A design moment for social care

Reform in stages

Adult social care in England was never designed in the way the NHS or other parts of the welfare state were after the Second World War. Instead, it evolved gradually through a series of partial reforms.

The National Assistance Act 1948 replaced the Poor Law framework but retained many of its underlying assumptions. Social care remained largely a safety net, with access shaped by means-testing and by local interpretation of eligibility. Over time, the legal framework became increasingly fragmented as new duties and powers were added through successive pieces of legislation.

A more coherent framework did not emerge until the Law Commission’s review of adult social care law, published in 2011. Many of its recommendations were implemented through the Care Act 2014, which consolidated decades of legislation into a single statute and placed the promotion of individual wellbeing at the centre of the system.

The Care Act created a framework that is more adaptable than is sometimes recognised. In effect, it operates like a balloon: the structure holds whether it is lightly inflated or filled more fully. The Act can support the constrained system that exists today, but it could equally accommodate a more ambitious settlement should government choose to expand entitlement, investment or prevention.

The legislation, therefore, provides the architecture for reform, even if the system operating within it remains limited.

Yet none of these reforms fully resolved the relationships between the system’s key components: funding, workforce sustainability, entitlement, prevention and the balance of responsibility between national and local government.

Nor did they address the structural imbalance between health and social care. The NHS remains the dominant institution in the wider system. Part of that imbalance reflects scale and funding. But part of it reflects visibility. The NHS is a nationally recognised public institution, while social care is experienced as a complex set of local services whose boundaries and responsibilities are often unclear.

The result is a system with strong statutory principles but persistent structural tensions.

The Casey Commission offers an opportunity to revisit those relationships. Not necessarily to produce an immediate comprehensive settlement, but to clarify how the system’s different parts should align.

The reform we almost had

This is not the first time social care has come close to structural reform.

In 2011, the Dilnot Commission proposed a cap on lifetime care costs. The proposal was not radical. It did not create a National Care Service or fully collectivise funding. But it would have changed the system in one important way: it would have made the state’s role more visible.

Care accounts would have tracked individuals’ progress towards the cap. Self-funders would have come into earlier contact with local authorities. The means test and the public safety net would have become more transparent.

Over time, that visibility might have altered the politics of social care.

Instead, implementation was repeatedly delayed and eventually abandoned. Care accounts were never embedded. The cap was postponed, revised and finally scrapped.

The system remained largely as it was: complex, uneven and often encountered only at moments of crisis.

Dilnot’s lesson is not simply that reform is politically fragile. It is that reform requires administrative readiness, narrative coherence and sector alignment long before legislation is enacted.

The current moment

The Casey Commission begins its work in a political environment that is both constrained and consequential.

Public understanding of social care remains limited. Fiscal pressures are acute. A general election will arrive within the next parliamentary cycle.

In these conditions sweeping reform within the current Parliament appears unlikely.

Yet Casey’s intervention matters because it recognises that the system is no longer operating within the assumptions under which it developed. People live longer with complex conditions. Expectations about independence and participation have changed. Workforce sustainability has become central to the system’s future.

The proposed Fair Pay Agreement brings this challenge into sharper focus. By establishing nationally negotiated workforce standards, it places central government in a more visible position of responsibility for workforce conditions and their funding consequences.

Historically, pressures in social care have often been absorbed through local variation in commissioning and pay. National workforce standards reduce that flexibility. Over time, they increase pressure for alignment between workforce policy, funding settlements and commissioning practice.

That alignment will not occur automatically. It will have to be shaped.

Taken together, the Fair Pay Agreement and the Casey Commission create what might reasonably be described as a design moment for social care.

The sector’s role

Government action alone will not determine whether this moment produces reform.

For many years, organisations across social care have argued powerfully for change. Providers have highlighted market fragility. Local authorities have described unsustainable financial pressures. Workforce organisations have made the case for fair pay. People who draw on care and support have spoken about inconsistency and lack of control.

These arguments are legitimate and necessary.

But when government is presented with multiple overlapping demands, without clarity about sequencing, cost exposure or risk-sharing, incremental adjustment becomes the safer political course.

Treasury caution increases. Ministers hesitate. Reform drifts.

If structural change is to be secured, the sector must increasingly complement advocacy with something else: shared design.

That means being explicit about trade-offs. Reform involves choices between pace and affordability, national consistency and local flexibility, expanded entitlement and fiscal exposure.

Trade-offs are not a constraint on ambition. They are how ambition becomes politically adoptable.

This does not require unanimity across the sector. But it does require a form of system stewardship, recognising that the long-term health of the system depends on how its different components align.

Visibility and public understanding

One of the persistent challenges in social care is its low public salience.

Many people encounter the system only when they or a family member face a crisis. The boundaries between health care and social care are poorly understood. The financial rules are opaque. There is no single institutional identity comparable to the NHS.

Polling suggests that while people value care for older and disabled people, social care rarely determines voting behaviour.

Structural changes may gradually alter this. If workforce standards are negotiated nationally, questions about how those standards are funded become more visible. If commissioning must align with workforce agreements, the relationship between national and local responsibility becomes clearer.

Visibility alone will not produce reform. But without visibility, reform struggles to build constituency.

The next 18 months

For the Casey Commission, the coming period will involve gathering evidence and shaping recommendations.

For the sector, the next 18 months represent a moment of responsibility.  The responsibility to clarify the problems government is being asked to solve.  The responsibility to align workforce reform with funding and commissioning realities. The responsibility to develop credible economic and operational analysis capable of withstanding Treasury scrutiny.

And the responsibility to work through difficult trade-offs before political decisions are required.

Reform will not emerge fully formed from a commission alone. Nor will it be secured through advocacy alone.

But Casey’s intervention signals that the conversation about the future of social care has begun again. The Care Act already provides a framework capable of supporting that future—whether in its current constrained form or as the basis for a more ambitious settlement, should government choose to expand entitlement, investment or prevention.

What happens next will depend on how we in the sector choose to respond.

Paul Burstow is Chair of the Social Care Institute for Excellence (SCIE). He served as Minister of State for Care Services from 2010 to 2012 overseeing the drafting of the Care Act and was a Liberal Democrat MP from 1997 to 2015.