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Adult Social Care in England: Policy, Spending and

Outcomes 2010-2015

Tania Burchardt,Polina Obolenskaya and Polly Vizard

Centre for Analysis of Social Exclusion

London School of Economics

Outline

• Coalition government’s inheritance

• Goals and policies

• Resources

• Outputs

• Outcomes

• Challenges for the current government

The Coalition inherited a system already under pressure

• Increasing life expectancy

• Increasing numbers of physically and cognitively impaired young people surviving into adulthood

• Multiple boundaries in financing and provision of social care: • NHS and local authorities

• universal, means-tested and needs-tested support

• individuals, families and the state

• residential and community care; direct payments

• public, not-for-profit and private providers

• Emerging concerns over care quality

Goals and policies• “Wherever possible, we want people to call the shots

over the decisions that affect their lives”

• “completely recast the relationship between people and the state: citizens empowered; individual opportunity extended; communities coming together to make lives better”

• “a much stronger society: one where those who can, do; and those who cannot, we always help”

... and cutting the deficit!

Box 1: The Coalition Agreement and party manifestos

Social care received little attention in the Coalition Agreement. Shared policies are underlined below; clauses in bold type stem entirely from the Lib Dems, while those in italics are solely from the Conservatives.

We will establish a commission on long-term care, to report within a year. The commission will consider a range of ideas, including both a voluntary insurance scheme to protect the assets of those who go into residential care, and a partnership scheme as proposed by Derek Wanless.

We will break down barriers between health and social care funding to incentivise preventative action.

We will extend the greater roll-out of personal budgets to give people and their carers more control and purchasing power.

We will use direct payments to carers and better community-based provision to improve access to

respite care.

There were no specific Conservative manifesto commitments that did not make it into the Coalition Agreement, although they had wanted voluntary insurance rather than a commission on future funding. In two areas, Lib Dem manifesto commitments were included but in a weaker form than originally expressed: to ‘Integrate health and social care to create a seamless service', and 'provide guaranteed respite care for the one million carers who work the longest hours’.

Local authorities responsible for

continuity of care when providers

cease to function

Adult social care policy timeline

Commission

on Funding of

Care and

Support (Dilnot

Commission)

2014 2015

National Dementia Strategy for England

Stronger statutory basis for Adult Safeguarding Boards

Changes to the right to request flexible working

Extension of statutory rights of carers to social services support

Health and Well-Being Boards (Health and Social Care Act 2012)

‘Putting People First’ vision for future of social care

More pooling of existing NHS and social care resources (Better Care Fund – delayed implementation)

Valuing People Now (strategy for people with learning disabilities)

Adult Social Care Outcomes Framework

New inspection regime by Care

Quality Commission

2010

New national criteria for social care eligibility based on level of need

National Carers’ Strategy

2016

PoliciesFuture funding• Commission on Funding of Care and Support (Dilnot Commission), 2010-2011• Significant relaxation of capital means test for residential care (announced in March

2013 budget – now postponed)• Lifetime cap on care costs (Care Act 2014, following Dilnot – now postponed)Eligibility criteria• New national criteria for social care eligibility based on levels of need (came into force

April 2015)Integration of health and social care• Health and Well-Being Boards (Health and Social Care Act 2012)• More pooling of existing NHS and social care resources (Care Act 2014; Better Care

Fund)Support for carers• Extension of statutory rights of carers to support from social services (Care Act 2014)• Changes to right to request flexible working (July 2014)Regulation, monitoring and inspection• Stronger statutory basis for Adult Safeguarding Boards (Care Act 2014)• Local authorities responsible for continuity of care (Care Act 2014)• Adult Social Care Outcomes Framework (from 2011)• New inspection regime by Care Quality Commission (from 2013)

Resources

• Total local government funding in England fell by 40 per cent from 2009/10 to 2014/15

• Total local government spending on adult social care fell by 10.3 per cent in real terms

• Total spending on adult social care including NHS joint arrangements and user charges (‘gross total cost’) fell by 7.4 per cent

• Spending on older people fell faster... despite a 10 per cent increase in the number of people aged 65 or over, and a 9 per cent increase in the number of people aged 85 or over

Resources did not match population growth

Population: 65 and over


100

110

120

130

140

150

160

170

1801

99

7/9

8

19

98

/99

19

99

/20

00

20

00

/01

20

01

/02

20

02

/03

20

03

/04

20

04

/05

20

05

/06

20

06

/07

20

07

/08

20

08

/09

20

09

/10

20

10

/11

20

11

/12

20

12

/13

20

13

/14

Ind

ex n

um

ber

s, 1

99

7/9

8=1

00

Labour Govt. Coalition Govt.

Resources did not match population growth

Spending: all

Spending: 65 and over



100

110

120

130

140

150

160

170

1801

99

7/9

8

19

98

/99

19

99

/20

00

20

00

/01

20

01

/02

20

02

/03

20

03

/04

20

04

/05

20

05

/06

20

06

/07

20

07

/08

20

08

/09

20

09

/10

20

10

/11

20

11

/12

20

12

/13

20

13

/14

Ind

ex n

um

ber

s, 1

99

7/9

8=1

00

Labour Govt. Coalition Govt.

Real terms growth in observed and demand-adjusted spending (whole population, and aged 65 plus), England, 2005/06 to 2012/13

Outputs

1.02m 0.96m

0.87m

0.67m

0.47m 0.51m 0.47m 0.38m

1.49m 1.54m

1.46m

1.34m

1.05m

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

1,800,000

2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14

Nu

mb

er o

f co

mm

un

ity

serv

ice

use

rs

Age 65 and over Age 18 to 64 Total

Less care was providedNumber of people receiving community-based services each year, by age

CoalitionLabour

Falling numbers of community service users

% change 000s of

clients in

2013/14

Age 18-64

2005/06 to

2009/10

2009/10 to

2013/14

Physical disability -1.1 -27.7 143

Mental health 19.0 -36.7 119

Learning disability 7.0 4.0 107

Substance misuse -0.9 -46.4 5

Other vulnerable people 3.8 -35.6 5

Age 65 plus

Physical disability -8.0 -31.3 571

Mental health 26.7 -18.7 78

Learning disability 18.3 22.6 10

Substance misuse -1.4 -20.1 0.5

Other vulnerable people -39.5 -40.4 13

Falling numbers of community service users

% change

Age 18-64

2005/06 to

2009/10

2009/10

to

2013/14

Physical disability -1.1 -27.7

Mental health 19.0 -36.7

Learning disability 7.0 4.0

Substance misuse -0.9 -46.4

Other vulnerable people 3.8 -35.6

Age 65 plus





Other vulnerable people -39.5 -40.4

...particularly in mental health

% change

Age 18-64

2005/06 to

2009/10

2009/10

to

2013/14






Age 65 plus






...and in substance misuse

% change

Age 18-64

2005/06 to

2009/10

2009/10

to

2013/14






Age 65 plus






Distribution of clients of community-based services by number of hours received per week, England, 2008/09 to 2013/14

Outcomes

ASCOF

• Domain 1: quality of life

• Domain 2: delaying and reducing the need for care

• Domain 3: experience of care and support

• Domain 4: safeguarding vulnerable adults

ASCOF

• Domain 1: quality of life

• Domain 2: delaying and reducing the need for care• some improvements mid-period, now worsening again

• Domain 3: experience of care and support

• Domain 4: safeguarding vulnerable adults

Domain 4: safeguarding

• Adult social care users survey: improving (66% feel safe in 2013/14 compared to 62% in 2010/11)

BUT

Year Alerts Referrals

Substantiated or

partially substantiated

(as % of completed

investigations)

2010/11 92,865 95,065 30,365 (41%)

2011/12 133,395 106,165 34,670 (41%)

2012/13 172,130 107,650 37,410 (43%)

2013/14 n/a104,050

individuals43%

Domains 1 and 3: Service users, carers (and ex-users?)

• Quality of life and satisfaction with services of service users has improved (7 indicators out of 11)

• Quality of life and satisfaction with services of carershas deteriorated (4 indicators out of 5)

• Quality of life and satisfaction with services of people who are no longer eligible to receive services ???

Number of unpaid carers, by age group, UK, 2002/3 to 2013/14 (Source: FRS)

0

1

2

3

4

5

6

20

02

/03

20

03

/04

20

04

/05

20

05

/06

20

06

/07

20

07

/08

20

08

/09

20

09

/10

20

10

/11

20

11

/12

20

12

/13

20

13

/14

No

. of

un

pai

d c

arer

s (m

illio

ns)

All

Wkgage

Pens

Child

Population aged 50 and over reporting to be informal carers, around 2007, OECD

8.0 8.7 9.3 9.8 10.3 10.7 10.8 11.0 11.2 11.4 11.7 12.0 12.1

14.6 15.2 15.316.2

0

5

10

15

20

%

Unmet need for care, by age group and number of difficulties, 2007/08 to 2011/12, UK (source: FRS)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

16-44 45-59 60-74 75+ Total 16-44 45-59 60-74 75+ Total

Individuals with moderate (1-3) difficulties Individuals with more severe (4+) difficulties

Perc

enta

ge o

f re

spo

nd

ents

wit

h u

nm

et n

eed

fo

r ca

re

2007-08 2009-10 2011-12

1. Effective integration of health and social care• Greater Manchester Combined Authority

2. Tackling high prevalence of poor standards of care and abuse• More emphasis on prevention (learning lessons from child

protection?)• Creating conditions that enable ‘relationships of care’ to

flourish (difficult in 15 minutes!)

3. Investing in the social care workforce• High turnover identified as a risk factor by CQC• Majority of domiciliary care workers are on zero-hour

contracts• Paying for significant increases in minimum wage 2016-2020

Challenges for the current government

4. Addressing unmet need and relieving pressure on unpaid carers• Shortfall in care expenditure was already £1.5 billion by

2012/13• Dilnot reforms postponed• Rise in number of unpaid carers and intensity of caring is not

sustainable

5. Reconciling further cuts and continued demographic pressure• Local authorities have been successful in affording some

protection to social care but LGA warns further cuts cannot be absorbed without risk to “basic services for vulnerable people”

Challenges for the new government

More need, less money

Projections of total local authority funding and population aged 75 or over, England, 2010 to 2019

40

50

60

70

80

90

100

110

120

130

2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Ind

ex

, 2

01

0 =

10

0

Populationaged 75+

LGA totalfundingforecast

Sources: ONS and LGA

The Coalition’s record on adult social care: policy, spending and outcomes 2010-2015

SPCC working paper 17http://sticerd.lse.ac.uk/dps/case/spcc/WP17.pdfTania Burchardt, Polina Obolenskaya and Polly Vizard, LSE

Forthcoming April 2016 in Lupton, Hills, Burchardt, Stewart and Vizard (eds) Social Policy in a Cold Climate, Policy Press.

http://sticerd.lse.ac.uk/dps/case/spcc/WP17.pdf

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