'National care service must be universal' as report exposes postcode lottery in access

People’s access to publicly funded long-term social care varies substantially depending on where they live, according to new analysis from The King’s Fund, which has set out proposals for reform aimed at creating a fairer system across England.

The think-tank found that 59% of local authorities had access rates for working-age adults and/or older people at least 20% above or below those of their nearest statistical neighbour – councils with similar social and economic profiles. In some cases, the proportion of people accessing care was more than twice that of a comparable authority.

The findings accompany The King’s Fund’s new report, Equal access: a fairer system of social care support for England, published as the government prepares for further reform through Baroness Casey’s review of adult social care, now due to report in 2027.

The King’s Fund is calling for an ‘equal access’ national assessment to reduce unwarranted variation in eligibility decisions, alongside universal access to at least some publicly funded care, a cap on lifetime care costs, national funding arrangements and clearer individual entitlements to support.

Simon Bottery, co-author of the analysis and Senior Fellow for Social Care at The King’s Fund, said: 'A national care service, which the Prime Minister has promised, must be genuinely national and ensure that all people, wherever they live, have the same access to social care support.

‘Our new proposals for an ‘equal access’ national assessment would help prevent this issue of unwarranted variation and ensure that access to social care support is not decided by your postcode.

The analysis compared councils using a Ministry of Housing, Communities and Local Government model that identifies statistical neighbours based on factors including deprivation, disability prevalence and median income. It found that variation in access rates reached 101% for working-age adults and 60% for people aged over 65.

In Thurrock, 7,680 older people per 100,000 accessed long-term care, compared with 4,810 in its statistical neighbour Medway. This meant Thurrock’s rate was 60% higher, despite the authorities having similar demographic and economic profiles. However, Thurrock’s access rate for working-age adults was 10% lower than Medway’s.

Other differences included Torbay, where the access rate for working-age adults was 101% higher than in Telford and Wrekin, while its rate for people aged over 65 was 24% higher. In Salford, access to long-term care among older adults was 52% higher than in Southampton, while the rate for working-age adults was 20% higher.

The King’s Fund said the variations were likely to reflect a combination of factors, including differences in levels of need and wealth, models of provision and councils’ ability to raise revenue through council tax. Although local authorities must assess care needs against national eligibility criteria, the organisation said there was sufficient subjectivity in assessments for people with similar needs to receive different outcomes in different areas.

The proposals would shift local authorities away from acting primarily as ‘gatekeepers’ to public funding and towards helping people identify and coordinate the support they need, including services across health and social care. The proposed system would also give individuals and families greater choice over how their care is arranged.

Bottery said: ‘But reform must go further than that and ensure that there is universal access to at least some publicly funded support, with a cap on the cost people are expected to pay to ensure that no one faces huge lifetime care bills. Currently, one in seven people aged 65 will spend at least £100,000 in lifetime care costs.

‘We must also introduce fairer, national funding of social care, with greater choice and control for people and their families over how their care needs are met.

The think-tank proposes that decisions about public spending on the new system, alongside the level of co-payments expected from people receiving support, should be reviewed every five years through projections of long-term care expenditure.

The proposals have been welcomed by the Social Care Institute for Excellence (SCIE) and Think Local Act Personal (TLAP), which highlighted the importance of fairness, clearer entitlements and greater control for people drawing on care and support.

Gerard Crofton-Martin, Interim Chief Executive at SCIE, said: “Inequities in adult social care are profound and persistent, and they demand urgent action. One of the core values of a caring society is fairness; it is indefensible that the availability and quality of people’s care and support are still inextricably linked to where they live, their socioeconomic circumstances, ethnicity, disability, or gender.

“SCIE’s research on care equity finds that these factors interact and accumulate across people’s care journeys, with each creating barriers that make it harder for them to find, access and sustain care around their individual circumstances and aspirations.”

Crofton-Martin said clearer entitlements could help people understand their rights and navigate the system, but added that reform would require an open discussion about how social care is funded.

He said: “A fairer care system will also require an honest conversation about funding. There are no easy answers, and difficult trade-offs will be unavoidable. Building greater public understanding of the value of social care and consensus through the Casey Commission will be essential; without taking the public with it, the Government will struggle to put forward a more generous settlement.”

Martin Walker, Head of Practice Improvement, Self-directed Support, at TLAP, said the proposals recognised the need to make choice and control a reality for more people receiving care.

He said: “People shouldn’t have to fit into whatever services exist in their area. They should be able to decide how they live, who supports them, and how their care is arranged. This is a right that is enshrined in law but not upheld or protected in practice.

“We have an opportunity now to design a National Care Service that gives people real power to shape their own support and focuses on their gifts, talents, life, culture, and choices. That means decisions made with people, not for them, and recognising that they are experts in their own experiences.”

The government has established the Casey Commission to make recommendations on social care reform and has launched a public consultation, the Big Conversation, to gather views on the future of the system.

The King’s Fund said its proposals were intended to contribute to that debate by addressing not only who pays for care, but how support is accessed and organised in practice. Bottery said: ‘The Prime Minister and Baroness Casey's commitment to reform is clear but we are still awaiting the concrete policies that will turn this vision into a reality. To achieve that, their proposals will need to focus not just on who pays but on how the wider system operates on the ground.’