Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: England’s social care models harm the poorest areas

BMJ 2018; 361 doi: (Published 27 June 2018) Cite this as: BMJ 2018;361:k2745
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}

Current models of local government funding systematically disadvantage people in deprived areas, compounding already entrenched health inequalities.1 The Joseph Rowntree Foundation found in 2015 that the most deprived English local authorities had experienced cuts of £182 more per head than the most affluent, “breaking the historic link between the amount a local authority spends per head and local deprivation levels.”23

A 2018 analysis showed that 25% of services in England’s most deprived local authority areas were rated inadequate by the Care Quality Commission, compared with only 15% in the 10 most affluent areas.4 It was published by the Labour Party’s research team, but the conclusions are compelling.

Local government relies on three main sources of income5: direct support grants from national government, business rates, and local council tax, based on the estimated value of privately owned residential properties. In December 2017 the government gave local authorities the permission to raise an additional 3% of council tax as a specially earmarked “social care precept” to help tackle social funding gaps locally.6

The more affluent the area, the higher the property values—hence the greater ability to raise income through council tax and precept. Income from business rates is generally higher in local authorities with thriving economies and higher employment rates.7 Affluent areas also have a higher proportion of homeowners and so commit a lower percentage of spend to publicly owned council housing for rental.

The 2010-15 coalition government reduced support grants to all local authorities, with the National Audit Office reporting a funding reduction of 28% from 2010 to 2014.8 Central funding support for local government is projected to fall by 77% by 2020.9 Council social care spending decreased by an estimated 13% from 2010 to 2016.10 Independent estimates show that around 400 000 fewer people were in receipt of social care in 2016 than in 2010.11 Unlike the NHS, such care is already rationed, based on strict eligibility criteria that exclude people with lower level needs, and is means tested. These cuts affect citizens’ lives, whether care recipients or family carers.12

Old age is a key driver of care needs, and relatively affluent areas often have a higher proportion of older residents. But people in more socioeconomically deprived groups have much shorter disability-free or healthy life expectancy after 65, so they may meet the threshold of need earlier.13 And wealthier areas will have more people who cross the means testing threshold for “self funding” their care, meaning less responsibility for local government.

Current social care funding models don’t match population need. They exemplify the “inverse care law” first described by Julian Tudor Hart,14 whereby those most in need receive the poorest access to care. They also render council tax regressive—further entrenching gaps between provision for rich and poor.15 None of this aligns with national policy ambitions to prioritise prevention, reduce inequalities, and improve population health.1617

Current social care funding models don’t match population need. They exemplify the ‘inverse care law’

The 2010 Labour and 2017 Conservative general election manifestos both contained proposals to use property value, even posthumously, to fund care. This would be a progressive move, as it would effectively tax wealth, not income, and would reduce inequalities reinforced by family wealth passing down to younger generations. Both proposals—crudely labelled by opponents as the “death tax” or “dementia tax”—were vigorously opposed and quickly binned.

The prime minister’s recent commitment to increase funding to NHS England by 3.4% a year did not include local government, public health, or social care.18 So, let’s hope that the Department of Health and Social Care’s ongoing review19 and resulting green paper can consider some radical solutions to reduce inequalities in social care provision, not entrench them.



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