. At its best it supports people to be independent, to thrive and so make the least demand on public support. At its worst it deprives people of agency in their own lives, makes them dependent and increases demand on public support. The former is described ‘strengths based and person centred’ and the latter ‘deficit based and resource centred'.

Directors have put a price on it. Over the past dozen years or so, The ADASS annual budget surveys report that councils across the country have agreed year in year out to cuts to their budgets in ‘efficiency savings’. They have amounted to £11BN, some 50% of annual spend on long term care. The top efficiency saving has been transforming practice to work with older and disabled people to identify their strengths and assets.

Research, however, shows the required transformation in practice has not happened.

Offering the efficiency savings is part of an annual ritual that all councils adopt when setting social care budgets. Alongside Directors offering up of efficiency savings, their councils allow increases for demographic change. These are consistently of the same order as the efficiency savings, about 3-4% a year.

The net effect is a stand still budget for the meeting of need ^[5]. The growth in budgets councils give to Directors is cancelled out by the savings Directors offer up. The Institute of Fiscal Studies notes the effect.

• The older population increased by 11.8% between 2015 and 2023

• Spend increased by 12%

• The number of people supported dropped by 10%

• Spending per service user increased by 24%

Conclusions

The public narrative is the social care system doing its very best under difficult circumstances. All it needs is more money to make everything the best it can be.

But the data paints a very different reality. It is a dysfunctional system that does not know how to make best use the money it has. Only people who have what it takes escape the mainstream system by managing their own care and support through a cash payment to empoly their own staff can be confident of using resources to make their lives better. And even they are under increasing threat as councils look for every opportunity to reduce their cash payment.

The concerns the Care Quality Commission have put to Parliament are of course important. But they pale in significance when seen against the issues raised by this data. The principle beneficiaries of the system are political leaders. Spending is kept to whatever resources happen to be available, while all needs for which there is no resource are simply disappeared. At both local and national levels, the system allows political leaders to believe they have done all they need to do.

Responsibility for change rests with political leaders, at both the local and national levels.

^[1] All raw data taken from NHS Digital Activity and Fnance report  https://digital.nhs.uk/data-and-information/publications/statistical/adult-social-care-activity-and-finance-report/2023-24

^[2] Costs of delivery vary around the country. For example the weekly unit cost of residential and nursing care was £844 in the North West and £1068 in the South West. Therefore all figures have been adjusted to the national averages to eliminate the impact of regional cost differences.

^[3] The ADASS Spring Budget Survey, 2025.

^[4] All figures adjusted to national averages to address regional cost differences.

^[5] The Kings Fund notes there has actually been a real terms growth in budgets since 2015. However, that has been absorbed by increases in prices paid to providers without any increase in needs met. https://www.kingsfund.org.uk/insight-and-analysis/long-reads/social-care-360