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Lay Summary
Need and unmet need among older people in the community
Amritpal Rehill, Tom Snell, Jose-Luis Fernandez, Raphael Wittenberg, December 2021


Given population aging, it is important for planning and budgeting purposes to understand how many older people (aged 65+) need long-term care and how many more will need this in the future. Not everyone with long-term care needs, even at a high level, will go on to receive Local Authority (LA) funded support.  

This paper investigates whether those who receive LA funded support differ from those receiving other kinds of support in terms of needs. The other types of support considered include those receiving (separately) privately purchased homecare, Attendance Allowance, unpaid care or no care. As well as need, there are a number of other factors that determine whether an individual will receive LA funded support. This includes how their needs impacts their wellbeing, financial eligibility and presence of an unpaid carer who already provides help with their needs to some degree. While potential presence of an unpaid carer was factored into the analysis, data limitations meant that financial eligibility and the degree to which needs impact on wellbeing were not. 

This analysis aims to provide useful evidence that can be used to assess what the likely effects would be if eligibility for publicly funded support is changed on any criteria other than needs. For example, if there are many individuals with long-term care needs at a similar level to those currently receiving LA funded care recipients, then we might see financial eligibility criteria as a bottleneck preventing those with needs accessing support. In this case changing the financial eligibility criteria might have a profound effect on the resulting number of people receiving LA funded care. If, on the other hand, there are relatively few individuals who have needs comparable to those receiving LA funded care then changing the financial eligibility criteria for care will likely not drastically affect how many people receive LA funded care.  

This paper also estimates what proportion of older people receive no support of any type (formal support either publicly or privately purchased, unpaid care or Attendance Allowance), yet have needs similar to those receiving LA funded support. This is a particularly important group to consider for policy makers, being the most likely to develop high-level needs and at the fastest rate. Policy currently focuses on prevention to minimise the speed at which needs are developed. It is therefore vital to understand how many more individuals there are in need of support to prevent needs from growing.  


Health Survey for England (HSE) data was analysed. This survey collects data from a random and representative sample of households in England annually. Data from 2015 to 2018 were combined and used for the analysis. In terms of needs, the HSE data captures help needed/received with Activities of Daily Living/ADLs and Instrumental Activities of Daily Living IADLs. ADLs cover needs related to fundamental activities needed for daily functioning, for example eating, bathing or toileting. IADLs consider needs with tasks that are typically required to live independently in the community (as opposed to care homes) and can cover such activities as travelling to social events, cooking, managing finances or shopping).    

Older people were sorted into separate groups based on what type of care they received. Individuals could receive multiple types of care, and so a hierarchy was created to split individuals into mutually exclusive groups. Those receiving LA funded support were put into the LA funded group, regardless of whether they received any other support. Of the remainder, those receiving privately purchased care were put into the privately purchased group, again regardless of whether they received any other type of care. This process was repeated to sort people into the Attendance Allowance group and then the unpaid care group. Receipt of Attendance Allowance was considered separately since eligibility for this benefit suggests a different average level of need, and the impact of receipt for this benefit may also differ, since the amount received does not necessarily need to be spent on a carer. Finally, the remaining individuals were then allocated into the ‘no care’ group. 

To sort individuals into having needs similar or dissimilar to people receiving LA funded care, it was necessary to determine what level of need those receiving LA funded care had. It was found that about 85% of LA funded care recipients met a threshold of 2+ IADL limitations if living alone and 3+ IADL limitations if living with others. This was chosen to be the cut-off for determining whether individuals receiving different types of care have similar needs to those receiving LA funded care or not. The level of need was intentionally set higher for those living with others, as this increases the probability of having an unpaid carer on hand which would likely reduce the probability of receiving LA funded support at lower levels of need.  We then calculated what proportion of those in different care groups met the threshold and separated the overall HSE sample by a) whether they met the threshold and b) the type of care they received. 

To explore how our choice of threshold impacted the results, alternative thresholds were explored. We also explored changing the hierarchy used to categorise people into different groups, so that those receiving unpaid care were considered of higher need than those receiving Attendance Allowance, since it is unclear which suggests a higher level of need and how receipt of Attendance Allowance might impact on needs (since it does not necessarily need to be spent on a carer). Finally, the analysis was also completed using a different dataset, the English Longitudinal Study of Aging (ELSA), which collected data slightly differently, to see what impact the dataset had on the results.



This study analysed only existing data and public advisors were not involved in analysing data or preparing the report.  


Across all of the analyses performed a clear pattern emerged. Those receiving publicly funded care were most similar to those receiving LA funded support. Using the initial cut-off, 85% of those receiving LA funded support met the cut-off as did 86% of those receiving privately purchased care. Those receiving Attendance Allowance were next most similar, though there was a considerable gap (46% met the initial cut-off). Those receiving unpaid care were slightly less likely to meet the cut-off (39% met the initial cut-off) than those receiving Attendance Allowance, and those receiving no care were least similar, with 10% meeting the initial cut-off. While the percentages meeting the cut-off varied by the level of cut-off chosen, the ordering remained the same. When ELSA was used as the data source, the ordering remained the same, but overall percentages meeting the initial cut-off were slightly lower for all groups. When unpaid care was considered to indicate a higher level need than Attendance Allowance, the results for the groups switched also. This is because we shifted those receiving both unpaid care and Attendance Allowance into the other group and those receiving both types of support are expected to have a higher level of need than those receiving only one type. 

When dividing the overall HSE sample we see that about 68% have no ADL or IADL needs. 9% have low level needs, which are likely not sufficient to warrant publicly funded care. 1% had needs similar to those receiving LA funded support but received no type of support.  


These findings indicate that a considerable proportion of individuals receiving different types of care have needs in line with those receiving LA funded support, particularly those privately purchasing support. This has implications for DHSC and policy makers in determining the likely consequences of changing eligibility criteria for support. Lowering financial eligibility criteria would likely mean a greater shift from those receiving privately purchased care to receiving LA funded care than from other groups. 1% of older people were found to have needs in line with LA funded care recipients but receive no type of support. This might indicate that social care practitioners have a role to play in ensuring that this group of people are identified  so as to increase the probability that they receive preventative support to slow the development of care needs. 


Amritpal Rehill,

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