Bigger isn’t always better for adult social care

The reorganisation of local government in 21 areas across England presents a once-in-a-generation opportunity to reset how adult social care (ASC) is delivered. How the next generation of adult social care services is set up will profoundly affect the quality of outcomes experienced by residents over decades, and also the ongoing financial resilience of new organisations. There is, however, room for a much more nuanced debate around scale than just focusing on population sizes and efficiency.

At IMPOWER, we’ve been engaging leaders and practitioners across the country to explore this issue, as part of our research project with District Councils’ Network.

We often hear the simplistic argument that bigger is better. Larger councils are presumed to deliver ASC more efficiently, with the ability to commission at volume and drive down costs. Does this really stand up to scrutiny and evidence from existing unitary councils?

There are areas where scale can be beneficial: capital-intensive specialist services, commissioning for complex provision, developing shared digital infrastructure, absorbing shocks, influencing health partners and negotiating with major providers. In these areas there may be economies in provision of adult social care services that can be driven by scale.  This doesn’t necessarily mean that smaller organisations cannot devise solutions but they do need to respond to this challenge.

However, scale is clearly not a single decisive factor in the quality of adult social care services. Using our IMPOWER Index, which benchmarks the relative cost and outcomes achieved for a range of key services, we’ve looked at data from every upper-tier local authority in England and found no clear link between the size of a council and the quality or productivity of its adult social care services. The top ten most productive systems in the country for older adults, on our assessment, range in population size from 160,000 to 750,000 people, whereas the top 10 for working-age adults social care services range from under 100,000 to well over half a million. Smaller authorities can outperform larger ones. Whatever drives effectiveness, it is clearly not scale alone.

Part of what’s missing from the “bigger is better” argument is​ the critical role of connection with a coherent place — of understanding people, building relationships, and working with neighbourhoods. Adult social care is fundamentally a people business. It’s relational, high-touch, and deeply embedded in local communities. There are no real economies of scale when it comes to one-on-one personal care.

This is where smaller councils, closer to their communities, can come into their own. The ability to deliver adult social care in a more personal, preventative and place-based way is a superpower. It brings the agility to intervene early, align housing and care services and manage demand more effectively. On the flipside we have heard the perspective from smaller care providers that centralising services too far from the communities they serve can undermine quality, responsiveness and trust.

Initiatives like Community Catalysts’ Micro-Provider network demonstrate that micro provision can achieve exceptional value. They can be ‘scaled out’, as in , where hundreds of micro providers provide thousands of hours of high-value support.

The risk, complexity and cost of disaggregating adult care services that are provided at county scale should be approached with humility and not under-estimated. The real opportunity is not just in efficiency, but in reshaping delivery footprints for adult social care and health systems around places that make sense of how people live their lives and at a scale that will support prevention through local integration and relationships.

Getting this right will be challenging in the short term but will then give systems the best possible chance of thriving for the long term.

As local partnerships work on their reorganisation proposals, we would encourage them to explore a range of options during the transition to new unitary authorities.  Our research suggests that these can be highly effective in managing risks to operational delivery during an interim period.  This has enabled a move to more sustainable structures and practice to be developed at a pace that can fully identify the opportunities to reset services at a scale that makes sense of place, demographics and care markets.

So, scale may bring efficiency under some circumstances. But it doesn’t guarantee effectiveness and can get in the way of the human dimension of care. The truly exciting challenge for local partnerships is to shape new adult social care systems that can work at multiple scales – doing “bigger is better” where it actually works, delivering services over places that make sense, but also integrating and building relationships at the most local level and within neighbourhoods. In areas that are working on reorganisation proposals, this requires a mature and informed debate between the leaders who are closest to these different levers at the moment, and a joint effort to bring the ambition and blueprint for new services to life.