The state of health care and adult social care in England 2024/25

The health and social care system is fragmented and under severe strain as it prepares for a major shift from hospital to neighbourhood care.

There is some encouraging evidence of innovation, but community services need significant investment in both capacity and capability to deliver the transformative shift called for in the government’s 10 Year Health Plan for England.

Without increased support to help community services deliver the vision of the plan, there is a real risk of erosion of the quality of care, with the most vulnerable groups of people bearing the greatest burden through longer waits, reduced access to care, and poorer outcomes.

Demand for services continues to rise across the health and care system and many people are waiting too long to get the help they need. Our 2024 Community mental health survey found a third of respondents reported waiting 3 months or more and 14% reported waiting more than 6 months between their assessment and first appointment for treatment. The longer people waited, the more people reported that their mental health got worse.

After identifying concerns about systemic issues across community mental health care, including a shortage of staff and a lack of integration between services, we have started a comprehensive inspection programme of community mental health services for working-age adults, crisis services and health-based places of safety.

As part of this programme we have engaged with providers, who told us that a lack of investment in community mental health services made it difficult to attract and retain staff with the right skills and to deliver good, person-centred care. People who used community mental health services described the negative impact of moving between different services – sometimes with different criteria about who could access care – and of having many different care co-ordinators.

We have previously voiced concern that if people don’t get the care they need when they need it, they can end up in crisis. Over the last year, the number of urgent and very urgent referrals to mental health crisis services has risen steeply.

Issues with getting access to care persist across the system.

Although work is underway to increase capacity and improve people’s access to a GP, around 1 in 3 (35%) of the respondents to the 2025 GP Patient Survey who had tried to contact their GP by phone, described it as difficult. The survey also found that access to GP services can be harder for some groups, including those living in the most deprived areas, autistic people and people with a learning disability, those with a mental health condition, a neurological condition or another long-term condition or illness.

We are especially concerned about the impact of this on certain groups of people – particularly older people. However, our inspectors have seen examples of GP practices working collaboratively with other services to improve people’s access to and experience of care.

In adult social care, the demand for support funded by a local authority continued to rise in 2023/24. Although staff vacancies in adult social care have fallen to pre-pandemic levels, they are still 3 times higher than in the wider job market – and vacancy rates in homecare services are more than double the rates in care homes. The ending of new care worker visas will likely put further pressure on recruitment, making it more important than ever that a sector-wide workforce strategy is agreed and that the recently announced fair pay agreement has an impact.

Through our local authority assurance work, we have seen the effects of a shortage of staff – both homecare staff and in the workforce delivering reablement packages. This results in people having to wait too long for a homecare service to enable them to live at home. Capacity within bed-based rehabilitation, reablement or recovery services is consistently the biggest cause of delayed hospital discharges nationally.

To help people stay in their own homes for longer, there is an urgent need to commission more community services – but we have identified factors that could limit the growth of the homecare sector. More providers are telling us that they are handing back contracts to local authorities due to rising costs – and an increasing proportion of the homecare market is made up of very small providers that may be less financially resilient.

For some years, we have been calling for a long-term sustainable funding solution for adult social care, with clear career development pathways and better pay, terms and conditions for staff. The Casey Commission will be an important milestone in reforming social care and the early focus on productivity, quality, digital services, workforce development and integration are all important. But this will not improve the core sustainability of adult social care, which will be looked at later in this parliament and will be crucial to the delivery of the 10-year plan.

In a previous State of Care report, we described the health and social care system as being ‘gridlocked’. While there have been some areas of improvement, there has been little improvement in the flow of patients out of hospitals to more appropriate care settings. On any given day in March 2025, nearly 6 in 10 patients who were ready to be discharged experienced a delay. This maintains pressure across the system, as hospital beds remain occupied, limiting capacity for incoming patients and creating knock-on effects in people’s care across the whole system, from how quickly they get seen in A&E to the length of time they wait for planned medical procedures, increasing the length of time people have to wait for medical procedures.

Once people are discharged from hospital, the whole system needs to work together to keep them well or they risk being readmitted. Over the last 10 years, there has been a steady increase in the percentage of emergency readmissions – with older people and people living in more deprived areas more likely to be readmitted within 30 days of being discharged from hospital.

We commissioned research from National Voices into people’s experience of the discharge process. This found that while the majority were happy with their discharge process, for others the negative impact was significant and could result in readmission. The research found one woman whose poor experience during her hospital stay and discharge process left her feeling ‘dehumanised’.

Once again, we are highlighting inequalities that risk increasing without targeted action. People living in the most deprived areas in England experience significantly poorer outcomes across multiple measures, with deprivation creating a cascade of disadvantage in access to healthcare. For example, children and young people in the most deprived communities are nearly 3.5 times more likely to need to have their teeth extracted in hospital because of decay, and the latest data from MBRRACE-UK shows that, compared with women from white ethnic groups, Black women were more than twice as likely to die during or up to 6 weeks after pregnancy, and Asian women were 1.3 times more likely to die during the same period.

The fragmented nature of the current system also means that more vulnerable groups of people are falling through gaps in care. For example, older people, people with dementia, autistic people and people with a learning disability, and people with complex mental health needs can struggle to navigate services, while their families and unpaid carers carry increasing burdens. Work on our dementia strategy highlights how badly a clear, accessible, easy-to-navigate pathway of care between social care, community care and other health services is needed.

In this year’s report, we highlight examples of services working together to deliver person-centred, co-ordinated care. This includes neighbourhood health services receiving good results from patient satisfaction surveys and attendance rates, advances in artificial intelligence helping reduce administrative burdens for GPs, and examples such as a new integrated urgent community response service that’s improved ambulance response times and is helping to keep people out of hospital if they can get the care they need nearer home.

However, we have also seen too many instances where poor co-ordination between health and social care, inadequate information sharing, and a lack of digital integration is creating barriers to good care.

The government's plan to rebalance the delivery of care from hospitals into communities is a crucial opportunity to act on making care less fragmented and halting the erosion of quality, but community services must be robust enough to support this shift.

Despite delivering comparative value for money compared with acute hospital alternatives, community services report struggling with funding and commissioning arrangements that prioritise hospital providers. These services also have fewer consistent national standards, targets or data to show evidence of their impact. In research we commissioned from the Nuffield Trust, integrated care system (ICS) leaders said that the concentration of limited resources in acute trusts and a national focus on acute sector metrics conflicted with attempts to move to community-focused, preventative approaches.

We are calling for more focus on community care and the necessary investment to make the shift away from hospital care successful – with particular attention to neighbourhoods in deprived areas – to avoid worsening existing inequalities.

We will play our part through our renewed focus and commitments, including listening to and acting on information from the public and taking action to protect people from poor care. This goes hand-in-hand with our work with providers and systems to drive improvement by identifying and promoting examples of innovation and person-centred care, and working with partners to develop solutions where we see barriers to delivering good care.

Professor Sir Mike Richards
Chair

Sir Julian Hartley
Chief Executive