The government has launched an independent commission to reform adult social care. The task force, led by cross-bench peer Louise Casey, will develop plans for a new national care service, one of Labour’s election manifesto pledges.
The process will have two phases. The first, which will identify critical issues and recommend medium-term improvements, will be reported in 2026. However, phase two, which will examine how to organise care services and fund them for the future, will not be reported until 2028.
Although sector organisations welcomed the announcement, there was unanimous concern that 2028 is far too long to wait for major change in social care, particularly for funding, and that things need to be done now to protect services.
The Association of Directors of Adult Social Services (ADASS) president Melanie Williams warned:
“unfortunately, the timescales announced are too long and mean there won’t be tangible changes until 2028.” Adding that “significant and immediate investment is required to enable adult social care to simply standstill.”
Frustration is not just with the timescale. Organisations involved and commentators feel that we have been here before, not just once or twice but many times over in the previous three decades. The information and ideas needed for reform are already out there, so why is another commission needed?
An analysis by The Health Foundation found that over the past 27 years, there have been two government commissions, one shorter government-commissioned review, three independent commissions, five white papers and 14 parliamentary committee inquiries on social care reform.
Added to this have been numerous other independently commissioned reports on social care from organisations involved, such as ADASS and think-tanks.
As Director of Policy at The Health Foundation, Hugh Alderwick, noted:
‘The adult social care system in England desperately needs reform after decades of political neglect and underfunding. So the government’s promise of a plan for social care is welcome. But we have been here before. The past three decades have seen a long line of reports and reviews making recommendations for social care reform, including from government commissions like the one announced today. The result has been delays and broken promises.’
And with so many reports available, is there really anything more to find out? As Melanie Williams from ADASS notes:
“We already know much of the evidence and options on how to reform adult social care, including our independently commissioned Time to Act report, and worry that continuing to tread water until an independent commission concludes will be at the detriment of people’s health and wellbeing.”
Recent policies have not helped the sector and could actually lead to the collapse of much social care, according to an analysis by The Nuffield Trust sent to the government in November 2024.
Tax and wage rises announced in the recent budget mean the care sector faces an extra £2.8bn cost burden from April 2025. The report warned that the consequences would devastate vulnerable and older people who rely on care services. Local authorities echoed these concerns, as did care home providers.
What have the previous commissions, inquiries and reports found?
The work done in the previous commissions and inquiries primarily focused on five difficult areas for social care: the charging system, funding, workforce, service delivery, and integration with the NHS.
The system for charging
Perhaps one of the most contentious issues is health care, which is considered a political minefield. Most commissions and reviews have proposed reforms to reduce healthcare costs and increase the number of people accessing publicly funded healthcare. Politicians, in turn, have baulked at the cost of such reforms and done little to change things.
Suggested reforms have varied – from making the existing system more generous by adjusting the means and need tests for accessing publicly funded support or limiting individual care costs by capping them by time or the amount paid through to universal access to social care, free the point of use like the NHS.
One of the most widely known proposals was made in the July 2011 Fairer Care Funding report from a Government Commission, often known as the Dilnot report, after Andrew Dilnot, chair of the commission. The report proposed a lifetime cap on individual care costs, an increase to the asset threshold for accessing residential care and free support for people entering adulthood with care needs. The Dilnot Commission’s recommendations to cap care costs and extend the means test were introduced as part of the Care Act 2014, but these have never been implemented due to successive government’s concerns over costs, most recently by Labour.
Funding
Also, a political minefield, funding reform for social care, has been looked at and then put to one side by successive governments for over 20 years. This is no longer an option, according to a report by The Nuffield Trust in November 2024, which warned that the system is close to breaking point with devastating consequences for vulnerable and older people.
Over the past quarter of a century most commission and committee reports have called for an increase in social care funding and for funding to be put on a more sustainable long-term footing, rather than often ad-hoc short-term funding increases to address crises.
Suggestions for the source of increased social care funding have included general taxation, increasing national insurance contributions for people aged 40 years and older and means-testing winter fuel payments to fund social care.
Workforce
The care system is nothing without staff, and the current structure has done little or nothing for decades to encourage good rates of pay, training opportunities, and good working conditions. The result is a system with a crisis in workforce recruitment and retention. Vacancy rates among care providers have risen sharply, and there are now estimated to be 131,000 vacancies.
Over the years, government committees have made calls for a national strategy to recruit, retain and develop the workforce. Other measures revolve around targeted recruitment actions, lowered visa requirements, measures to ‘professionalise’ the workforce, and improvements to terms and conditions.
Most recently, in July 2024, Skills for Care, the workforce development body for adult social care in England, published the first ever adult social care sector Workforce Strategy. The previous Conservative government had refused to develop a strategy or be involved, so Skills for Care, in collaboration with a number of other organisations, went ahead without government involvement.
The Workforce Strategy covers the next 15 years and is designed to complement the NHS plan, published in June 2023. As in the NHS plan, the strategy covers attracting and retaining staff, training, and transformation. The publication came at the same time as a joint report from The Nuffield Trust and the Health Foundation that calls for the introduction of national pay banding to tackle low pay in adult social care and encourage key workers to stay in the industry.
Service delivery
Since 1997, many reviews, including government white papers, have proposed national policy changes to support new approaches to care. The reviews support increasing personalisation, choice, and control over care and offer many ideas for organising and delivering care services.
Integration with the NHS
Reform of the NHS over recent years has focused on integrating care, with the introduction of integrated care systems. This has included a step towards closer working with the social care system.
Several commissions and inquiries on social care have identified options to improve coordination and integration with health care services. The most ambitious ideas propose moving to a single health and social care system, with a joint budget and single commissioning bodies to plan and purchase local services. Back in 2010, the Labour Manifesto contained plans for a National Care Service similar to the NHS. In 2020, the public services union Unison renewed the call for a national care service, releasing a strategy document, Care after Covid, to make the case for a radical shakeup.
Other proposals from commissions and committees have called for support for coordination between local authorities and NHS bodies, such as requiring joint workforce planning or expanding shared care records. Recent select committees have also included specific recommendations on the role of social care in integrated care systems (ICS), which were established in 2022.
Inadequate care providers and off-shore companies
One issue that the numerous government commissions and committees have not addressed closely is the actions of private companies in the adult social care market. Privatisation of the social care system began in the 1980s and there is now little state-owned provision.
Integration with the NHS, which is state-owned and free to access, with a system dominated by for-profit companies, many of the largest of which are owned by companies overseas, could prove to be a difficult hurdle in any reform process.
Local authorities are paying vast sums to private companies, who are not necessarily providing even an adequate service or paying their workforce adequately.
Back in 2016, the Centre for Health and Public Interest (CHPI) reported on the consequences of the privatisation finding that “both the quality of care in adult social care and the terms and conditions of the workforce have declined over the past two decades as a result of privatisation.”
An investigation by The Guardian in 2022 found that almost half a billion pounds has been spent buying beds in the worst care homes in England in the last four years, driving profits for private investors while residents suffer unsafe treatment.
To make matters worse, a few large operators are making profits but funnel them to private equity investors overseas, whilst others are in difficult financial positions and struggling to remain financially viable. As a whole this makes for a highly unstable market, one where borrowing is high, staff pay is low and tight cost controls are in place.
What immediate action is needed?
Alongside the announcement of the Social Care Commission was a package of short-term proposals which included more investment in the Disabled Facilities Grant, allowing people to apply for funding to carry out work such as widening doors, improving access, or building an extension. Plus care workers will be trained to perform further duties such as blood pressure checks, reducing the need for patients to travel to their doctor or clinics. A digital platform for medical information to be shared between the NHS and care staff will also be created.
Although “promising,” according to ADASS these measures are not enough and the organisation called for the government to use the forthcoming spending review to “lay the foundations for reform by stabilising adult social care and investing in the workforce,” or the government risks “further deterioration of care and support, making reforming the sector more difficult in future years.”
Sector organisations and commentators are unanimous in wanting faster action on social care and not waiting for the commission to report.
“This commission will simply confirm what we already know,” noted Professor Martin Green OBE, Chief Executive of Care England, adding “how many more reports must we endure before action is taken? The harm caused by the Government’s inaction is already deep, and the consequences for those who currently draw on care will be irreparable if immediate intervention is not forthcoming. Waiting until 2028 is not an option.”
Care England urged the Government to match the commission with immediate action, including funding support and workforce initiatives, to stabilise the sector while long-term reforms are developed.
Nuffield Trust Director of Policy Natasha Curry called for more urgent support given that the sector is now under immense financial pressure following the changes to National Living Wage and National Insurance and also called upon the government to use the Spending Review as an opportunity “to make a marked break with the past, and commit the necessary investment into social care.”
Will this commission be different?
The impact of all the reports on government policy over the past 27 years has been limited, and the problems in social care that existed in the 1990s/2000s continue and have got worse.
Whilst funding and media attention have flowed to the NHS and its problems, social care received little attention and increased funding.
The blame for this lack of action and the current crisis situation lies with politics and politicians. What was needed was a cross-party agreement, but historically, there has been little willingness to actually achieve this and bring about reform. Added to this has been the eagerness of certain strands of the media to misinterpret ideas to produce misleading headlines that scare the public and the result is the crisis social care now faces.
Health and Social Care Minister Wes Streeting, in his defence of the commission in The Guardian, acknowledged the way politics and politicians have derailed previous attempts at social care reform but said that this government is committed to “doing politics differently.”
He also defended the timescale and that work in previous commissions will be fed into this one, so it won’t be “starting from scratch”.
Dear Reader,
If you like our content please support our campaigning journalism to protect health care for all.
Our goal is to inform people, hold our politicians to account and help to build change through evidence based ideas.
Everyone should have access to comprehensive healthcare, but our NHS needs support. You can help us to continue to counter bad policy, battle neglect of the NHS and correct dangerous mis-infomation.
Supporters of the NHS are crucial in sustaining our health service and with your help we will be able to engage more people in securing its future.
Please donate to help support our campaigning NHS research and journalism.
Comments are closed.