Adult
Services &
Health
Overview
The County Councils Network's manifesto proposals for adult services and health outlines the need for the incoming government to prioritise a long-term plan for investing in social care and progressing wider system reform. This plan should be focused on stabilising the market, rebuilding prevention, developing community services, and addressing barriers to housing with care. Alongside this, the government should immediately prioritise improving outcomes and reducing costs in working age adult provision, while putting in place reforms to integrated care system and improving hospital flow and discharge.
requests in England
some 15,000
Our priorities
Our Priorities
Our Vision
Adult services, which encompass support for both older and working age adults, have never been more in the spotlight, nor more important to our society. They can be a truly transformative, with timely and well-resourced services ensuring that some of the most vulnerable people in our communities are cared for, while aiding them to live independent and fulfilling lives.
Our vision for services is built upon establishing a preventive, people focused service, ensuring individuals are cared for in the home of their choice, enabled to live active lives, and supported by responsive services when they need them. This requires recruiting and retaining a sufficient and appropriately skilled workforce; managing the transition away from traditional forms of residential care towards preventative forms of community-based care; investing in rapidly advancing technologies; and truly integrating services across health, housing, and public health.
By giving councils the right powers, while investing in and reforming health and care services, county authorities can work in tandem with government to ensure a sustainable and high-quality system for the long-term. County Councils Network research has shown that by doing so, some 18% of the 60,000 adults in publicly funded care homes could be better supported independently in the community, while 90,000 more individuals every year could access more effective short-term care. This wouldn’t just mean better outcomes but reduced costs and improved productivity right across the health and care system.
Adult social care
The services provided through adult social care have rightly attracted social and political attention as a result growing financial and demand challenges.
Per-person spend on adult social care in county areas has increased by 50%: going from £237 per person in 2013/14 to £357 per person in 2023/24. The number of requests for services is at all-time high, with 955,000 requests for services in counties last year. Underpinning this has been a persistent workforce challenge, with an estimated 65,000 vacancies in the sector within county areas.
It is recognised by all political parties that adult social care requires both investment and reform, and the landmark Care Act (2014) and recent White Paper, People At The Heart of Care, have contained proposals that have been widely welcomed across the sector. However, the reality is that the ambitions of these reforms have never been fully realised.
The necessary and fundamental shift towards community-based, preventative services envisaged within the Care Act has been limited by funding constraints and hospital discharge policies. At the same time, reforms aimed at tackling the workforce crisis have failed to address low pay, poor working conditions and an over reliance on overseas recruitment, which continues to restrict the capacity of the system.
Over recent years, there have been significant injections of additional funding. However, while this funding has helped stabilise services, it has been short-term, fragmented, and come at a time of an acute rise in post-pandemic demand and historically high inflation – limiting the ability of councils to expand the availability of care packages and invest in services for the long-term.
The government have already provided the necessary clarity that charging reforms in adult social care will not be implemented this parliament. However, this was only ever one part of the reform agenda, with the government setting out its new ambitions to create a ‘National Care Service’. To-date, the government have not set out details of the proposals, but a recent survey of County Councils Network revealed that the introduction of a national care service is regarded as a high priority by less than one in ten member councils (9%), with 50% saying it was a low priority and 41% neutral. For the policy to be a success, the government must provide urgent clarity on what a national care service means in practice and ensuring structural reform does not become an unnecessary distraction.
The County Councils Network proposals below set out that an incoming government must ensure councils remain at the heart of a locally delivered service, while delivering both investment and reform. All existing funding for services must be retained, with a commitment to meet increased spending need over the course of the parliament and reforming the distribution of funding between councils. Additional investment must be prioritised on expanding the availability of care packages for those most in need and enabling investment in community-based, preventative services, rather than unnecessary structural changes.
Working age adults
Although the challenges facing the adult social care system have received increasing attention in recent years, the growing needs of working-age adults and the life-long disabled requiring care are consistently overlooked. Some 40% of people receiving adult social care support in England are individuals aged 18-64 with a disabled condition such as a learning disability, a physical disability or a mental health condition.
As forthcoming research by Newton (November 2024) will show, national expenditure on support for working age and lifelong disabled adults has risen by over a third between 2020 and 2023. Support for working age and lifelong disabled adults has now become the largest area of expenditure in adult social care, making up 63% of all care and support costs in England in the financial year 2022/23 - £10.1bn. This is despite the total volume of individuals with a learning disability supported not having risen over this period.
Rises in costs above inflation are primarily being driven by the type and complexity of care, with more individuals receiving higher cost and support-level packages. Rising placement costs are also the product of inappropriate and insufficient housing options, including the availability of local authority housing and supported living for those with lower support needs.
Moreover, with councils more reliant on limited 24-hour residential and nursing placements, councils are exposed to needing to use more expensive out of area placements to meet local needs, with councils also struggling to contain costs due to providers resistant to changing packages of support and who are seen to prioritise the more financially lucrative market of older adults who pay for their own care.
These challenges facing working age adult social care services are only set to escalate as a large cohort of the growing number of younger people with SEND transition into adult services over the coming decade, with initial analysis by Newton suggesting forecasting a net increase in expenditure for support for 18-24-year-olds for adult social care of at least 40% more by 2030.
The County Councils Network proposals outline that the new government must place greater focus on working age and lifelong disabled adults in the national conversation around social care reform. This should include a review of the national funding model and operation of the market; the development of new housing solutions to reduce the reliance on supporting living; and implementation of a lifelong strategy for prevention and support.
Integration & Public Health
The interface between councils and the health service has always been a prime focus of policy makers in Westminster. The last Parliament has seen the continued fusion of health and care, with the creation of Integrated Care Systems (ICSs). In 2022, the County Councils Network and IMPOWER carried out a ‘stock take’ of how these fledgling organisations, which found highly differing ways in which each of the 42 ICSs in England were developing and engaging key council partners. Across the country there many positive experiences but too many areas were experiencing poor collaboration and some councils felt locked out of the decision-making processes.
Arguably the greatest focus of collaboration between councils and the NHS through ICSs since their inception has been on hospital discharge. The County Councils Network’s recent report with Newton showed people being admitted to hospital unnecessarily and significant delays during hospital stays, which mean people spend longer in hospital than they need to.
Strategically, this recurring issue is often viewed simplistically, as a problem for the health service primarily driven by a lack of capacity in social care. As a result, policy solutions have tended towards the government making short-term investments in care beds to ease demand during the winter period, even though the efficacy and value for money of such solutions is often patchy.
Newton’s report showed that an alternative approach of investing more in home-based therapy, community and intermediate care, while improving practices within the health and care system, could mean 175,000 older people avoid being admitted to hospital; 6 million bed days could be saved; and 80,000 elderly people could live more independent lives each year.
Equally important to pushing forward a preventative health agenda is the role of council public health services. The transfer of public health from the NHS to local authorities has been a real success story for local government at a time of well-documented financial challenges. Councils have improved key outcomes on life expectancy, smoking, and healthy habits, while the role of services in combating the Coronavirus pandemic further vindicated the transfer.
The County Councils Network proposals below outline that an incoming government should ensure councils are given a more prominent role in ICSs and policies to improve hospital discharge should focus on expanding home-based reablement, immediate care and home-based recovery. The role of council public health services should be harnessed and built upon, including through the development of health disparities white paper.
our proposals
Adult Services & Health
More focus should be placed on working age and lifelong disabled adults in the national conversation around social care:
- The needs of working age and lifelong disabled adults must be given more profile in policy decision making around adult social care which is often focussed almost exclusively on the needs of older people.
- Develop an aligned strategy between local and national partners to ensure individuals are at the centre of service design.
Review the national funding model for working age and lifelong disabled adults:
- Review the operation of the market and consideration of the reforms needed nationally to enable councils to more effectively manage their market, reduce costs and improve long-term outcomes.
- Government and appropriate bodies such as the Competition and Markets Authority should place similar scrutiny on the existing functioning of the market for social care of this cohort as that already placed on social care of children and older adults, as placement costs are rising at similar rates.
- National, local government and social care providers should work together to develop a more effective approach to managing the market.
- In the forthcoming Mental Health Act reform, section 117 arrangements and funding need to be reviewed, alongside a fundamental re-think of the broken Continuing Health Care system - both of which, at present, are denying working age adults free NHS care when they are entitled to it and, also, are distorting the market because spot-purchased NHS care inflates costs.
Develop housing solutions for disabled adults to reduce reliance on supported living:
- Ensure a sufficient supply of supported housing (including that with new models of wraparound care) should be an important consideration in the building 1.5m homes, to improve outcomes and reduce cost of delivering social care for working age adults.
- Housing policy should be considered alongside social care policy as a key treatment intervention for adults with substance misuse problems.
Develop a cohesive lifelong strategy for prevention and support that better supports transition at key stages of life (e.g. between children’s and adults services):
- Encourage better co-ordination and preparation for children in the SEND system for entering adulthood – including clearly identifying for young people and their families whether they are likely to be eligible for additional support as adults given the significantly higher thresholds.
- All existing funding levels for adult social care services must be retained and baselined in council budgets, including all funding provided through the dedicated social care grant and Improved Better Care Fund (iBCF). A review, and where possible, consolidation of different fragmented funding streams should be undertaken alongside providing greater long-term certainty.
- The operation of the iBCF should be reviewed, ensuring that the fund is primarily directed by councils towards investment in preventative and community based adult social care services rather than supporting acute costs across the NHS.
- Clarify the future approach to pooled funding and grant allocations between councils and Integrated Care Boards (ICBs), ensuring that all funding dedicated to adult social care is routed directly through local authorities, with greater flexibility to allocate funding to local needs.
- Commit to meeting all increased spending need in adult social care over the course of the parliament through central government funding. Additional investment must be prioritised on expanding the availability of care packages for those most in need and enabling investment in community-based, preventative services.
- The government should seek to consult on, and implement, an updated Adult Social Care Relative Needs Formula, building on and updating independent proposals put forward by the Personal Social Services Research Unit at the University of Kent.
- Develop mechanisms to strengthen local, rather than national, lines of accountability with clear arrangements for oversight of major decisions between Integrated Care Boards (ICBs) and local authorities, as a minimum covering budget allocations and significant service reconfiguration.
- Ensure that ICS boundaries are co-terminous with upper-tier local authorities, including a more defined role of 'Place' in local delivery and establishing place-based partnerships.
- Review ICB membership annually with a particular focus on ensuring appropriate local authority and adult social care representation.
- Minimise delays to simple hospital discharges requiring no adult social care (Pathway 0) as a national priority and bring national focus to attendance and admissions avoidance by increasing the scope of preventative work able to be conducted within adult social care and public health.
- Focus additional funding for hospital discharge on expanding home-based reablement, immediate care and home-based recovery – and specifically the NHS community nursing and therapy workforce required for this – rather than short-term care bed capacity.
- Develop good practice and capability development for system strategic commissioning arrangements, such as intermediate care or demand and capacity planning, and reform information and data-sharing governance and standards.
- Review the present range of statutory duties and discretionary services expected to be delivered by local authorities related to adult social care to assess whether they have enough funds to conduct these.
- Ensure that any policy or regulatory changes are fully assessed for their financial impact on local authorities – including indirect market costs - and local authorities receive no new unfunded burdens.
- Review the lessons learnt from the recent introduction of Care Quality Commission Adult Social Care Assurance inspections, ensuring they fully take into account resource constraints of local authorities when assessing the effectiveness of local authority adult social care delivery.
- Work with councils and care providers to review the regulatory system for care provision, particularly with a view to developing new models of 24/7 nursing home care which reflect changing needs and workforce supply.
- Priority must be given to a long-term plan for investing in meeting existing needs and progressing wider system reform, focused on stabilising the market, rebuilding prevention, developing community services and addressing barriers to housing with care. This should build on, and fully realise, the ambitions of Part 1 of the Care Act.
- The government must ensure that councils remain at the heart of delivering services locally as part of a National Care Service and structural changes to the delivery adult social care are avoided. Any establishment of new national bodies to oversee the delivery and standards of care services must be fully consulted upon by an incoming government to ensure councils retain flexibility to meet local needs.
- Work with councils to deliver the principles of the optimised model outlined in CCN’s report, The Future of Adult Social Care, prioritising investment in preventative short-term services, community-based care, and older people’s housing.
- Equal parity must be given to the needs of working age adults in considering future reform and investment in adult social care. A particular focus of a future government should be on the additional demand likely to be placed on adult social care services as a result of the increase in the number of children on Education, Health and Care Plans (EHCPs) as they transition to adult services.
- A national approach to 'what works' in adult social care should be developed and communicated in a systematic way to ensure the sector understands the evidence-based interventions that can drive down cost and maximise independence.
- Retain, and build on, public health as a core function of local authorities, recognising the success of the transition of these statutory duties to councils.
- Work with the Office for Health Improvement and Disparities to develop and publish a health disparities white paper to help tackle the wider determinants of health.
- Review and assess the level of public health grants given to local authorities to effectively discharge their duties in this vital area, including consulting on, and implementing, a new formula for distributing allocations.
- Ensure public health is placed at the heart of all strategies relating to adults and children’s social care recognising that the best way of reforming these systems would be by reducing present record levels of demand.
- Consider the impact of the rise in children and young people with mental health issues, not only ensuring their needs are met in the existing system, but also considering what the future impact on adult social care services may be.
- Develop and broaden the welcome focus on expanding substance misuse treatment to include more support and funding for housing interventions.
- Take a more imaginative approach, combining a cross-country national plan and practical measures, to supporting unpaid carers to continue caring; have lives of their own; be able to access support and breaks; and to be able to retain, or return to, employment.
- Support the social care sector to address the fundamental underlying issues which impact on the recruitment and retention of care workers, one which genuinely improves pay and conditions and recognises specific challenges in county and rural areas. Any reforms or strategies must be fully funded by central government.
- Through pay and conditions reform, the government should seek to reduce the widespread reliance on overseas recruitment in the care sector, while tackling challenges with visas and improving joint working and early-stage vetting between the Home Office, the Care Quality Commission and councils around licences for care providers.
- Urgently invest in a national recruitment and workforce development strategy for local authorities and care providers.
- Make housing one of the fundamental priorities within comprehensive social care reform, underpinned by clear national prioritisation and funding.
- Anticipate and implement the forthcoming recommendations from the national Older People’s Housing Taskforce.
- Develop a national approach to promote and incentivise a broader range of supported housing for working age adults, including the generation of younger people with special educational needs and disabilities moving into adulthood.
- Develop a national career pathway for the housing with care workforce as part of a national social care workforce plan.
- Reform the regulatory and funding frameworks and spatial planning requirements for accessible housing and housing with care, to enable more adults to live in a home of their choice at any age, as an alternative to 24/7 residential or nursing care review.
Our Evidence Base
The Future of Adult Social Care
This report sets out a new blueprint for delivering social care. It outlined that councils should be empowered to lead reform through new ways of working and improved practices for councils, care providers and the NHS, which can increase peoples’ independence and deliver significant savings.
Key findings:
- At least 90,000 additional older adults each year could benefit from greater access to short-term services, such as reablement, to reduce or prevent their need for long-term-care. This, coupled with services being more effective, could reduce long-term care costs by £867m a year.
- Around one fifth – 10,800 – of older adults who go into long-term residential care each year could be supported to live in a more independent setting, such as their own home. This could reduce long-term care costs by £178m a year.
- Working age adults with learning disabilities outside of residential care receiving formal support could be enabled to develop the skills they need to live more independently. In turn, they could have their level of required home care support hours reduced by 8% on average – delivering £261m in savings per year.
Working Age Adults: The forgotten story of social care
Through extensive new data analysis and engagement with local authorities, this forthcoming report with Newton is focused on developing a better understanding of how councils can best manage the needs of individuals with social care needs aged 18 to 64 and with a life-long physical disability.
Areas of focus:
- New insights on the growth in working age adult expenditure and the drivers of rising care and support costs, including new forecasts on the future profile of spending.
- Explore the specific challenges facing this cohort of service users, including the barriers to improving outcomes and reducing care and support costs.
- Examine through new modelling the impact of younger adult transitioning from the SEND system to adult social care, including new projections on the likely impact of future in the coming years.
- Offer an evidence-based understanding to raise the profile of working age adult social care at a national level and key asks from central government, as well providing meaningful guidance and insight for local systems.
Optimising Hospital Flow and Discharge
This study explored how the system which admits and discharge older people from hospital and support their care needs could work better. This could potentially improving the lives of tens of thousands and reducing costs to the NHS and local government.
Key findings:
- Around 175,000 fewer older people each year could avoid being admitted to hospital through improved decision-making from frontline health professionals with patients instead supported in the community. This represents one in 10 admissions and could free up thousands of beds and reduce costs by £600m a year.
- Six million bed days could be saved by reducing delayed discharges, including 500,000 from ‘simple’ discharges.
- For those discharged from hospital, over 80,000 elderly people could live more independent lives each year – such as in their own home – if improved decisions are made by professionals and there is more investment into intermediate care and therapy within these settings. This could reduce local authority costs by £1bn a year.
