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

This report highlights where we have seen particular variation and inequalities for some groups of people, including frail and older people.

As the health and care sector considers a shift into the community, understanding the support required for frail and older people is crucial to address these imbalances.

Experiences of follow-up care after hospital discharge

To find out more about people’s experiences of care following discharge from hospital, we commissioned research from National Voices (a coalition of health and social care charities) to focus on the support available for older people living with frailty.

National Voices used findings from:

• a follow-up survey that we sent to 704 people who had responded to the 2023 NHS Adult inpatient survey who were aged over 65 and who indicated that they were living with frailty; we collected 144 responses from this follow-up survey
• 9 interviews with people who completed the follow-up survey, complemented by 8 supplementary interviews with people who are more at risk of experiencing health inequalities.

Of the 144 respondents, 78 received care in the community after discharge and 64 did not. Two people didn’t know whether they’d received follow-up care or not. Overall, the people who completed the questionnaire and took part in interviews reported having a positive experience when it came to being discharged from hospital and receiving follow-up care in the community. The most common types of follow-up care were a paid carer providing personal care, and NHS nurses providing medical care. Follow-up care also included examples of physiotherapy or occupational therapy.

Emphasising the importance of such care, most respondents who received follow-up care either ‘strongly agreed’ or ‘agreed’ that this allowed them to recover fully, regain or maintain their independence, and reduced the amount of support they needed from their friends and family. The vast majority of respondents were discharged back to their home. Most people agreed that the care helped them stay independent and that they felt able to raise concerns if necessary.

I really can't think of anything [that would have improved my experience of care after leaving hospital]. I was surprised how exceptionally good the physiotherapists (both at home and later in outpatients) were.

[Survey respondent]

However, several interviewees shared issues that emerged from a poor discharge process. Delays, poor co-ordination or poor communication during the discharge process left some people feeling confused and unhappy, which can negate an otherwise positive experience of treatment during their hospital stay.

Similarly, where survey respondents reported dissatisfaction with their discharge experience, this related to not feeling ready to leave hospital and not receiving a safety and welfare check at the right time.

I was discharged with zero plan and my GP organised homecare – I required 148 days of carer visits before being deemed safe to get myself washed and dressed. My husband is also my full-time carer.

[Survey respondent]

All of a sudden, they said, ‘oh you’re going home’. I wasn’t happy with that[...] It was causing enough anxiety as it was without having to worry about that[...] we haven’t got transport, we had to rely on my wife’s sister to come and pick me up. It was badly orchestrated.

[Interview participant]

While feedback on follow-up care tended to be positive, some negative aspects were highlighted through people’s responses to the survey. This included that care didn’t always meet people’s emotional needs and that staff didn’t take the time to discuss people’s medical and non-medical needs. Respondents also said that they didn’t receive care from the same members of staff throughout their recovery.

They don’t see the human being, they only see the problem/ailment to be fixed. I may be old but I have lived a life. Never once did anyone ask me what I thought, what I felt, how I could be helped. I was a problem to address and not a person in my own right.

[Survey respondent]

I was back into full caring mode for [husband] but I was [recovering] from a double bypass and aortic valve replacement. I didn’t have the physical or mental strength to cook, clean, wash, shop for us both […]. Very depressed but no one I was able to talk to.

[Survey respondent]

The failure to take a holistic approach to delivering care had a negative impact on the emotional wellbeing of some research participants.

Of the 64 respondents to the questionnaire who did not receive follow-up care after being discharged from hospital, more than half felt that they did need follow-up care at the time. Not receiving follow-up care despite needing it led to wide ranging negative outcomes. These included the need to go back into hospital, friends and family taking on unpaid caring responsibilities and a deterioration in their emotional wellbeing.

I felt very vulnerable both physically and mentally. I had to rely on friends to do a lot as I don’t have family nearby. I was unable to have a shower easily and found it difficult to climb stairs. I ended up seeing a psychologist due to PTSD post surgery.

[Survey respondent]

Access to GP services

We are concerned that challenges in getting access to GP services can have a different impact on the experiences and outcomes of older or frail people.

Findings from the 2025 GP patient survey showed that the likelihood of people not doing anything when unable to contact their GP practice, or not knowing what the next step would be, was highest for people aged 85 and over (23%) and lowest for those aged 35 to 44 (15%).

This is particularly concerning as older adults – especially those living with frailty – are at greater risk of poor outcomes, such as falls or emergency hospital admission because of deterioration from relatively minor ailments.

We also hear feedback from older people and their loved ones about how this can affect their health, wellbeing and trust in services.

My father called the GP surgery every morning at 8am but was consistently met with an engaged line. The surgery was only accepting emergency cases, and no home visits were available. My father is elderly and frail, and should have been given priority for a consultation due to his age and health concerns. He was suffering from a persistent chest problem and pain in his hip and leg. Due to the lack of care and inability to secure an appointment, his health deteriorated.

(Give feedback on care)

If people do not have family or loved ones to advocate on their behalf, this may increase the risk of them falling through the gaps. It is important that local systems have effective processes to ensure that vulnerable people without advocates – whether formal or informal – are not at a disadvantage when navigating the health and care system, and receive the support they need.

Hospice services for adults

Since introducing our assessment framework in 2024, we have assessed 25 hospice services for adults. Of these, over a third (9 services) have been rated as outstanding, three-fifths (15 services) have been rated as good, and only one service is rated as requires improvement. No services have been rated as inadequate.

While hospices provide support for people of all ages who need palliative care or are reaching the end of their lives, they can also provide a range of interventions to support older adults experiencing advanced frailty. They can help people to live well until the end of their lives, reducing the need for them to be admitted to hospital and supporting them to achieve their preferred place of death. They can also support an earlier discharge from hospital for frail patients.

Across the 21 inspection reports published in 2024/25, it is evident that the people receiving care from hospices are at the centre of how these services are delivered and run. Reports described services and staff that take time to understand a person’s physical, emotional, psychological, and spiritual needs, and who try their best to ensure they meet these needs, resulting in positive experiences and outcomes

We saw that some hospice providers were taking steps to widen their provision for people living with frailty and other life-limiting conditions that often overlap, such as dementia, as these groups have repeatedly been shown to be under-served by palliative and end of life care services. Changes in care for these people included improving the physical environment and setting up support groups for people with dementia, run by specialist staff such as link nurses or a community dementia nurse. We also saw specialist support groups and outpatient provision for people with Parkinson’s or motor neurone disease, and for autistic people and people with a learning disability.

As well as adaptations for people already using a service, we have seen evidence of considerable community outreach to ensure that services were proactively targeting people who reflect the demographics of the local community. This included:

• outreach to minority ethnic communities
• links with local faith leaders to tailor provision to people of different religions
• highlighting and attempting to reduce socioeconomic inequalities in access to hospice services
• building relationships with local LGBTQ+ organisations to improve access and quality of care for people in these groups.

Through our inspections, we also saw evidence of providers proactively reaching out to different inclusion health groups in their community, including local homeless populations. One service worked with prisons to ensure people could also access end of life care. Another hospice service rated as outstanding had worked with external. For example, the service held events, as part of ongoing community engagement, to encourage people in ethnic minority communities to access services. The service had also reached out to local groups, including women’s groups, refugees’ groups, homeless charities and stakeholders.

Most hospices that we inspected in 2024/25 were providing good or outstanding care – despite pressures in the system. But staff shortages and their impact on safe staffing levels was a recurring theme. Although services had identified risks in this area and mitigated them effectively, there was evidence of negative impacts on enabling people to access care, including long waiting lists for some services.

In most cases it was clear that providers were striving for a 24-hour, 7 days a week service. This included through both in-person assessment and care or advice and support lines as well as inpatient care for those who needed it. Some providers were able to achieve this, either by themselves or in collaboration with others.

However, other providers had to reduce their provision due to staffing constraints. They did this either by reducing inpatient bed capacity to maintain safe staffing ratios, or by reducing the hours of community provision

For example, a hospice service that we rated as outstanding used a safe staffing tool which took into account staff numbers, skill mix and patient acuity. If the tool flagged ‘red’, the inpatient leadership team would escalate to the Clinical Director who could decide to close the service to admissions. This helped the service ensure and monitor clinical safety and effective patient care. Senior management met regularly to ensure they had clear oversight of performance and risks, and the service was working in partnership with other local organisations to ensure the sustainability of their workforce planning.

In some cases, providers had been able to work with local community and district nursing teams to maintain overnight cover.

Despite these challenges, there is evidence that most of the hospice providers we inspected were committed to working collaboratively and in partnership with other services involved in people’s care. We saw evidence of hospices maintaining regular communication with acute hospitals, GPs and community health services to promote continuity of care for people and to ensure their needs and preferences were known and respected by all services involved in their care. We also saw how some providers gave training to other services, such as paramedics and care homes, to support provision of good end of life care, reduce A&E attendances and emergency admissions, and to enable people to remain at home if preferred.