THE (TRUE) STATE OF SOCIAL CARE

A dysfunctional system that does not know how to use its resources to make lives better

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 on 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 just require more money.

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

·      allowing people the agency in how their own lives are lived necessary for them to retain control, independence and dignity

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

As a result it’s a system that induces dependency and in so doing creates demand. The data also shows that the system simply disappears needs for which it has no resource. In combination, these factors mean the system can never know how much funding is required for people to have the wellbeing the law expects.

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 using public resources to lead the best life possible for them.

The following analysis shows evidential base to justify the above. The data relates to the year 2023/24.

What needs are being met?

There is an understanding that councils’ distinguish between needs that are ‘eligible’ for public funding from those that are not. Only those deemed ‘eligible’ attract public funding. 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) it is 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.

·      For working age people, the range is astonishing. The lowest spending 10% of councils – 15 - spent £23.8K and the highest 10% double at £47.1K.

·      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^[2].

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.

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 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 annual budget survey of Directors^[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 set budgets sufficient to meet all needs. But this is an undeliverable demand. Firstly they have no idea how much sufficient would be. Secondly, even if they did, budgets are set in a highly combative if not brutal process where all services compete for limited public funds. 

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

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. The means test ensures only people without sufficient income or wealth are financially eligible. The numbers of people who get past the means test within a community obviously reduces as overall affluence of communities increases.

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

The 10% of councils serving the more affluent communities tend serve larger and older communities. Thus they served between them 991,174 people over 65 compared to just 738,444 between the councils serving the poorer communities. However, they served a far smaller percentage of their older populations.

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% morepeople per their populations - 49.8 per 1,000 population against 69.3 – and did so 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 most per working age person not only served 60% fewer people per population than the 10% who spend the least – 11.4 per 1,000 population against 7.1 - but they also spent 24.5% more - £320 per 1,000 population against £260.

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

The well-known lament of social care’s leaders is that they don’t have the funding to deliver any kind of vision to make the lives of people the best they can be. So the question arises – how much better are those councils that are spending so much more on peopl

The answer is not only are they not making lives better, they may actually be making them worse.

One broadly accepted measure is the extent to which people are being supported to remain in their own home. The converse, therefore, is the rate of admission to residential and nursing care.

·      The 10% of councils that spent the least per person served 54,905 older people between them of whom 16,915 were in residential or nursing care – 29.5%. The 10% highest spending councils served 49,600 people, of whom 22,425 were in residential or nursing care – 45%

·      This means that people served by councils who spend the most per person are 50% more likely to find themselves in institutional 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 industry standard measure of success in making lives better, the more money a council has the worse it makes lives.

Another source of information is the annual survey of service users and family carers. Doubts have been raised about the reliability of these survey results. When people are asked by the system itself for their opinions about the service which they depend on so heavily will fear to be critical. However, whatever bias this creates 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 care represent the most restrictive, least independent option for people, it is also much more costly. For older people, nationally 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.

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^[4] per week, 32% more than the 10% who spent the lowest per person who paid just £826.

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

Councils pay whatever price they have the money to.

Fair price for care?

With virtually all provision provided independently, there has long been an issue of how much councils should pay providers. What is a fair price?

The answer is no-one knows.

·      The highest paying 10% of councils pay £1,202 a week for residential and nursing for older people, and the lowest 68% less at £716 a week

·      The figures for working age people are even more stark with a difference of 108% - the highest paying councils spend £2,299 a week and the lowest £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 so the required price averages 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 know there is a world of 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. They call the former ‘strengths based and person centred’. They call the latter ‘deficit based and resource centred.

And they have put a price on it. Over the past dozen years or so, councils across the country have agreed year in year out to cuts to their budgets in ‘efficiency savings’. They have amounted to £11BN. ADASS state that the top savings priority has been working with older and disabled people to identify their strengths and assets.

The elimination of the bad, dependency inducing social care would have the effect of virtually doubling the resource available for long term care. But the evidence makes clear that has not happened.

Alongside the annual ritual of Directors offering up of efficiency savings, their councils allow increases for demographic growth, primarily amongst the older people. These are consistently of the same order as the efficiency savings, about 3-4% a year. Over a 12 year period, that would amount to growth of the older population of between 36-48%. The growth has, of course, not been anything like that.

The net effect of this annual budget setting ritual is a stand still budget^[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%

This is not the pattern to be expected from a strategy rooted in transforming dependency creating practices to independence creating practices. Its more of the same.

Conclusions

According to all the public messaging, social care is a system doing its very best under difficult circumstances. It acts fairly and transparently driven only by the best interests of the people who rely on it. All it needs is more money to make everything the very best it can be.

But this does not describe what is a very different reality. It is a deeply dysfunctional system that does not know how to use the money it has to make lives better. Only people who have what it takes escape the mainstream system by managing their own care and support through a cash payment can be confident of using resources to make their lives better. And even they are under increasing threat as councils look for every which way 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 public messaging that protects 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, they are allowed to believe they have done all they need to do. They can safely ignore any noises off stage about a funding gap.

Professional leaders remain committed to the status quo and the public messaging that maintains it. 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