Designing social care: from ambition to reality

Adult social care in England is often described as a system. In practice, it is better understood as a set of arrangements that have evolved over time, shaped by successive reforms but never fully brought together as a coherent whole.

There is no shortage of agreement about what social care should achieve. The Care Act sets out a clear ambition, grounded in wellbeing and individual rights. Work across the sector has helped to articulate that ambition in more accessible terms, including through “I” statements that describe what good care should feel like in people’s daily lives.

What is less clear is how those ambitions are translated into arrangements that can be delivered consistently, understood by the public, and recognised in people’s lived experience.

This matters because the wider context is shifting. The Casey Commission has been established to build a clearer public mandate for reform, including through deliberative engagement. At the same time, policy attention is focused on workforce, choice and control, and integration with the NHS.

Yet reform has historically stalled despite repeated attempts. The system remains fragmented, and progress has been incremental rather than structural.

The purpose of this series is to explore that gap between ambition and delivery.

It does so by focusing on four related questions:

Article 1: Why reform stalls

Agreement on purpose has not translated into a system that can be delivered in practice.

Reform has not failed for lack of ambition or consensus. The Care Act and wider sector thinking provide a clear account of what social care should achieve.

But the key elements of the current arrangements — funding, entitlement, workforce, commissioning and delivery — are not aligned.

Without clarity about how these elements fit together, reform remains partial and incremental. Public understanding is limited, trade-offs are avoided, and political risk outweighs momentum for change.

Article 2: What needs to be designed

Reform depends on working through the choices that shape how social care operates in practice.

Reform is not a statement of principle. It is a set of choices about how arrangements would work in practice.

Four sets of questions sit at the heart of this:

• what is guaranteed, and for whom
• how costs and risks are shared over time
• who is responsible for what, across national and local government, health and care, and individuals and families
• how consistency in outcomes is achieved within a diverse provider market, including the shift from crisis response to earlier intervention

These questions reflect an existing mixed economy, in which responsibility is already distributed across the state, individuals, families and providers.

Reform requires working through how these elements are aligned — and where they may need to be rebalanced.

Article 3: Who makes it work

Reform depends not only on policy, but on the capacity to deliver and sustain change.

Previous attempts at reform have focused on legislation or funding. Less attention has been given to how change is translated into practice.

A functioning approach depends on infrastructure and capability, including:

• workforce development and leadership
• standards and guidance
• commissioning and accountability
• data, evidence and learning
• a sustainable and innovative provider market

These functions exist but are not yet organised as a coherent whole. Reform also takes place within a mixed market, where providers, investors and self-funders play a central role in delivery.

The challenge is not to start from scratch, but to bring these elements into alignment in a way that can be enacted and sustained over time.

Article 4: What reform must achieve

Reform must be judged not only by coherence, but by whether it delivers fair and consistent outcomes.

Adult social care is experienced unevenly. Access varies, outcomes vary, and people’s experiences of care are not consistent.

These differences are not incidental. They reflect how the system is organised — including funding arrangements, workforce capacity, commissioning practices and the structure of the provider market.

Addressing this requires attention to three dimensions of equity:

• equity of access — who gets support, and when
• equity of experience — whether people feel informed, heard and in control
• equity of outcomes — whether care improves lives and reduces avoidable harm

Work by SCIE and others highlights a persistent gap between ambition and experience, and the importance of co-production in shaping solutions that work in practice.

Reform must therefore be judged not only by whether it is coherent, but by whether it produces outcomes that are fair, consistent and recognisable in people’s lives.

Overall framing

This series does not propose a single model for reform.

It argues that progress depends on something more fundamental:

• clarity about how the current arrangements fit together – and where they fall short
• a willingness to work through trade-offs with the public, people who draw on care and political leaders
• a shift from advocacy towards shared design
• and a focus on whether outcomes are fair and consistent in practice

In that sense, it is intended to contribute to the wider public and policy conversation now underway — including the work of the Casey Commission — by focusing not only on what should change, but on how change becomes possible.

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.