The state of health care and adult social care in England 2025/26

Over the past year we have continued to improve our operational performance, significantly increasing the number of our inspections.

This has given us a clearer and more current picture of quality across the health and care system than we've had in recent years. There is still much to do, but this year's State of Care report is built on that stronger evidence base.

It finds a system under pressure, with a social care market in flux and changing shape at an unprecedented pace, while persistent inequalities mean people's experience of care remains fractured, too heavily dependent on where they live and who they are. Improvement and innovation are struggling to keep up with rising demand for care.

Demographics in England are shifting towards an ageing population, as well as a working-age population with increasingly complex needs. The number of people needing health and adult social care services continues to grow and, in many areas such as community mental health services, the complexity of that need is also increasing.

There are signs of real progress in how the system is responding, including more GP appointments, better use of digital solutions, and shorter waits for elective care. Throughout this report, we have highlighted examples of local innovation, including neighbourhood models and integrated teams, which are making it easier for people to access care.

But this progress risks being outpaced by people’s increasing need for care, against a backdrop of persistent and localised inequality. Prevention, one of the key shifts identified in the 10-Year Plan, is widely recognised as a crucial part of the answer – reducing demand before it reaches crisis point and helping to tackle inequalities at source. Yet it too often lacks a clear strategy for delivery, or clear accountability for outcomes.

Our report this year finds substantial variation in access, quality, and outcomes across every part of the system we regulate.

In primary care, ratios of staff to registered patients vary considerably by area, which can affect the quality of care people receive. Uptake of annual health checks for people with severe mental illness varies widely by integrated care board (ICB) area, despite this group facing a significantly increased risk of premature death. In hospitals, our analysis found variation in maternal readmissions by ethnicity, reflecting entrenched disparities in maternal safety for Black women.

In children's health, hospital admission rates for conditions including bronchiolitis, asthma and diabetes with links to social deprivation vary sharply by region, and levels of tooth decay for children living in the most deprived areas are more than double those in the least deprived areas.

Overall, children and young people are experiencing some of the sharpest increases in need for care and waiting times across the system, even as some adult waiting times have improved. This is starkly illustrated in community health services where over 80,000 children and young people – almost 11 times the number of adults – have been waiting over a year for an appointment. At the same time, the number of children waiting for first contact with mental health services rose nearly a third in 2 years.

We also highlight inequalities not just for those using care, but those delivering it. A key strength of the health and social care workforce is its diversity – failure to support this diversity has consequences not only for staff but for the people who rely on them. Staff who feel valued and included are more likely to stay, delivering continuity of care and reducing the need for temporary staffing solutions, which can increase risk. Our inspections of the well-led key question look at how organisations are monitoring and managing equality, diversity and inclusion in their workforce. There is more work to do in this area, as NHS Workforce Race Equality Standard reporting shows, but trusts who take steps to ensure fairness for all staff are more likely to provide high-quality care.

Within adult social care, the market is changing rapidly. Underpinning much of this change is how well local authorities are equipped to shape and plan for the care their communities will need, and a funding model that remains fragile. This is leaving both providers and local authorities exposed to pressures that are contributing to a reshaping of the market largely by accident rather than by design. Homecare is fragmenting, with a growing number of small providers entering the market and significant variation in strategic commissioning by local authorities.

Care homes, meanwhile, are consolidating, with more of the available care home beds now located in large care homes and recent increases in institutional investors acquiring homes. This trend towards consolidation of property ownership by institutional investors and the fragmentation of community-based provision seems likely to continue and we will continue to monitor quality carefully to ensure it does not come at the cost of a good experience of care.

Commissioning is one of the most powerful levers to drive quality, equity, and the sustainability of social care, as our local authority assessments have highlighted. But within this changing market, we have found that some local authorities are struggling to meet people's needs. Care providers are increasingly looking for people who can self-fund their care in order to remain financially viable. This risks reducing choice or capacity for people who rely on council-funded support, which is already subject to significant regional variation.

Pressures in one part of the system often compound others – and challenges in access to social care are also contributing to delays in hospital discharge, while gaps in community mental health provision, particularly for people being discharged from inpatient mental health care, are placing further pressure on community services.

This comes despite some improvements in social care staffing, with vacancy and turnover rates in social care falling slightly – although concerns about the impact of reductions in international recruitment remain. We have identified leadership as the area most in need of improvement – this is significant because well-led services deliver better care, which is true of all sectors. Despite significant pressures, we continue to see many excellent examples of high quality and compassionate care – a testament to the hard work of staff.

Ten years ago, we warned that adult social care was approaching a tipping point. Although the intervening decade saw a historically overlooked sector pushed into the public consciousness by the pandemic, successive governments have not resolved the long-term funding of social care. Now, this government's renewed focus on social care offers an important opportunity for meaningful solutions in social care that improve outcomes across the whole health and care landscape – but only if reform addresses workforce, funding, commissioning, prevention, and inequalities together.

In addition to the sustainable funding solution we have consistently called for, work to improve commissioning across the system is needed to design care purposefully around people’s needs. It is also vital that clearer national standards are set so that people who use adult care services, and their carers, know what they can expect. If a National Care Service is to deliver real change it must address these issues.

We are committed to playing our part – working with providers, commissioners, stakeholders and, most importantly, people who use health and social care – to assess quality, drive improvement and keep people safe.

We will also seek to encourage innovation and collaboration across the system, including working with partners to understand and support the safe implementation of technology and AI to improve care.

The measure of success for all of us who regulate, commission, lead or work in health and social care is not how well each part of the system performs on its own It’s how well those parts work together for the people who need them, regardless of who they are or where they live.

Kay Boycott
Interim Chair

Baroness Julia Neuberger DBE
Chair

Dr Arun Chopra
Interim Chief Executive