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

Demand for services is increasing across a health and social care system that is already under severe pressure – affecting how easily people can access care and the quality of care they receive.

There is also unwarranted variation in people’s experience of services across the country and inequality is particularly affecting people in the most deprived areas.

In some places, there are promising signs. We see examples of innovation, excellent care and improvements in quality that are making a difference for people. Although there are many challenges in shifting the focus and resources to deliver services in the community, we have seen positive examples of pilot schemes and new initiatives that appear to support this change.

But our work also exposes issues about the readiness of the system for a shift to delivering neighbourhood care, as well as concerns for how some people experience care – such as for older people, people with dementia and people using maternity services.

Access and demand for care

Demand for GP services is still growing, resulting in more pressure on services. Over 700,000 more patients were registered with a GP on average in 2024/25 compared with 2023/24, and the number of appointments has risen by nearly 10% over the last 2 years. In the 2025 GP Patient Survey, only half (53%) of the respondents who had tried to contact their GP by phone reported that it was easy.

Access to NHS dental care remains a challenge. The number of units of dental activity completed in England increased marginally in 2024/25, but still remains 8% lower than pre-pandemic levels. And there is variation in how much contracted dental activity is delivered: data from 2023/24 shows that dental practices in the top-performing integrated care system (ICS) area completed 97% of their contracted dental activity, compared with 48% in the lowest-performing ICS area.

In community health services, there has been a 26% increase in the number of children and young people waiting to access care between January 2023 and December 2024, compared with a 19% increase for adult services. But most notably, the number of children and young people waiting for over a year for these services increased almost threefold in this period.

In adult social care, the demand for support funded by a local authority continued to rise – new requests for care were 4% higher in 2023/24 than in the previous year, and 8% higher than in 2019/20. For adults of working age, there has been a large growth in demand for support, with requests per 100,000 people 14% higher than 4 years earlier. But, over the last 20 years, the proportion of older people who receive local authority-funded long-term social care has fallen from 8.2% to 3.6%.

Pressures in one part of the system affect other parts. This is true for hospitals, which are affected when there is a lack of access to preventative and community-based support.

For example, delays in access to rehabilitation, reablement or recovery services were the biggest cause of delayed discharge for people who had been in an acute hospital for 14 days or longer (26%). And the 2025 GP Patient Survey found that 6.6% of people went to A&E when they could not contact their GP practice or did not know what the next stop would be – this was 4 percentage points higher for people in the most deprived areas.

In 2024/25, people were still waiting too long for mental health care and were unable to access the care they need when they needed it. During the year, there was an average of 453,930 new referrals to secondary mental health services every month – an increase of 15% from 2022/23. Furthermore, a third of the respondents (33%) to our Community mental health survey reported waiting 3 months or more.

Demand for urgent and emergency care services remains high, but the way in which people are accessing this care is changing. While there was a drop in the volume of calls to NHS 111 in 2024/25, calls to ambulance services have continued to increase, with the volume of ‘hear and treat’ responses also rising. The number of attendances at all types of urgent and emergency care services has also risen, with the biggest increases at single service facilities for specific conditions (type 2 services) and minor injury units (type 3 services).

And patients are still waiting too long in A&E: in 2024/25, 1,809,000 people waited over 12 hours from the time of their arrival until they were either admitted, transferred or discharged, which is 169,000 (10%) more people than in 2023/24.

Workforce and capacity

Vacancy and turnover rates in adult social care have continued to fall but, at the same time, international recruitment has declined rapidly, and ending new work visas for care workers is a cause for concern. Vacancy levels for adult social care staff are currently 3 times higher than those of the wider job market.

Rising financial pressures continue to be a risk for the sustainability of some adult social care services, including in the homecare sector. Despite an 11% growth in the sector during the last year, we are concerned that some homecare providers have said they are handing back local authority contracts due to rising costs. We are also concerned about the burden on unpaid carers.

District nursing services are an important part of shifting care from hospital settings into the community, but the number of qualified district nurses per 10,000 people aged 65 and over has dropped by 50% in the last 14 years. A shortage of qualified staff in district nursing is contributing to a shift away from providing holistic care to delivering services in a task-based way.

Regardless of changes in the way GP appointments are being delivered, we still hear that people struggle to get appointments. While there are more full-time equivalent (FTE) GPs in training per 100,000 patients, the number of FTE fully-qualified GPs per 100,000 patients has reduced.

Mental health services continue to face systemic recruitment and retention challenges as staff feel burnt out and overworked. Hospitals are also facing workforce challenges. We continue to hear how persistent understaffing and a poor mix of skills, along with pressure to admit patients to hospital despite a lack of capacity, affects the wellbeing of staff and therefore the care that people receive.

People’s experiences

We analysed a wide range of experiences for this report, which consistently shows a need for more person-centred care, with an emphasis on better communication, co-ordination, and collaboration with other services.

Holistic care that addresses both physical and mental health needs is essential – especially for people with multiple conditions. But too often, information is not shared properly, and services are not joined up.

There are significant challenges around funding and system working, as poor communication and collaboration between services, and problems with shared care protocols can have a negative impact on people’s experience of care, the co-ordination of their care and transitions between care pathways.

While there has been some improvement, people are still facing long waits for elective care, and the length of time people must wait varies across the country. This has an impact on the quality of care people receive – our 2024 Adult inpatient survey found that 43% of elective patients said their health deteriorated while waiting to be admitted to hospital. Findings from the community mental health survey also highlighted the impact of long waits for people with mental health needs with results showing that the longer people waited, the more people said their mental health got worse.

Navigating the care system remains challenging, especially for people with needs that are more complex to meet or who have limited advocacy – this includes people living with dementia, autistic people and people with a learning disability and people living in more deprived areas.

The 2025 GP Patient Survey found that people aged 85 and over were most likely to not do anything when unable to contact their GP or when they were unsure what the next step would be. This is particularly worrying because of the risk of poor outcomes for this population group, such as falls or being admitted to hospital as an emergency.

Inequalities and concerns for specific groups of people

In the report, we have highlighted how deprivation affects people’s access to, and experience of, health and social care. For example, the 2025 GP Patient Survey highlights that people living in the most deprived areas can find it harder to access GP appointments. Furthermore, older people and people living in more deprived areas are more likely to be readmitted within 30 days of being discharged from hospital.

Variation at both a regional and ICS level is leading to inconsistent quality across the country. For example, in 2024/25, the average ambulance handover time at the ICS level ranged from 16 minutes 8 seconds to 1 hour 50 minutes 39 seconds. And in 2023/24, the rate of children and young people who were admitted to hospital for tooth extractions due to decay ranged from 994 per 100,000 young people under 19 years in one ICS to 17 per 100,000 young people in another ICS.

In this 2024/25 report, we focus on some specific concerns for particular groups of people. The concerns involve issues around safety, quality, workforce, and inequalities:

• Our research with people aged over 65 showed that most had a positive experience when it came to being discharged from hospital and receiving follow-up care in the community. However, some said they didn’t feel ready to be discharged, and follow-up care didn’t meet their emotional needs. Others did not receive the care they felt they needed, leading to a deterioration in their health or mental wellbeing. Some family and friends also took on unpaid caring responsibilities due to these gaps in care.
• Some systems are using data to proactively identify older and frail people who are at risk of falls and hospitalisation, and are providing targeted interventions to reduce this risk. However, system leaders report that workforce challenges are limiting their ability to increase support of older and frail people.
• Although more people in England are being diagnosed with dementia, staff in health and social care do not always understand the specific care needs of these people and providers do not always have the necessary knowledge of person-centred approaches and dementia-friendly environments.
• Despite the same issues being reported over the last 10 years, efforts to address the underlying causes of poor maternity care have continued to fall short. Too many women are still not receiving the high-quality maternity care they deserve, and some women with protected characteristics under the Equality Act 2010 remain at greater risk of harm. The national maternity review, announced in the government’s 10 year plan, presents a real opportunity for change.
• Autistic people and people with a learning disability can find it challenging to get an appointment with their GP, because booking systems may not offer the flexibility and choice that they need. Our research also suggests that there are not always the right reasonable adjustments to make primary care a positive experience.
• In 2024/25, we delivered a series of Independent Care (Education) and Treatment Reviews (IC(E)TRs) into the care and treatment of autistic people and people with a learning disability who are in long-term segregation. Reviews for some people noted there was no discharge plan in place, or even that they had not had discussions about being discharged or leaving long-term segregation.
• Longstanding inequalities in mental health care for Black men continue. Staff must be properly trained to fight racism and support Black men with respect and understanding, and services need to be held accountable when they fail to do the right thing.
• Our joint targeted area inspections with Ofsted, His Majesty’s Inspectorate of Constabulary, Fire and Rescue Services, and His Majesty’s Inspectorate of Probation looked at serious youth violence. They showed that children with special educational needs or disabilities are waiting too long to have their needs assessed, which makes them more vulnerable to the consequences of serious youth violence.

Signs of improvement and innovation

Although the system is under serious pressure, we have seen evidence of innovation and improvement making a difference for people. In our assessments, we continue to see how good leadership can promote a culture of openness and learning.

The government’s 10 Year Health Plan aspires to a new model of care where a neighbourhood health service is designed around the individual – and science and technology will be key players. This year, we have seen examples of neighbourhood health services receiving good results in patient satisfaction surveys and attendance rates, and there is evidence of technological advancement.

Harnessing the advances in artificial intelligence (AI) is seen as one of the core elements of shifting care from analogue to digital in the government’s plan. We know some GPs are using AI, mainly to reduce administrative burden. And in our work, we support initiatives to drive positive change by using technology.

Deprivation of Liberty Safeguards

The number of applications to authorise the deprivation of a person’s liberty have continued to increase significantly over the last decade – far beyond the levels expected when the safeguards were designed, which often results in lengthy delays.

Issues with the Deprivation of Liberty Safeguards (DoLS) system continue to disproportionately affect certain groups of people. Our survey of Mental Capacity Act leads in hospitals highlighted particular concerns around older people, including those with dementia.

We are still seeing wide variation in how local authorities are managing DoLS applications – while some report not having any backlogs, others are still struggling to meet demand.

The wider policy landscape in health and social care is changing – the introduction of the Mental Health Bill in Parliament and the government's recent announcement that it intends to take forward the consultation on the Liberty Protection Safeguards are likely to have implications for the DoLS system.

Health and social care systems

It’s vital that the health and adult social care sectors work effectively as a system and that they prioritise improvements in areas of concern.

This year’s State of care report draws on findings from our assessments of how local authorities are meeting their duties under the Care Act and new research that we commissioned Nuffield Trust to carry out with ICSs on the progress made against inequalities and their readiness for the 3 shifts set out in the NHS 10 year plan.

While systems demonstrate strong leadership foundations and are piloting innovative approaches, they report systemic barriers to large-scale and enduring change.

Efforts are hampered by the concentration of limited resources in acute hospital trusts and a national focus on acute sector metrics, which is in conflict with attempts to move towards community-focused, equity-centred, preventative approaches. There is some progress on moving hospital-based expertise into the community, but systems report disagreements on how to shift resources to prioritise community services.

Systems report good progress on using data-driven approaches to understanding the needs of local populations and targeting interventions. However, data-sharing across organisations remains a problem, and the quality and completeness of data is variable. Systems are making most progress in supporting older and frail people in activities focused on prevention, assessment and planning, and multi-disciplinary working – but workforce challenges are hampering these efforts.

Local authorities are working to provide targeted interventions, often using public health data, to prevent future care needs and avoid hospital admissions. We have seen proactive approaches, often involving community and voluntary sectors, and examples of community-based early intervention and other work to help keep people well in their own homes.

Partnership working is evident in efforts to make sure people are safely discharged from hospital and back home. Reablement services were working well when there were strong partnership working networks between hospital staff and local authority social work teams. But again, barriers to success included staff shortages and recruitment problems.

Although local authorities have worked to increase and improve their homecare capacity through reviews and new approaches to commissioning, insufficient homecare capacity often affects the ability of hospitals to discharge people safely, which affects the flow of the system and leads to long delays for care and waiting lists, and then affects people’s health and wellbeing.