This trend – shown in the map above – is supported by calculations based on two spending data sources, from council accounts and a collection by the Health and Social Care Information Centre.
Parts of the Midlands, London and Yorkshire also appear to have seen larger cuts, but this is less clear.
Much of the South and some of the Midlands have fared better, with some sub-regions showing small real terms growth – albeit probably not enough to keep pace with demand.
Is the data robust?
Social care spending information is very inconsistent. Several factors make it difficult to compare across years and areas. These include differences in recording, treatment of income from fees and the NHS, shifts in grant funding, and various changes to local circumstances that skew the picture. HSJ’s calculations are very likely to underestimate the actual size of cuts to publicly funded spending as they are based on gross spending – not adjusting for increases in fees to individuals.
However, two experts, King’s Fund assistant policy director Richard Humphries and John Bolton, former director of strategic finance for social care at the Department of Health, said HSJ’s use of the information to identify patterns across several years and at the level of NHS England sub-regions was reliable (though it has the downside of masking variation within them).
The North/South divide described above is reflected in both sources of data, covering cross-cutting three year periods, and in calculations of both total and median CCG change.
You can compare different measures from the two sources for yourself in this chart – click on an indicator to add or remove it:
What is the reason for the pattern and will it continue in the next few years?
The main reason for the regional pattern is the much greater reliance of some councils – particularly in poorer areas – on government grants for income, as opposed to council tax or other sources. It is severe reductions to government grants in recent years which have been the big driver of cuts to local authority income and spending.
The spending review on Wednesday will set national budgets and few are expecting these to lead to anything but further large cuts in council grant funding in the coming years. That said, ministers have said they would like to find a way to give greater protection to social care, and it was reported this weekend the government would allow greater increases to council tax as long as the income was ringfenced for social care.
Mr Humphries said: “If there are more cuts to local government, we can expect to see this pattern again over the next five years.” He said the council tax freedom would not necessarily make a difference, and pointed out they had already been able to make small increases, and that further shifts were likely to make only a small difference to overall income. He added: “Councils that can raise the least from council tax are the most deprived areas, especially in the Midlands and North, where social care needs are likely to be the greatest.
“So while greater flexibility for councils is to be welcomed, on its own this measure will not address the growing pressures on the social care system, especially in places where needs are greatest.”
Professor Bolton said the main factor causing the pattern was that “grant funding has historically been higher for deprived areas. By definition the more deprived you are the more you are losing money as you lose the grant.”
However, he said several factors complicated the picture locally, for example councils’ varying ability or desire to spend reserves. Councils in the South tend to have larger reserves, Professor Bolton said. Others may have received “windfalls” they can spend, perhaps from cost cutting restructures, while others have very little wriggle room.
Similar factors made it difficult to predict the pattern of cuts in coming years, he said. He also highlighted local decisions about council tax and rates, which could impact the pattern of social care spending. Local authorities “will be looking at how to they manage their council tax and the new opportunity their [control and receipt of] their business rates gives them”, he said.
This will also be shaped by the fact some councils receive virtually no grant funding following recent cuts, so have little left to lose from further reductions.
Might some areas have cut more than others because there is less need for social care?
The proportion of over-75s is larger in many parts of the South than elsewhere. However, in richer areas more people are able to buy more private care.
Neither Mr Humphries nor Professor Bolton thought the reductions were linked to need. Mr Humphries pointed out that a third of adult social care was for people with learning disabilities rather than older people.
There is generally higher hospital bed use in poorer areas, mainly due to greater ill health, as well as higher admissions for conditions that should be managed out of hospital, suggesting a need for community support. A snapshot of delayed transfers of care from hospital in September indicates a high rate attributed to social care in some northern regions. None of these are necessarily reliable indicators of need.
You can use these charts to look at some of these service indicators alongside rates of change in social care spending – click on an indicator to add or remove it:
What impact are the cuts having on the NHS?
In its own evidence to this year’s spending review, NHS England, arguing for protection for adult social care services, has highlighted their impact on the health service, and said every £1 cut to the former also causes a 30p cost for the NHS.
Few in the NHS doubt that social care reductions are having an impact. This is keenly felt operationally; the most commonly cited examples being delayed discharges clogging up hospitals, and inadequate preventative support leading to admission. Both are contributing to intense pressure in emergency and acute services.
Official figures show delayed discharges attributed to waiting for social care have grown rapidly over the past year. There are some indications of a spike in mortality among very old people, which some have linked to care cuts.
Several NHS commissioners told HSJ that social care spending cuts were having a dramatic impact on the NHS and were a big factor in their own calculations about the need to cut costs and reshape services in coming years.
Professor Bolton cautioned that there wasn’t strong evidence on the size of the impact on the NHS. He said: “The evidence up until now appears to be that both impact each other equally.”
Both he and Mr Humphries said while social care was a factor in poor out of hospital support, in many cases inadequate community and primary health services were as much of a problem.
Professor Bolton also pointed out it was not only social care spending, but also availability and cost of workforce – which may be more of a problem in the South – affecting care availability and quality.
What do the cuts do to combined overall local health and care spending?
Commissioners are increasingly pooling budgets with local authorities and attempting to consider public spending in their area as a whole, rather than separate pots. The approach has some national encouragement – Jeremy Hunt has said he wants a “fully merged health and social care system”.
Moves in this direction mean the total locally controlled pot of money for health and care for an area may be an increasingly important figure. NHS England chief executive Simon Stevens is seeking to bring together the separate elements of NHS funding (CCG, primary care and specialised budgets) in calculations for next year’s allocations.
Adding figures on CCG operating expenditure to adult social care spending at CCG level suggests that between 2013-14 and 2014-15 there were dozens of CCG areas where the combined pot fell in real terms. However, the figures are not sufficiently reliable to be certain of these shifts at the level of single areas and in a single year, so we have not published them. Comparable NHS figures are not available for previous years.
Should CCG allocations be changed based on adult social care spending cuts?
Some areas have seen and are seeing huge cuts to social care, sufficient to substantially reduce overall health and care spending, and make a big difference to NHS services. The health service in these areas has and will have to help out, and deal with the implications. This is increasingly recognised and accepted at national level. On this basis Liverpool and Newcastle Gateshead CCGs have a strong case.
However, some CCG leaders told HSJ they were concerned about the prospect of CCGs taking on funding linked to social care cuts because they thought it was risky to formalise their responsibility for council underfunding.
Blackpool CCG chief clinical officer Amanda Doyle said her area had seen big social care and public health cuts. She said: “We have to recognise CCGs will be most impacted in those areas that have had the biggest cuts to social care and public health. But it is very difficult to expect the NHS to compensate [for that].”
Mr Humphries and Professor Bolton also recommended caution.
Professor Bolton said “a lot of people are now saying the only way to solve this is to… have a single allocation through the NHS” for both health and care. But he warned this would involve major risks. Some experiments with joining the two suggested the NHS was not well suited to taking control of care, and “doesn’t get social care”, often being too risk averse, he said.
Mr Humpries said accounting for care cuts in allocations would be a “slippery slope”. “That would be the NHS taking on responsibility for funding of social care. I can see the argument but I don’t think in the long term that is sustainable.” He said he supported a move to single health and care budgets, but it needed to be done with proper government backing and funding, rather than on an ad hoc basis.
Mr Stevens has expressed similar concerns about the better care fund, under which some of NHS allocations are subsidising social care.
It may mean any recognition of social care cuts in CCG allocations in the next few years is likely to come not through a formal alteration to the funding formula, but a more sympathetic pace of change in annual growth, as suggested by Liverpool CCG finance director Tom Jackson.
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