Adult Social Care Activity and Finance Report, England - 2020-21

Long term care is provided to clients on an ongoing basis and varies from high intensity provision such as nursing care, to lower intensity support in the community such as the provision of direct payments to arrange regular home care visits.

Whereas short term care is designed for a time limited period, and in the case of ST-Max with the aim of reducing or removing the clients need for ongoing care, long term care has no fixed time period and is delivered for as long as it is required.

Please Note: There are some differences in how information on long term care is collected between the ASC-FR and SALT returns.

For example, activity data includes those receiving long term care with a Primary Support Reason (PSR) of Social Support, whereas this PSR is not included in long term expenditure (instead being recorded as a combined short term/long term spend total).

In addition, information regarding support settings is recorded using different categories between the returns, and so this data cannot be directly compared.

Therefore, care must be taken when comparing the two returns; some comparisons of general trends can be made, but more direct comparisons, such as an average cost per person, are not recommended.

Nearly 75% of total gross current expenditure is spent on long term care (£15.6 billion), which consists of residential, nursing and community care.

This represents an increase of £233 million (1.5%) compared to 2019-20. Gross current expenditure is spent on long term care evenly between the two age groups and this is the first year since the ASC-FR collection started where more was spent on those aged 18-64 in long term support (50.4% on clients aged 18 to 64 and 49.6% on clients 65 and over). This switch in proportion has arisen through an increase of £334 million spent on the 18-64 group where 111 of 149 local authorities (excluding the two where estimates were used) showed a year on year increase and a decrease in spending of £102 million for those aged 65 and over, with the East of England region accounting for over half of this decrease.

In activity terms, the total number of clients receiving long term support in the year has fallen each year since 2015-16 to 2019-20. In 2020-21 the first year-on-year increase occurred. There were 841,245 clients in receipt of long term support, an increase of 2,715 (0.3%) clients from the previous year, possibly influenced by the inclusion of activity funded under COVID-19 hospital discharge arrangements, and a decrease of 31,275 clients (3.6%) since 2015-16.

When considering those accessing long term support by client age, there had been an increase each year for clients aged 18 to 64 and a decrease each year for clients 65 and over until 2019-20 where both trends stop, see Figure 12 below.

Source: SALT Collection, 2020-21, NHS Digital - See Table 2 in Reference Data Tables and previous publications

In total, 841,245 clients were supported at some point in the year, with 616,180 of these clients (73.2%) in receipt of long term support at year end. Of this latter group, 459,395 clients (74.6%) had been receiving long term support for one year or more.

Although the collections do not capture intensity of support, the high proportion of clients that had been supported for 12 months or more at the end of the year reflects a need for ongoing support. As can be seen in Figure 13, the 18-64 age group has a higher proportion of clients in long term care at year end receiving long term support for one year or more (84.5%), compared to those aged 65 and over (67.5%).

Figure 13: The number of clients accessing long term support during the year, at year end, and for more than 12 months, by age group, 2020-21

Source: SALT Collection, 2020-21, NHS Digital - See Table 33 in Reference Data Tables

Figure 14 illustrates whilst the 18 to 64 age group accounts for 34.4% of all adults that accessed long term support at any point during the year, this increased to 47.1% of all clients who have accessed services for more than 12 months at year end.

Source: SALT Collection, 2020-21, NHS Digital - See Table 33 in Reference Data Tables

In 2020-21, 9 in 1,000 18 to 64 year olds received long term support during the year, while 53 in 1,000 clients aged 65 and over received this type of support (both rates unchanged from 2019-20).

Source: ASC-FR and SALT Collections, 2020-21, NHS Digital - See Table 33, 43 and 44 in Reference Data Tables. As referenced at the start of the long term section, long term activity and long term expenditure are not directly comparable.

Figure 15 shows that although just over one-third of long-term activity was provided to clients in the 18 to 64 age group in 2020-21, this age group accounted for just over half (50.4%) of the gross current expenditure for long term care during the period.

One explanation for this is that long term support for 18 to 64 year olds typically covers more complex care needs, and as a result, unit costs for both nursing and residential are much higher for this age band (unit costs are not available for community care). This is explored in more detail in the section regarding Primary Support Reasons.

Over half (57.4%) of all clients receiving long term support at the year-end are female. Data is not collected on gender split for short term care.

Source: SALT Collection, 2020-21, NHS Digital - See Table 41 in Reference Data Tables

Support setting is the primary setting where the client receives services. Expenditure and activity data collect information regarding support setting using different categories. The main difference is for the community care setting. Expenditure data is captured using a mixture of delivery mechanism and support setting, whereas activity data is captured by delivery mechanism only, and so comparisons regarding support setting are limited between the two data sources, and discussion of the two collections has been separated in this section.

Use of hierarchies in support setting

An individual may receive care in multiple support settings throughout the year. To avoid double counting a hierarchy is used to ensure counts of those receiving support in the year are not duplicated.

An individual can only be counted under one setting in the hierarchy – for example if an individual received both residential and nursing care in the year, they would be counted under nursing care only.

For the purposes of this section therefore, analysis on support setting will focus instead on those receiving services at the end of the year. This provides a snapshot figure of the number of people in each support setting at year end.

Data on the support settings for those receiving care in the year can be found in the reference tables accompanying this report.

Source: SALT Collection, 2020-21, NHS Digital - See Table 35 in Reference Data Tables and previous publication

Source: SALT Collection, 2020-21, NHS Digital - See Table 39 in Reference Data Tables and previous publication

As seen in Figure 21 below, for both age groups, residential care accounted for the highest proportion of gross current expenditure.

However, when considering all elements of community care (consisting of direct payments, home care, supported living and other long-term care), this accounts for 49.1% of gross current expenditure on long term care, while residential care accounts for 35.8%.

Expenditure on nursing care (19.3%) and home care in the community (23.3%) were also key areas of expenditure for those aged 65 and over. Supported living (25.0%) and direct payments (16.7%) accounted for the second and third highest proportions respectively of expenditure (after residential care) for those aged 18 to 64.

Source: ASC-FR Collection, 2020-21, NHS Digital - See Table 43 and 44 in Reference Data Tables

In 2020-21 gross current expenditure on long term care increased by £233 million (1.5%) since the previous year, and this was split across support settings. The biggest increase in expenditure was for ‘Community: Supported Living’ which has risen by 10.1% (£210 million) since the previous year. Nursing care saw the biggest decrease both in monetary and percentage terms, by 7.9% (£153 million).

Source: ASC-FR Collection, 2020-21, NHS Digital - See Table 45 in Reference Data Tables and previous publication

A primary support reason describes why the individual requires social care support. It is important to note that for example, an individual may have a learning disability but would not be recorded under Primary Support Reason ‘Learning Disability support’ if their primary reason for support identified at assessment falls under one of the other classifications. This is collected in both the activity and finance data collected by NHS Digital.

Some local authorities have previously reported difficulty in correctly allocating activity and expenditure across these categories, and this should be taken into consideration when analysing this data. Comparison of trends in the data, however, does provide useful insight into how long-term care is provided by local authorities.

Whereas ST-Max is predominantly provided to clients with a primary support reason of physical support, the picture in long term care is more varied. In particular, the most common primary support reason for the client needing support differs by age group.

As can be seen in Figure 23, for those aged 18 to 64 the most common reason for requiring support was learning disability (this was the primary support reason for 46.1% of clients receiving long term support in the year). The next most common support reasons were physical support (29.7%) and mental health support (18.6%).

Source: SALT Collection, 2020-21, NHS Digital - See Table 35 in Reference Data Tables

For those aged 65 and over the most common primary support reason was physical support (74.1%) followed by support for memory and cognition (13.4%).

Although the expenditure return does not include the Social Support primary support reason, examination of this data shows a similar trend to that of activity data. Physical Support accounted for the majority of gross current expenditure on those aged 65 and over (63.8%), while learning disability support accounted for 69.7% of expenditure on those aged 18 to 64.

Source: ASC-FR Collection, 2020-21, NHS Digital - See Table 45 in Reference Data Tables

At England level, learning disability support has the highest unit costs for both those aged 18 to 64 and 65 and over. As seen in Figure 25, as care for those clients aged 18 to 64 is more likely to be due to a primary support reason of learning disability, these increased costs are likely to have more impact on overall unit costs for this age group.

When looking at the data for clients accessing services at year end, within the 18 to 64 age group, learning disability accounts for almost half (49.0%) of the activity by primary support reason. By support setting, 18-64 year olds with learning disabilities in a nursing setting make up only 15.0% of all clients accessing services at year end. This increases to 47.8% for clients in a community support setting and even further to 62.8% of those in a residential care setting.

As a result, residential unit costs tend to be higher than nursing costs for this age band, due to the increased expenditure associated with learning disability support, as seen in Figure 25.

When considering 2020-21 data, a number of local authorities advised that their unit costs were impacted due to their response to the COVID-19 pandemic, and the associated funding to support the sector. Full details are available in the supporting data quality outputs.

Figure 25: Overview of weekly costs of care by primary support reason, 2020-21

Source: SALT and ASC-FR Collection, 2020-21, NHS Digital - See Table 53, 54, 37 and 38 in Reference Data Tables

The numbers of clients supported in long term care during the year varies regionally, as can be seen in Figure 26 below. This shows the number of clients receiving long term support in the year per 100,000 population by age group.

The North West Region has the highest number of clients aged 18 to 64 accessing long term support during the year, with 1,005 clients per 100,000 population. In the 65 and over age group the North East is highest with 7,355 clients per 100,000 population, closely followed by London with 6,865 clients.

From a local authority perspective, the six local authorities with the highest number of clients aged 65 and over accessing long term support per 100,000 are all in London. The London region now reports seven of the ten local authorities reporting the highest proportion of clients aged 65 and over supported per 100,000 population.

Figure 26: Number of clients accessing long term support during the year per 100,000 adults, by age group and local authority, 2020-21

Source: SALT Collection, 2020-21, NHS Digital - See Table 36 in Reference Data Tables