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Publication, Part of

Health Survey for England, 2021 part 2

Official statistics, National statistics, Survey

National Statistics

Social care for older adults

Summary

This report includes results from the 2021 Health Survey for England describing the need for and receipt of social care among adults aged 65 and over. It compares social care needs and receipt by age, sex, household income, area deprivation, longstanding illnesses and health status.

Detailed tables accompanying this report can be accessed here.


Key findings for 2021

  • 24% of men and 28% of women aged 65 and over needed help with at least one Activity of Daily Living (ADL) in the past month. 21% of men and 29% of women needed help with at least one Instrumental Activity of Daily Living (IADL).
  • The proportions needing help with ADLs or IADLs increased with age from 21% of adults aged between 65 and 69 to 52% of those aged 80 and over. Need for help with two or more ADLs or IADLs also increased with age from 15% of adults aged 65 to 69 to 40% aged 80 and over. 
  • 22% of adults aged 65 and over had an unmet need for help with at least one ADL, and 15% had an unmet need for help with at least one IADL.
  • Adults aged 65 and over from the most deprived area were twice as likely to need help with ADLs and IADLs as adults living in the least deprived areas. The proportions who had received some help and who had unmet need were also higher in more deprived areas.
  • More than half of adults with a limiting longstanding illness needed help with ADLs (53%) and IADLs (51%), compared with less than 10% of those with a non-limiting longstanding illness or no longstanding illness. 

Introduction

Contents

The Health Survey for England (HSE) has included questions on social care for adults aged 65 and over every year since 2011. This report describes older adults’ need for social care and to what extent care is provided, including analysis by age, sex, income, area deprivation and longstanding illness. 

The data are based on a representative sample of the adults aged 65 and over living in private households. Adults in hospitals and care homes were not included in the sample. 

Background

Social care is the provision and receipt of help with personal care and domestic tasks to help enable individuals to live as independently as possible. It impacts the lives of many, including those who require formal care and support, their families, unpaid carers, and the social care workforce. Overall, social care affects over 10 million adults of all ages in England at any one time (Source: People at the Heart of Care: adult social care reform white paper).

Between 2021 and 2022, local authorities in England spent £22 billion on adult social care. There were almost 2 million requests for adult social care support from 1.4 million new clients. Adults over 65 years of age made up 69% of those requests (Source: Adult Social Care Activity and Finance Report, England, 2021-22).

The current demand for social care services is expected to increase due to an ageing population, better diagnosis, and higher survival rates in premature babies. It is predicted that by 2050 one in four people in the UK will be aged 65 and over, increasing from one in five in 2018 (Source: Overview of the UK population - Office for National Statistics). The impact of the COVID-19 pandemic on both physical and mental health will contribute to future demand for social care (Source: People at the Heart of Care: adult social care reform white paper). 


Methods and definitions

Methods

Questions for those in need of, or in receipt of, social care were asked of adults aged 65 and over. In 2021, these questions were part of the telephone interview. 

The current modules of social care questions were developed in 2009 and 2010 and first used in the HSE 2011. They are designed to investigate different, but related, areas.

  • The need for and receipt of social care among adults aged 65 and over
  • How those services are provided by paid-for and unpaid carers
  • The characteristics and experiences of adults who provide unpaid social care and support to family members, friends and neighbours. 

Core questions for adults aged 65 and over are included in HSE in every year. More detailed questions alternate every other year, covering either the nature of care received by older adults (as in HSE 2021) or focused on the experience of unpaid care givers. 

More detailed information about the modules can be found in the HSE 2011 report.

While social care may be needed by and provided for people of any age, the sample for the HSE does not include sufficient numbers of social care recipients among children and adults aged under 65 to allow robust analyses of the patterns of need and receipt of care among different groups and therefore these questions are only asked of adults aged 65 and over. Only private households were included in the sample, and older adults in hospitals and care homes are not covered.   

The full questionnaires can be found within the Survey Documentation.

Definitions

Measuring need for and receipt of social care: ADLs and IADLs
The need for and receipt of social care is measured using a number of Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). ADLs are activities relating to personal care and mobility about the home that are fundamental to daily living. IADLs are activities which, while not fundamental to functioning, are important aspects of living independently. A total of thirteen ADLs and IADLs were used in the HSE and are shown in Table A; these were carefully selected to represent a full range of key activities.

The ADLs and IADLs included in the social care module allow an approximation of the Barthel Index, a measure of ability to live independently at home for older people. For further details see the 2011 report.

Table A: Summary of Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs)

ADLs IADLs
Having a bath or shower Doing routine housework or laundry
Using the toilet Shopping for food
Getting up and down stairs Getting out of the house
Getting around indoors Doing paperwork or paying bills
Dressing or undressing  
Getting in and out of bed  
Washing face and hands  
Eating, including cutting up food  
Taking medicine  
ADLs and IADLs and the Care Act 2014 eligibility criteria

The Care Act 2014 outlines the eligibility criteria for accessing adult care and support under The Care and Support (Eligibility Criteria) Regulations 2014. Under these guidelines, a person is eligible for care if they cannot achieve two or more specified outcomes in their day-to-day life, and as a result experience significant impact on their well-being. This criterion differs to the HSE definition of need which defines adults aged 65 and over to be in need of care and support if they said there was at least one ADL or IADL that they could manage on their own with difficulty, could only do with help, or could not do at all. 

Although the national eligibility criteria threshold appears to be higher, there are differences between the outcomes it uses and the ADLs and IADLs measured in the HSE. In some ways the outcomes in the eligibility criteria are broader and they do not distinguish between types of activity as the HSE does for ADLs and IADLs. An instrumental activity such as getting around in the community safely and being able to use facilities such as public transport, is one outcome alongside others focused on more personal activities, such as being able to dress and being appropriately dressed.

Table B compares the national eligibility criteria with the ADLs and IADLs where there is an obvious correspondence.

Table B: Comparison between national eligibility criteria, ADLs and IADLs

National Eligability Criterion

ADLs IADLs
Managing and maintaining nutrition.

Eating, including cutting up food.

Shopping for food.

Maintaining personal hygiene.

Having a bath or shower.  

 

  Washing face and hands.  

Managing toilet needs.

Using the toilet.

 

Being appropriately clothed.

Dressing and undressing.

 

Being able to make use of [their] home safely.

Getting up and down stairs. 

 

 

Getting around indoors. 

 

 

Getting in or out of bed.

 

Maintaining a habitable home environment.

 

Doing routine housework or laundry.

Making use of necessary facilities or services in the local community, including public transport and recreational facilities or services.

 

Getting out of the house.

There are no direct equivalents among the eligibility criteria for the ADL ‘taking medicine’ or the IADL ‘doing paperwork and paying bills’. Similarly, several of the national eligibility criteria – developing and maintaining family or other personal relationships; accessing and engaging in work, training, education or volunteering; and carrying out childcare responsibilities – have no equivalent ADLs or IADLs. Some of the ADLs and IADLs affect more than one criterion, for example being able to get in or out of bed, get up and down stairs and get around indoors all have an impact on most of those eligibility criteria concerned with daily home life, such as maintaining personal hygiene and managing toilet needs. 

Although the HSE measures of need are not directly comparable with the 2004 Care Act eligibility measure, both sets of criteria identify adults with multiple needs for care and support, and there is likely to be some overlap between those needing help with two or more ADLs or IADLs and those qualifying under the national eligibility criteria.

Need for help and unmet need

For each ADL and IADL, participants aged 65 and over were asked whether they could: 

  • carry out the activity on their own, 
  • manage on their own with difficulty,
  • only do the activity with help, or 
  • could not do it at all. 

Where ‘need’ for help is discussed in the report, it refers to people in the last three categories.

For the IADLs relating to shopping, housework and paperwork, participants were asked to exclude help which was provided simply because of the way household responsibilities were divided.

Participants who indicated that they needed some degree of help for at least one ADL or IADL were asked whether they had received any help in the last month. 

‘Unmet need’ refers to cases where participants indicated that they needed help with a particular ADL or IADL but had not received any help with it in the last month. Participants could be receiving help with one or more activity but also have unmet needs for other ADLs or IADLs.


Care needs of adults aged 65 and over

Ability to perform ADLs and IADLs in the last month

Adults aged 65 and over were asked how well they could carry out each of the 13 Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). Those who said they could not carry out the activity without help were combined into a category of adults aged 65 and over who had need for help with that activity. 

Among ADLs, adults aged 65 and over were most likely to need help with 

  • getting up and down the stairs (20%)
  • having a bath or shower (13%)
  • dressing and undressing (13%). 

For more information: Table 1

Among IADLs, adults aged 65 and over were most likely to need help with  

  • shopping for food (20%)
  • doing routine housework or laundry (19%). 

For more information: Table 1

For most ADLs, participants who needed help were most likely to say that they could manage the activities on their own but with difficulty. A smaller proportion of adults aged 65 and over said that they could do these activities only with help, or not do them at all.

Where help was needed, participants were most likely to say that they needed help with two or more ADLs or IADLs in the last month (24%). 

Need for help with ADLs and IADLs, by age and sex

69% of adults aged 65 and over reported that they could perform all the ADLs and IADLs on their own without help. The proportions who needed help with at least one ADL in the last month (26%) or at least one IADL (25%) were similar. 

The proportion who did not need help decreased with age from 79% of adults aged 65 to 69, 69% of adults aged 75 to 79, and was much lower (48%) among those aged 80 or over. 

Consequently, the proportions needing help increased with age from 21% of adults aged between 65 and 69 to 52% of those aged 80 and over. Need for help with two or more ADLs and/or IADLs also increased with age: from 15% of adults aged 65 to 69 to 40% aged 80 and over. 

A higher proportion of women than men aged 65 and over needed help in the last month: 34% of women needed help, compared with 27% of men. This was true for both ADLs (help needed by 28% of women and 24% of men) and IADLs (help needed by 29% of women and 21% of men).

For more information: Table 2

Receipt of help and unmet need in the last month, by age and sex

Help with ADLs

11% of adults aged 65 and over received help in the last month with at least one ADL. This included similar proportions of men (10%) and women (11%).

The proportions who received help with ADLs in the last month was similar for adults aged between 65 and 79 (9%-10%) and was higher (17%) for those aged 80 and over.

Help with IADLs

17% of adults aged 65 and over had received help in the last month with at least one IADL. A higher proportion of women (21%) than men (13%) received help with at least one IADL in the last month.

The proportions who received help with IADLs in the last month increased with age from 11% of those aged 65 to 69 to 17% of those aged between 75 and 79 and was highest among those aged 80 and over (33%).

Unmet need

Adults who had some need for help with an ADL or IADL but who had not received help with that activity in the last month were categorised as having unmet need. It was possible to have received help with some ADLs or IADLs and still have unmet need for help with others. 

Of adults aged 65 and over, 22% had some unmet need for help with ADLs; Similar proportions of men and women had some unmet need for help with ADLs.

Unmet need for help with ADLs increased with age, from 14% of those aged 65 to 69 to 36% of adults aged 80 and over.

Unmet need for help with IADLs was lower (15%). Similar proportions of men and women had some unmet need for help with IADLs. 

Unmet need for help with IADLs increased with age, from 10% of those aged 65 to 69 to 25% of those aged over 80.

For more information: Table 3


Need for and receipt of help in the last month, by household income

The HSE uses the measure of equivalised household income, which takes into account the number of adults and dependent children in the household as well as overall household income. In this topic report, households are divided into tertiles (thirds) based on this measure. Data reported by income tertiles have been age standardised to account for difference in age profiles across household incomes. 

For information about how equivalised income is calculated, see the HSE 2021 Methods report.

The proportion of adults aged 65 and over who needed help with at least one ADL or IADL varied by household income.

  • In the lowest income group, 33% needed help with at least one ADL, and 31% needed help with at least one IADL. 
  • In the middle income group, 20% needed help with at least one ADL, and 19% needed help with at least one IADL.
  • In the highest income group, 21% needed help with at least one ADL, and 21% needed help with at least one IADL.   

For more information: Table 4

Adults aged 65 and over in the lowest household income group were more likely than those in higher income groups to have received help with ADLs and IADLs. 

  • For ADLs, 13% in the lowest household income group received help compared to 7% in other groups.
  • For IADLs, 21% in the lowest household group received help, compared with 13% in the middle income group and 12% in the highest household income group.

For more information: Table 4

There was a similar pattern by household income for unmet need. Adults aged 65 and over in the lowest household income group were more likely to have an unmet need for help than higher income groups. 

  • In the lowest household income group, 28% had an unmet need for help with ADLs and 19% had unmet need for help with IADLs.
  • In the middle income group, 17% had an unmet need for help with ADLs and 10% had unmet need for help with IADLs.
  • In the highest income group, 19% had an unmet need for help with ADLs and 14% had unmet need for help with IADLs.

For more information: Table 4


Need for and receipt of help in the last month, by area deprivation

The English Index of Multiple Deprivation (IMD) is a measure of area deprivation, based on 37 indicators, across seven domains of deprivation. IMD is a measure of the overall deprivation experienced by people living in a neighbourhood, although not everyone who lives in a deprived neighbourhood will be deprived themselves. To enable comparisons, areas are classified into quintiles (fifths). Data reported by IMD quintiles have been age-standardised to account for different area age profiles.

For further information about the IMD, see the HSE 2021 Methods report.

Adults in the most deprived areas were twice as likely to need help with ADLs and IADLs than those in less deprived areas. In the least deprived areas 20% of adults needed help with ADLs, and this proportion increased with the level of deprivation to 44% in the most deprived areas.  There was a similar pattern for adults who needed help with IADLs: from 19% in the least deprived areas to 45% of those in the most deprived areas.

For more information: Table 5

The proportion of adults aged 65 and over who received help with ADLs was lowest in the least deprived areas (8%) and increased to 19% in the most deprived areas. The pattern was similar for IADLs: 12% received help in the least deprived areas compared with 36% in the most deprived areas.

For more information: Table 5


The proportion of adults aged 65 and over who reported an unmet need for help with ADLs and IADLs was twice as high in the most deprived areas compared to the least deprived areas. In the most deprived areas, 38% had an unmet need for help with ADLs, compared to 17% in the least deprived areas. 

There was a similar pattern for unmet need for help with IADLs; this was reported by 26% in the most deprived areas, compared with 12% in the least deprived areas. 

For more information: Table 5


Need for and receipt of help in the last month, by limiting longstanding illness

Longstanding illness is defined as ‘any physical or mental health condition or illness lasting or expected to last 12 months or more’. A longstanding illness is defined as limiting if the participant reports that it reduces their ability to carry out day-to-day activities. The prevalence of longstanding illness is described in the HSE 2021 report on Adults’ health.

Two in five (40%) adults aged 65 and over had a limiting longstanding illness, and one in five (20%) had a non-limiting longstanding illness. The proportion of adults aged 65 and over with a limiting longstanding illness increased with age, from 31% of those aged between 65 and 69, to 57% of those aged 80 and over. The proportion with a non-limiting longstanding illness did not vary by age. 

More than half of adults aged 65 and over who had a limiting longstanding illness needed help with at least one ADL (53%). This compares with 9% of those with a non-limiting longstanding illness and 7% of those with no longstanding illness. This pattern was also observed for IADLs, with 51% of those with a limiting longstanding illness, 8% with a non-limiting longstanding illness and 8% with no longstanding illness needing help.

The proportion of adults who received help in the last month was higher in adults with a limiting longstanding illness (24% for ADLs and 38% for IADLs) than for those with a non-limiting longstanding illness (1% for ADLs and 4% for IADLs) or no longstanding illness (2% for ADLs and 4% for IADLs).

Just under half of adults aged 65 and over with a limiting longstanding illness had an unmet need for help with ADLs (45%), and 29% had an unmet need for help with IADLs. 8% of those with a non-limiting longstanding illness had an unmet need for help with ADLs, and 6% had an unmet need for help with IADLs. Among those with no longstanding illness, 7% had some unmet need for help with ADLs and 5% had an unmet need for help with IADLs.

For more information: Table 6



References

Department of Health and Social Care (2021) People at the Heart of Care: adult social care reform white paper. https://www.gov.uk/government/publications/people-at-the-heart-of-care-adult-social-care-reform-white-paper 

Department of Health and Social Care (2022) Build Back Better: Our Plan for Health and Social Care. https://www.gov.uk/government/publications/build-back-better-our-plan-for-health-and-social-care/build-back-better-our-plan-for-health-and-social-care 

NHS Digital (2022) Adult Social Care Activity and Finance Report, England 2021-22. https://digital.nhs.uk/data-and-information/publications/statistical/adult-social-care-activity-and-finance-report/2021-22 

NHS England (2019) The NHS Long Term Plan. https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf

Office for National Statistics (2022). Overview of the UK population: 2020. https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/articles/overviewoftheukpopulation/2020 


Last edited: 16 May 2023 9:31 am