Simon Bottery (King’s Fund) and Natasha Curry (Nuffield Trust)

The long-term care (LTC) system* in England restricts access to publicly funded support to people with the highest needs and lowest assets and/or income. People who do not qualify are required to fund their own care and there are no available long-term care insurance products. Since 2014, repeated attempts have been made to reform access to the long-term care system but none has succeeded.

Needs and means-testing criteria are set nationally but are administered and financed by 153 local authorities, which in practice results in some variation in access. Services are provided by 18,500 independent providers, [1]. Quality of services is regulated by a national body, the Care Quality Commission. Services are staffed by around 1.6m workers, the majority of whom are front line care workers [1]. Pay in the sector is low and recruitment and retention are ongoing challenges. There is increasing use of technology in the sector, with around 75% of providers now using electronic care records [2].

*In England, the term ‘adult social care’ is usually used rather than ‘long-term care’. The terms cover similar activities but are not exactly the same: ‘social care’ includes both long-term support and short-term support for working age adults and older people, and it excludes some support normally included within an international definition of long-term care, such as some long-term healthcare support and some disability-related payments. In this overview, we use the term ‘long-term care’ to mean the activities and expenditures normally described in England as ‘adult social care’.

Responsibility for national policy on long term care in England is held by the United Kingdom Department of Health and Social Care (DHSC). In the other three nations of the UK – Scotland, Wales and Northern Ireland – policy is the responsibility of the national legislative bodies and the systems do vary in some elements of eligibility and access [3].

In England, the main roles of the DHSC are setting the legal framework for access to long-term care, the regulatory framework for minimum quality standards and ensuring adequate funding is available to the 153 local authorities in England who have statutory responsibility for ensuing people get the social care they need. Individual local authorities set their own local budgets, funded mainly from locally-raised revenue supported by some national grants. On average, spending on social care for adults represents around 40 per cent of the total spending of these local authorities [4].

Responsibility for local authority finance overall rests with the Ministry of Housing, Communities and Local Government. Regulation of long-term care services is the responsibility of an independent body, the Care Quality Commission.

Some services, such as advice and information and short-term support, are available to anyone with care needs, without a means test. There is also a small non-mean tested cash payment available for disabled people through the welfare benefits system^[1] and some people whose long-term care need arises primarily from a health condition may receive long-term support without a means test through the healthcare system.

However most long-term support is means-tested and therefore only available to people with the highest needs and lowest financial assets. Other people are required to self-fund any care they need. There is currently no private long term care insurance available in England [5].

Financial assets are typically people’s savings and – if a person is moving into a care home – their property. The means test sets two important cut-off points (‘thresholds’) for these assets [6]. The lower threshold, currently £14,250, is the point below which an individual does not have to contribute anything towards their care from their assets (though they will most likely still have to contribute to the costs of their care from their income). The upper threshold, currently £23,250, is the point above which an individual will have to fund all their social care costs. Between these two thresholds, individuals have to contribute on a sliding scale using a formula which assumes that individuals have £1 of income for every £250 of assets.

Access to publicly funded adult social care varies significantly by age [7]. In 2023/24, fewer than 1 in 100 18-24 year olds received publicly-funded social support during the year, compared to 4 in 100 75-84 year olds and 12 in 100 people aged 85 and over. Requests for support, and access to care, has grown across all ages groups in recent years although this increase has been sharpest among working age adults. There is limited data about the extent of self-funded social care. Around a third of people in care homes are estimated to be funding their own care, though this varies according to age – around half of all older people but only 2% of working age adults are self-funding [8]. Around a quarter of those receiving home care are estimated to be self-funding [9].

^[1] Note that the benefits system is undergoing changes which has implications for eligibility for these payments

Care services are regulated by an independent national body, the Care Quality Commission, which assesses whether providers are safe, effective, caring, responsive to people’s needs and well led. The CQC undertakes inspections of providers and publishes ratings for each provider as either outstanding, good, requires improvement or inadequate, and has the power to close services where necessary. The CQC was heavily criticised by a recent government-commissioned review [10].

Most social care services are delivered by independent sector home care and residential care providers, which are mainly for-profit companies but also include some voluntary sector organisations. If they qualify for publicly funded support, many people will have care organised and purchased by their local authority, though some people with disabilities can choose to directly employ individuals (‘personal assistants’) to provide their care and support [11].

Around 37% of organisations employ fewer than 5 staff, over half employ fewer than 10 and 85% have fewer than 50 employees [1]. Large organisations with more than 250 employees make up only 2% of all organisations, though they employ almost half (46%) of the total adult social care workforce.

Social care is often broken down into two broad categories of ‘short-term support’ and ‘long-term support’ [12]. Short-term support refers to a care package that is time limited, usually with the intention of maximising the independence of the individual using the care service and eliminating their need for ongoing support. Long-term services are provided on an ongoing basis and range from high-intensity services like nursing care to supported living and lower-intensity community support.

Around 8.9% of people in England (4.7m) are unpaid carers, of whom 1.4m provide more than 50 hours of care each week [13,14].  Support for unpaid carers is a statutory responsibility of local authorities, and around 300,000 unpaid carers receive support such as advice and information, services and cash payments from them [15]. 1.4m carers are also able to claim a national cash benefit, Carer’s Allowance, which is intended to compensate carers for loss of income as a result of their caring duties [16].

England has followed a loose policy of supporting people to live independently at home, where possible, rather than in institutional settings. However, the policy is applied inconsistently between areas and not always supported consistently nationally. In 2023/24, around 600,000 people in England received state-funded long-term community support (compared with around 257,000 who receive residential care support) [12]. This typically involves provision of care in people’s homes, though it can also encompass other settings such as day centres. Over 130,000 people – most often, working-age adults – receive cash payments (known as ‘direct payments’) to arrange their own community-based care.

England has a relatively small provision of extra-care housing compared to countries such as New Zealand and the United States [20].

Since 2012 there has been an overall fall in the number of residential and nursing home places in England compared to the older population.

England now has around 450,000 care home places, split fairly evenly between residential care homes and nursing homes (which are required to have registered nurses on duty) [17]. The great majority of residential care settings are owned by private sector providers [18]. Around half of places in care homes for older people are funded by local authorities, though care homes providers argue that the fees paid are often insufficient [8]. As a consequence, privately funded residents typically pay around 40% more for their places than publicly-funded residents [19].

Despite widespread public use of technology such as smartphones, and openness on the part of people using care to considering technology in care, adoption of assistive technology has been limited in England. There is some usage of technology such as remote monitoring but technology is still frequently discussed in terms of its potential rather than its current usage [21]. The shape of the market, with care provided by 18,500 separate and usually small organisations, may help account for this. One further explanation for this is that people who draw on services have not been adequately consulted in development of technology.

There are around 1.8m long-term care roles in England [11]. Over three quarters of staff work for independent sector employers – mainly private sector for-profit organisations but also non-profits [11]. The remainder are split fairly evenly between health-service employers, local authority employers and individuals who employ their own personal assistants. Compared with the population of England, a higher proportion of adult social care workers are female and from an ethnic minority group,

Around three quarters of staff work in direct care roles as care workers or support workers [1].

There is no register of social care staff in England, unlike the other nations of the United Kingdom [22].

There are a high number of vacancies in the sector. [1]. Vacancies grew steadily from around 2012/13 and plateaued at around 7 percent before the Covid-19 pandemic. Immediately after the pandemic, however, vacancies rose sharply and the government was forced to relax restrictions on overseas workers. As a result, vacancies fell but remain higher than before the pandemic. Immigration rules have since been tightened once more and there has been a sharp drop in the number of applicants for care visas [23].

Pay is a key factor in vacancy levels. [1]. England introduced a statutory minimum wage across all sectors of the economy in 2015/16 and, as a result, care worker pay increased in real terms every year afterwards. However, pay in other sectors increased more quickly. In 2012/13, care workers were paid more than retail sales assistants but by 2019/20 this was no longer the case. Many care workers would be paid more in entry-level posts in supermarkets. [24]. Furthermore, pay does not routinely increase with experience – in 2024/25, a worker with 3 years’ experience could expect to earn only 4 pence more than a new starter making retention challenging.

In 2024, the new Labour government began legislating for a sector-wide pay, terms and conditions agreement in adult social care, though the precise scope and timeline for this is not yet clear [25].

Data systems have improved significantly since the Covid-19 pandemic. National government now has access to up-to-date data on some core issues such as staff absences and care home vacancy levels. Work is also underway to create an individual-level data set for social care, giving a better understanding of how services work together and the outcomes for people using them [26]. There is also significant effort to support providers to adopt electronic (rather than paper-based) care records and around 75% of care providers now have capacity to use them.

The principle of personalisation – ensuring users of services have as much choice and control over their care as possible – is core to the culture of long-term care in England, though its implementation is patchy. The 2014 Care Act introduced a right for people to receive long-term support as a cash payment with which they could purchase their own services [27]. However it has brought about little change in the number of people who do this.

More recently, many local authorities have moved towards adopting ‘asset-based’ or ‘strengths-based’ approaches to provision of long-term care [28]. These aim to identify and support individual’s capabilities and connect them more closely into their existing networks, communities and other forms of support. However, there is a concern that these approaches can sometimes be a screen for reducing the state-provided support to individuals [29].

Since 2015/16, more people have requested long-term care support from their local authorities but fewer have received it. [30]. This is despite a real-terms increase in expenditure by local authorities on long-term care. [30]. The most likely explanation for this is that the cost of providing care has increased. In real terms, since 2015/16 the average weekly fee for working-age adults has increased by 13%, the average weekly fee paid for older people has increased by 33%, and the average hourly rate for home care has increased by 18% [30]. These cost increases have in turn been driven by the cost to providers of staff pay, which has risen in real terms as a results of the statutory minimum wage.

Since Covid-19, local authorities have also struggled to process new requests for support. , care to begin or an assessment of their needs . Over 400,000 people are waiting for an assessment or for care to begin [31].

An in-depth analysis of the experience of the social care system in England during the early part of the Covid-19 pandemic found that the sector had entered the pandemic in a fragile state following a period of austerity and that the pandemic exposed and exacerbated structural weaknesses of the system [32]. The report identified the following pre-existing weaknesses that need to be addressed to build a system that is more resilient in the face of future crises:

• Complex governance and a lack of clarity over accountability within the social care system hindered basic communication and collaboration and created delays and confusion in rolling out a response to covid-19.
• There a lack of adequate preparedness at a national and local level for pandemics and other crises within the sector.
• The complexity and diversity of the sector were not adequately considered by government in its initial response. This was particularly evident when it came to the workforce, with guidance and policy not adequately taking into account the insecure nature of employment and low levels of access to sick pay.
• While emergency financial support was welcome, it was slow to reach providers and did not provide sufficient certainty or flexibility to stabilise the sector.
• There was a lack of data and information about who uses and provides care, particularly for self-funders and people relying on, and providing, unpaid care.
• The residential care estate relies to a large extent on outdated buildings which impeded the adequate implementation of infection prevention and control guidance.

Since 2014, England has made repeated but unsuccessful attempts to reform eligibility to its long-term care system [33]. This would have involved making the existing means test more generous by increasing the upper threshold so that more people would be entitled to some state-funded support and introducing a lifetime limit on care costs so that those having to pay for their own care would have costs ‘capped’ (in the most recent planned reform, at £86,000) [34]. Legislation to introduce these reforms was passed in 2014 but implementation has been abandoned on three occasions, most recently in 2024, due to the cost of the reforms.

The current government has not set out plans for reform of long-term care except for its intention to create a ‘fair pay agreement’ for care workers [35]. It has, however, established a new independent commission to be led by Baroness Casey set to run from April 2025 until 2028 and intended to set out a future for the system. This is the latest in a succession of reviews, commissions and inquiries on the topic stretching back to 1997.

Bottery S. and Curry N. (2025) Long-Term Care System Profile: England. Global Observatory of Long-Term Care, Care Policy & Evaluation Centre, London School of Economics and Political Science. https://goltc.org/system-profile/england/

[1] Skills for Care. (2024). The state of the adult social care sector and workforce in England 2024. https://www.skillsforcare.org.uk/Adult-Social-Care-Workforce-Data/Workforce-intelligence/documents/State-of-the-adult-social-care-sector/The-state-of-the-adult-social-care-sector-and-workforce-in-England-2024.pdf

[2] Department of Health and Social Care. (2025, February 6). Adult social care in England, monthly statistics: February 2025. GOV.UK. https://www.gov.uk/government/statistics/adult-social-care-in-england-monthly-statistics-february-2025

[3] Dodsworth, E., & Oung, C. (2023, February 2). Adult social care in the four countries of the UK. Nuffield Trust. https://www.nuffieldtrust.org.uk/comment-series/adult-social-care-in-the-four-countries-of-the-uk

[4] Local Government Association. Save local services: How is £1 of council funding spent? https://www.local.gov.uk/about/campaigns/save-local-services/save-local-services-how-ps1-council-funding-spent

[5] Rosanes, M. et al. (2023, March 8). Long-term care insurance in the UK: What’s going on? Insurance Business UK. https://www.insurancebusinessmag.com/uk/guides/long-term-care-insurance-in-the-uk-whats-going-on-438786.aspx

[6] Department of Health and Social Care. (2024, February 9). Social care charging for care and support: Local authority circular 2024 to 2025 (LAC(DHSC)(2024)2). GOV.UK. https://www.gov.uk/government/publications/social-care-charging-for-local-authorities-2024-to-2025/social-care-charging-for-care-and-support-local-authority-circular

[7] Bottery, S., J. Danielle. (2025, May 21). Social care 360: Access. The King’s Fund. https://www.kingsfund.org.uk/insight-and-analysis/long-reads/social-care-360-access#2.-service-delivery

[8] Office for National Statistics. (2023, July 6). Care homes and estimating the self-funding population, England: 2022 to 2023. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/socialcare/articles/carehomesandestimatingtheselffundingpopulationengland/2022to2023

[9] Office for National Statistics. (2023, July 26). Estimating the size of the self-funding population in the community, England: 2022 to 2023. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/socialcare/bulletins/estimatingthesizeoftheselffunderpopulationinthecommunityengland/2022to2023

[10] Department of Health and Social Care. (2024, October 15). Review into the operational effectiveness of the Care Quality Commission: Full report. GOV.UK. https://www.gov.uk/government/publications/review-into-the-operational-effectiveness-of-the-care-quality-commission-full-report

[11] Skills for Care. (2024, October). The state of the adult social care sector and workforce in England. https://www.skillsforcare.org.uk/Adult-Social-Care-Workforce-Data/Workforce-intelligence/publications/national-information/The-state-of-the-adult-social-care-sector-and-workforce-in-England.aspx

[12] NHS England. (2024, October 31). Adult social care activity and finance report, England, 2023–24. https://digital.nhs.uk/data-and-information/publications/statistical/adult-social-care-activity-and-finance-report/2023-24

[13] Office for National Statistics. (2023, February 13). Unpaid care by age, sex and deprivation, England and Wales: Census 2021. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/socialcare/articles/unpaidcarebyagesexanddeprivationenglandandwales/census2021

[14] Office for National Statistics. (2023, January 19). Unpaid care, England and Wales: Census 2021. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandwellbeing/bulletins/unpaidcareenglandandwales/census2021

[15] Bottery, S., & Jefferies, D. (2025, May 21). Social care 360: Workforce and carers. The King’s Fund. https://www.kingsfund.org.uk/insight-and-analysis/long-reads/social-care-360-workforce-carers

[16] Office for National Statistics. (2023, January 19). TS039: Provision of unpaid care, 2011 and 2021. https://www.ons.gov.uk/datasets/TS039/editions/2021/versions/3/filter-outputs/58deae48-907f-47fc-9a2d-d09f98c206e7

[17] Bottery, S., & Jefferies, D. (2025, May 21). Social care 360: Providers. The King’s Fund. https://www.kingsfund.org.uk/insight-and-analysis/long-reads/social-care-360-providers

[18] LaingBuisson. (2024, October). Adult social care in the UK: Scale, structure, funding and financial performance of the independent sector. Homecare Association. https://www.homecareassociation.org.uk/asset/F26B2E4B%2DC183%2D45E8%2DABC6274E97EE24AC

[19] Competition and Markets Authority. (2017, November 30). Care homes market study: Summary of final report. GOV.UK. https://www.gov.uk/government/publications/care-homes-market-study-summary-of-final-report/care-homes-market-study-summary-of-final-report

[20] Bottery, S. (2021, January 22). Why is there so little extra care housing in the UK? It’s not for lack of evidence about its benefits. ARCO. https://www.arcouk.org/blog/why-is-there-so-little-extra-care-housing-in-the-uk-it%E2%80%99s-not-for-lack-of-evidence-about-its

[21] Bottery, S., & Mistry, P. (2023, August 1). Technology in adult social care: Very wide potential – but only if developed in partnership. The King’s Fund. https://www.kingsfund.org.uk/insight-and-analysis/blogs/technology-adult-social-care-potential-partnership

[22] Social Care Wales. (2025, March 27). Adult care home worker registration. https://socialcare.wales/registration/adult-care-home-worker-registration#:~:text=Information%20about%20the%20registration%20of%20adult%20care%20home,the%20registration%20fee%3F%20What%20responsibilities%20do%20employers%20have%3F

[23] National Audit Office. (2025, March 17). Immigration: Skilled Worker visas. https://www.nao.org.uk/reports/immigration-skilled-worker-visas/

[24] Bottery, S. (2022, August 23). Odds stacked against it: How social care struggles to compete with supermarkets on pay. The King’s Fund. https://www.kingsfund.org.uk/insight-and-analysis/blogs/how-social-care-struggles-compete-supermarkets-pay

[25] Department for Business and Trade. (2024, October 18). Social care negotiating bodies and Fair Pay Agreements [Factsheet]. GOV.UK. https://assets.publishing.service.gov.uk/media/67e3d38f6e54ea5b2b8ee2c1/social-care-negotiating-bodies-and-fair-pay-agreements.pdf

[26] NHS England. (2023, July). Adult Social Care Client Level Data. https://digital.nhs.uk/data-and-information/data-collections-and-data-sets/data-sets/adult-social-care-client-level-data

[27] Care Act 2014, c. 23. (2014). Legislation.gov.uk. https://www.legislation.gov.uk/ukpga/2014/23/contents

[28] Social Care Institute for Excellence. (n.d.). Asset-based approaches for integrated care. https://www.scie.org.uk/integrated-care/research-practice/enablers/asset-based-places/

[29] Institute for Government. (2023, October 30). Performance Tracker 2023: Adult social care. https://www.instituteforgovernment.org.uk/publication/performance-tracker-2023/adult-social-care

[30] Bottery, S., & Jefferies, D. (2025, March 3). Social care 360. The King’s Fund. https://www.kingsfund.org.uk/insight-and-analysis/long-reads/social-care-360

[31] Curry N, Oung C, Hemmings N, Comas-Herrera A and Byrd W (2023) Building a resilient social care system in England: What lessons can be learnt from Covid-19? Research report, Nuffield Trust and Care Policy and Evaluation Centre. https://www.nuffieldtrust.org.uk/research/building-a-resilient-social-care-system-in-england-what-lessons-can-be-learnt-from-covid-19

[32] Association of Directors of Adult Social Services. (2024, July 16). ADASS Spring Survey 2024. https://www.adass.org.uk/documents/adass-spring-survey-2024/

[33] Curry, N., Lobont, C., Dayan, M., Hemmings, N., & Oung, C. (2024, October 9). The state of social care in England and the case for a comprehensive social care strategy. Nuffield Trust. https://www.nuffieldtrust.org.uk/resource/the-state-of-social-care-in-england-and-the-case-for-a-comprehensive-social-care-strategy

[34] Department of Health and Social Care. (2024, September 12). Adult social care charging reform: Further details. GOV.UK. https://www.gov.uk/government/publications/build-back-better-our-plan-for-health-and-social-care/adult-social-care-charging-reform-further-details

[35] Department for Business and Trade. (2024, October 10). Next steps to make work pay (Web accessible version). GOV.UK. https://www.gov.uk/government/publications/next-steps-to-make-work-pay/next-steps-to-make-work-pay-web-accessible-version

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