Social Care News and Features

Access to care for older people in England is “poor and unjust”, an analysis has found.

There was a fourfold difference between the councils with the highest and lowest proportions of older adults receiving funded long-term care, said the Institute for Government (IfG).

While some of this was related to factors known to drive need, such as rates of disability or local deprivation, access was lower in areas with higher proportions of older people, found the think tank.

‘A poor and unjust means of determining access to care’

“This is a poor and unjust means of determining who accesses care that could substantially improve people’s quality of life,” it said.

The same areas tended to have higher rates of unpaid care being provided, suggesting informal carers were stepping in to fill the gap in funded care, added the IfG.

The report, part of a series on the performance of public services funded by the Nuffield Foundation charitable trust, was based on official data on the numbers of people receiving care from councils, local authority spending and levels of unpaid care, disability and deprivation. The IfG also interviewed a small number of social care policy experts, government officials and practitioners to inform its findings.

Sharp fall in share of older population receiving care

The think tank found that there had been a sharp fall in the proportion of older people receiving funded long-term care over the past two decades, from 8.2% in 2003-04 to 3.5% in 2023-24. In contrast, the share of working-age people accessing long-term care had been broadly stable, at 0.8% in both 2003-04 and 2023-24.

This may partly reflect a fall in the proportion of older people reporting a disability, which fell from 53.1% in 2011 to 35.2% in 2021, as measured by the Census, a trend accompanied by a fall in the number of older people requesting care and support from their local authority. The latter fell from 9.5 people for every 100 in 2017-18 to 8.6 in 2022-23.

However, the IFG stressed that the fall in the percentage of older people accessing care was significantly greater than the drop in the proportion requesting a service.

Fourfold variation in access to care between areas

Beneath the national fall, there were significant local variations, with the share of the older population accessing care in 2023-24 ranging from 2% to 7.8% between authorities, excluding two councils that now offer free home care, whose rates were even higher. By comparison, the share of working-age adults accessing care ranged from 0.4% to 1.5% between areas.

In line with the fact that social care is means-tested, as well as the association between disability and poverty, differential access was partly explained by relative deprivation, the IFG found.

Excluding London councils, about 5% of adults aged 65+ received long-term care in the most deprived tenth of local authorities, compared with 2.9% in the least deprived tenth. Deprivation had a smaller impact among working-age adults, with the share of the population accessing care ranging from 0.6% in the least deprived tenth of areas to 0.8% in the most deprived tenth, in an analysis that included London authorities.

The IfG also found that access to care rose in line with levels of self-reported disability in the local area, with this relationship being stronger among older adults than those of working age. A one percentage point increase in the proportion of the 65+ population that was disabled was associated with a 0.2 percentage point increase in the proportion that received care, said the IfG.

Impact of the proportion of older people in an area

However, it also found a “strong negative relationship” between the proportion of the adult population aged over 65 in an area and the proportion of that population that received long-term care, despite this having no link to people’s needs or means.

For each additional percentage point of the adult population that was over 65, there was a 0.16 percentage point decline in the share of over-65s who received long-term care on average.

The relationship remained, though not to the same extent, when the think tank adjusted for the impacts of deprivation, disability rates, local authority spending power, the local social care vacancy rate and other factors related to need, such as the proportionsof older people who received pension credit, who lived alone and in rented accommodation or who were over 80.

After taking account of these factors, a one percentage point increase in the adult population aged over 65 was associated with a 0.08 percentage point decline in the share of over-65s receiving long-term care.

Councils with larger older populations ‘may be rationing care’

The IfG acknowledged that there could be other need-related factors that could be driving these differences.

However, it added that one interpretation of the results was that councils “struggle to meet the higher demand for adult social care services that come with large older populations”.

“Given budgetary constraints, local authorities with larger over-65 populations are unable to provide every person over the age of 65 with the care they need, reducing the likelihood that an individual will receive the care they need,” it added.

The think tank also found that the negative relationships between access to care for older people and the age of the local population had existed since 2004-05, but had grown stronger over time.

Less of a postcode lottery in care for working-age adults

However, it found no significant relationship between the proportion of adults who were aged over 65 and the proportion of working-age adults who received care.

Along with the fact that there was less variation between in the proportion of the working-age population receiving long-term care, it concluded that working-age adults with care needs had a similar likelihood of receiving care wherever they lived in the country.

Those interviewed for the paper suggested two possible explanations for this: that younger adults were more likely than older people to have relatives who advocated for them and that there were greater social expectations to fund care for those of working age than for over-65s.

More unpaid care in areas with poorer access to support

The analysis found that a greater proportion of people were delivering unpaid care in areas where older people were less likely to receive funded services. For each additional percentage point of the 65+ population that received long-term care, 0.61 percentage points fewer people provide unpaid care,

It also found a link between the proportion of the population providing unpaid care and the proportion of the adult population aged over 65, where access to care tended to be lower.

On average, an additional percentage point of the adult population aged 65+ was associated with an additional 0.09 percentage points of the population providing 1–19 hours of unpaid care per week, though this did not control for other characteristics of local authorities.

Government ‘may be subsidising unpaid labour’

It said these findings could be interpreted in two ways. On the one hand, in some areas, friends and relatives may prefer to provide care to older loved-ones, reducing local authorities’ requirement to provide care. On the other hand, relatives and friends may be stepping in because councils were less prone to fund care.

Though the report said both were likely to be happening to some extent, interviewees told researchers that the second was likely to be more prevalent.

“If this is the case, it means that the government subsidises lower access to care with unpaid labour from friends and family,” it added.

Also, it found that the higher the proportion of older people receiving long-term care, the lower the likelihood of people providing unpaid care.

The limits of rationing

Despite its findings on access to care, the IfG report showed that the proportion of council budgets spent on long-term care for older people rose in proportion to the share of the adult population aged over 65.

The report said this indicated the limits of rationing and that there was a level of need above which it was “very difficult to deny an individual care”. At this point, the relative size of the over-65 population was the key determinant in how much councils would spend on long-term care for the age group.

With the population of people aged over 65 set to grow faster than the general population over the coming decade, this suggested that, all things being equal, councils would have to spend a growing share of their budgets on long-term care for older people.

It also found a statistically significant relationship, outside of London, between the amount of money councils had available to spend – their so-called “spending power” – per resident and rates of access to long-term care.

Question marks over whether budget increases will enhance access to care

Following the recent spending review, councils’ spending power is due to rise by 2.6% in real terms from 2026-29, just above the forecast growth in the over-65 population (2.1%).  The government has also said that councils will have £4bn more available to spend on adult social care in 2028-29 than 2025-26.

However, the IfG raised doubts over whether how far money would translate into better access to care, due to the cost pressures arising from annual increases in the national living wage (NLW), which many care workers are paid, and the government’s decision to end overseas recruitment into the sector. It said the latter would “almost certainly require providers to increase wages”, translating into councils having to raise fees.

At the same time, the government is planning to introduce a fair pay agreement for adult social care, which is also likely to raise costs through increased wages and better terms and conditions.

Meanwhile, the government is also consulting on changing the way funding is allocated to councils in order to better reflect need, including for adult social care. However the IfG said it was unclear whether this would “rebalance some of the disparities in access for older adults that this report has identified”.

‘A useful but depressing analysis’

The report also comes with the government having commissioned Baroness (Louise) Casey to carry out a review into the sector in order to produce proposals for long-term reform. She will produce an initial report next year, setting out how the government can deliver a so-called national care service over the subsequent decade, and then a final report by 2028, recommending longer-term reforms.

The IfG warned that this timescale created the prospect of the sector being “largely unreformed for years to come”, an issue echoed by Age UK.

Its charity director, Caroline Abrahams, said the IfG’s “useful but depressing analysis” had identified a postcode lottery in access to care for older people and echoed the report’s finding that this was “clearly unjust”.

She added that the report strengthened the case for the government “to take action on obvious injustices like the funding shortfall impacting places and older people in the short term, rather than sitting on its hands until Baroness Casey submits her findings”.