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Adult social care in England: overview

In the first of a series of reports on the adult care system, the National Audit Office has highlighted the main risks and challenges as the system changes radically. The report points out that government does not know if the limits of the capacity of the care system to continue to absorb pressures are being approached. It warns that major changes to the system to improve outcomes and reduce costs will be challenging to achieve.

The report details increasing pressures on the system: adults with long-term and multiple health conditions and disabilities are living longer; demand for services is rising while public spending falls; and there is unmet need for care. Government is engaging well with the adult care sector and aims to tackle the pressures in the adult care system through introducing the Care Bill.

While the need for care continues to rise, local authorities’ spending on adult social care fell by 8 per cent in real terms between 2010-11 and 2012-13. The longer term trend of reducing the amount of care provided has continued, but NAO analysis shows that local authorities have also improved their ability to control their costs in delivering core services since 2010-11. Local authorities are making efficiency savings by changing contractual agreements, paying lower fees and negotiating bulk purchasing discounts.

Paying lower fees to independent sector providers of care can put pressure on their financial sustainability, with some providers reporting problems meeting all but users’ basic needs and investing in training for their staff. Over the last ten years, many local authorities have raised the eligibility level they set for individual packages of care. Eighty seven per cent of adults now live in local authorities that arrange care services only for those with substantial or critical needs.

Today’s report also highlights the increasing pressure on other parts of the care and health systems. Informal carers now provide more hours of care per week and on average they are getting older. In addition, poor-quality social care can lead to unnecessary emergency hospital admissions. National and local government do not know the capacity of the care and health systems to continue to absorb these pressures and how long they can carry on doing so.

The adult care system is changing significantly and rapidly. The Department for Communities and Local Government is expecting  local efficiency initiatives, service transformation and the Better Care Fund to help local government manage financial pressures. However, there is weak evidence for which ways of commissioning and providing services are the most cost-effective. The Care Bill will introduce significant changes for local authorities which will be challenging to plan for because of a lack of information, lack of evidence on what works and short timescales.

The NAO warns that, while the Department of Health and the Department for Communities and Local Government are working together to understand the cumulative implications of changes to, and reduced spending on, health and social care, welfare and related local services, other departments are not. For example, changes to benefits for adults with disabilities and their carers will put further strain on care users’ ability to pay for their own care and for informal carers to provide support.

Adult social care, including care of an ageing population, is one of the big issues we face at present. It is important to understand this in the context of the wider healthcare system of acute and primary care. There are no easy answers, but we need to think clearly and in a joined-up way about the predictable and growing challenges in years to come.

Amyas Morse, head of the National Audit Office

Notes for Editors


Spending on adult social care managed by local authorities, 2012-13 (includes £2.5 billion user contributions)


Of adults in England limited 'a lot' in day-to-day activities by illness, disability or old age, 2011


Of local authority adult social care service users very or extremely satisfied overall with their care and support, 2012-13


Unitary and upper-tier local authorities in England responsible for adult social services

5.4 million         

Unpaid informal carers, 2011

1.5 million

People working in adult care

£10 billion

Estimated spending on care and support by self-funders, 2010-11

£55 billion          

Estimated value of informal care and support, 2011

87 per cent        

Of adults live in local authorities that set their eligibility threshold to meet substantial or critical needs only

1. Press notices and reports are available from the date of publication on the NAO website, which is at Hard copies can be obtained from The Stationery Office on 0845 702 3474.

2. The National Audit Office scrutinises public spending for Parliament and is independent of government. The Comptroller and Auditor General (C&AG), Amyas Morse, is an Officer of the House of Commons and leads the NAO, which employs some 860 staff. The C&AG certifies the accounts of all government departments and many other public sector bodies. He has statutory authority to examine and report to Parliament on whether departments and the bodies they fund have used their resources efficiently, effectively, and with economy. Our studies evaluate the value for money of public spending, nationally and locally. Our recommendations and reports on good practice help government improve public services, and our work led to audited savings of almost £1.2 billion in 2012.

PN: 19/14