Key statistics 

• 19% of England’s population lives in rural areas, yet these areas cover around 85% of the country’s land area 

• people living in rural areas generally have better overall health outcomes than those in urban areas, including longer life expectancy 

• however, rural areas contain small pockets of significant deprivation and poor health outcomes that may be hidden within overall averages 

• rural populations tend to be older on average, with higher proportions of residents aged 65 and over compared with urban areas 

• the sparsity of rural populations and greater travel distances can affect access to services, employment and support networks 

Key messages 

• overall health indicators in rural England often appear favourable, but they can mask significant local variations in deprivation and health outcomes 

• rural populations are typically older, increasing demand for health and social care services 

• geographic sparsity and distance between communities can influence access to services and support 

• local authorities need detailed knowledge of rural populations to identify hidden health challenges 

• better local data and more granular statistics are needed to reveal health disparities within small rural communities 

Policy implications 

• improve local data collection to identify hidden deprivation and health needs in rural areas 

• develop rural-specific public health strategies rather than relying on national averages 

• strengthen collaboration between health services, social care providers and local authorities in rural communities 

• consider transport, service accessibility and population ageing when planning rural services 

• support community-based approaches that address local health needs in dispersed populations 

Gaps 

• national and regional statistics often mask variation within rural communities 

• limited granular data exists on health outcomes in smaller rural settlements 

• further research is needed to understand how service accessibility affects health outcomes in rural areas 

• more evidence is needed on the effectiveness of rural-focused public health interventions 

Commentary 

This report examines the health and wellbeing of people living in rural England and highlights the complexity of rural health outcomes. Rural areas cover most of England’s land area but contain a relatively small proportion of the population. Despite this, rural communities play an important role in the national health and social care landscape. 

On average, people living in rural areas experience better overall health outcomes than those living in urban areas. For example, life expectancy tends to be higher and some health indicators appear more favourable. However, these averages can hide important differences within rural communities. 

The report emphasises the presence of “hidden deprivation” in rural areas. Small pockets of poverty and poor health may exist within otherwise affluent rural districts. Because rural populations are smaller and more dispersed, these issues may be less visible in national or regional statistics. 

Rural populations also tend to be older than urban populations. Higher proportions of residents aged 65 and over increase demand for health and social care services, including community support and long-term care. 

Geography plays an important role in shaping access to services. Rural communities often experience longer travel distances to healthcare facilities, fewer public transport options and limited availability of specialised services. These factors can make it more difficult for people to access timely support. 

From a health and social care equity perspective, the report highlights the importance of recognising rural diversity. While some rural areas experience strong health outcomes, others face significant challenges linked to deprivation, ageing populations and limited service access. 

The report argues that local authorities need detailed understanding of their rural populations in order to identify and address these challenges. More granular data and locally tailored policies may help ensure that rural communities receive appropriate support and that hidden inequities in health and wellbeing are addressed. 

Key statistics 

• adult social care in England is delivered by more than 14,000 provider organisations, creating a large and highly fragmented market 

• around 840,000 people receive long-term social care support, many of whom rely on services delivered by independent sector providers 

• approximately 84% of adult social care services are provided by the independent sector, including private and voluntary organisations 

• local authorities purchase a large proportion of care services but do not directly control the structure of the provider market, which has developed through private and voluntary sector provision 

• the Covid-19 pandemic placed significant financial and operational pressure on providers, highlighting existing vulnerabilities in the market 

Key messages 

• the adult social care provider market in England is highly fragmented, with thousands of organisations delivering services 

• long-term structural pressures, including funding constraints and workforce shortages, affect provider sustainability 

• the Covid-19 pandemic exposed existing weaknesses in the social care market 

• local authorities play a key role in commissioning services but have limited influence over market structure 

• reform efforts must address wider structural issues rather than focusing solely on funding increases 

Policy implications 

• strengthen oversight and support for the sustainability of social care providers 

• review commissioning and contracting practices to promote stable service provision 

• improve long-term funding arrangements for adult social care 

• support local authorities in market shaping and service planning 

• develop national strategies that consider the structure and resilience of the provider market 

Gaps 

• the report focuses on market structure rather than detailed analysis of service quality or care outcomes 

• limited analysis is presented on how market fragmentation affects different regions or local populations 

• further research is needed on the relationship between funding levels, provider sustainability and care quality 

• additional evidence is required on how policy reforms may reshape the social care provider market over time 

Commentary 

This report examines how adult social care services are organised and delivered in England. Unlike the NHS, which is largely publicly funded and structured through national systems, adult social care is delivered through a complex market made up of thousands of independent organisations. 

More than 14,000 providers deliver social care services across England. These organisations range from small local charities and family-run care homes to large national care companies. This diversity creates a highly fragmented system, where services vary widely in size, resources and organisational structure. 

Local authorities play an important role in commissioning care services for people who are eligible for publicly funded support. However, most care is delivered by independent sector providers rather than directly by councils. This means that local authorities influence the market through commissioning and contracts but do not directly control how the market develops. 

The report highlights long-standing financial pressures within the sector. Many providers operate on narrow financial margins, particularly when providing services funded by local authorities. These pressures can affect provider stability and the ability of organisations to invest in workforce development or service improvements. 

The Covid-19 pandemic placed additional strain on providers. Increased costs, staff shortages and infection control requirements exposed existing weaknesses in the system and raised concerns about the resilience of the care provider market. 

From a health and social care equity perspective, the structure of the provider market can influence access to services. Differences in local provider availability, financial stability and commissioning arrangements may affect the availability of care across regions. Some areas may have a wider range of providers and services, while others may face shortages or limited choice. 

Overall, the report argues that reform of the adult social care system must address the underlying structure of the provider market. Sustainable funding, stronger market oversight and clearer national strategy may be needed to ensure stable and equitable access to social care services across England.

Key messages 

• the cost of delivering social care services continues to increase, with notable regional and sectoral variation 

• workforce costs represent a major proportion of overall social care expenditure 

• low pay and challenging working conditions contribute to recruitment and retention difficulties across the sector 

• public funding has not consistently kept pace with rising costs of care provision 

• detailed cost data is essential for planning and allocating resources within health and social care systems. 

Policy implications 

• funding allocations should reflect the true cost of delivering social care services 

• workforce pay and conditions need to be addressed to support recruitment and retention 

• policymakers may need to consider regional variation when determining funding distribution 

• robust cost data can support evidence-based planning of health and social care services. 

Gaps 

• the report focuses on cost estimates rather than service outcomes 

• limited analysis of how cost pressures affect access to services or care quality 

• further research is needed on how financial pressures influence different population groups. 

Commentary 
This report provides a detailed overview of the financial structure of health and social care services by analysing the unit costs associated with different types of provision. By examining workforce expenses, service delivery costs and regional variation, it highlights the financial pressures facing providers and local authorities. 

Workforce costs emerge as a central driver of rising expenditure. Staffing accounts for a significant share of care costs, meaning that wage levels, recruitment difficulties and staff turnover directly influence the financial sustainability of services. These pressures are particularly visible in domiciliary care, where travel time, fragmented working hours and insecure contracts can make recruitment more difficult. 

The report also draws attention to variation in costs and funding between regions. Differences in local authority budgets, labour markets and service demand contribute to uneven financial conditions for providers. These variations can affect how services are delivered and funded across different areas. 

From a care inequities perspective, the findings highlight how financial pressures can translate into uneven access to services. Where funding does not reflect the real costs of providing care, providers may withdraw from local markets or increase fees for self-funding individuals. This can leave people in some areas facing reduced service availability or higher personal costs, reinforcing disparities in access to care based on geography and financial resources. 

Overall, the report demonstrates the importance of accurate cost data in understanding the financial foundations of the care system. Aligning funding with the real costs of service delivery is an essential step toward reducing financial inequities and ensuring that care services remain sustainable and accessible.