Reform must address the uneven reality of care
19 June 2026
By Paul Burstow, Chair of the Board, SCIE
Core proposition
Reform must be judged not only by how the system is organised, but by whether it delivers fair and recognisable outcomes in people’s lives.
The earlier articles in this series have argued that social care lacks alignment: between purpose and delivery, between policy and practice, and between different parts of the system. They have suggested that reform depends on working through design choices and strengthening the conditions for delivery.
But there is a further question that sits alongside these.
What difference does the system actually make — and for whom?
The uneven reality of care
Adult social care is not experienced consistently.
Access varies. The availability of support, the threshold for receiving it, and the speed at which it is provided differ across places and populations.
Experience varies. The way people are treated, the extent to which they feel informed or in control, and the continuity of care they receive are not uniform.
Outcomes vary. The extent to which care enables people to live well, maintain independence and participate in their communities differs significantly.
These differences are not incidental. They follow recognisable patterns.
They reflect how the system is organised and what it prioritises — including funding arrangements, workforce capacity, commissioning practices and the structure of the provider market. They are also shaped by wider factors such as geography, income, ethnicity, disability and the availability of local services.
What is often described as variation is, in many cases, inequity: differences that are avoidable, and that arise from the way the system functions. Some inequities arise from uneven delivery. Others are rooted more deeply in structural barriers — including poverty, racism, ageism, disability discrimination and the way services are designed or funded. Reform therefore has to address both: the way care is delivered, and the conditions that shape who is able to access, influence and benefit from it.
Why equity matters
Equity in social care should be a clear aim of a future care service. It is about the absence of unfair and avoidable differences in:
- access to care and support
- experience of services
- outcomes in people’s lives
This reflects a broader understanding of care as something that supports people to live well, rather than simply something that meets minimum needs.
It also connects directly to the principles set out in the Care Act — particularly wellbeing, personalisation and prevention — and to wider work across the sector to articulate what people should be able to expect from care and support in practice.
The question for reform is therefore not only whether services are available, but whether they are:
- accessible to those who need them
- appropriate to people’s circumstances
- and effective in improving people’s lives
A focus on equity means reform can achieve the core principles articulated in the Care Act and advocated by people who draw on care and support.
Evidence and the problem of fragmentation
There is a substantial body of evidence on inequities in social care.
It shows consistently that people’s experience of care is shaped by where they live, their economic circumstances, and their personal characteristics. Differences in access, quality and outcomes are widely recognised.
At the same time, the system faces increasing demand, uneven distribution of resources and persistent pressures on workforce and provision. These pressures do not fall evenly. They tend to reinforce existing differences between places and populations.
Yet this evidence has often been difficult to use in practice.
It is dispersed across multiple sources. It is presented in different formats. It is not always accessible to those making decisions about policy, commissioning or service delivery.
As a result, decisions are frequently made without a clear and shared view of what the evidence shows.
This is not simply a gap in knowledge. It is a gap in how knowledge is organised, connected and applied.
The contribution of the Care Equity Evidence Hub
The Care Equity Evidence Hub, developed by SCIE, is intended to address this problem.
It brings together research, data and practice evidence on inequities in social care into a single, accessible resource. It organises that evidence around areas where inequities are known to arise — including workforce, geography, financial arrangements and the experience of different groups.
Its purpose is not simply to catalogue what is known. It is to support the use of that knowledge in practice.
This reflects a wider insight emerging from SCIE’s work: that improving care depends not only on generating evidence, but on making it usable — connecting it to decision-making and grounding it in the realities of delivery.
It also reflects the importance of co-production. Understanding inequity requires attention not only to data, but to lived experience — how people navigate the system, where it works, and where it does not.
Equity as a design and delivery question
The existence of inequities raises a further question. Are these differences the result of design or of delivery? In practice, they are both.
Design choices — about funding, entitlement and responsibility — shape how resources are distributed and who bears risk.
Delivery conditions — including workforce capacity, commissioning capability and provider viability — shape how those resources are translated into care.
The two are closely connected.
A system that is coherent in design but weak in delivery will still produce uneven outcomes. A system that is well delivered in some places but not others will reinforce variation.
Equity therefore depends on alignment.
It requires that the principles set out in policy are matched by the conditions needed to realise them in practice.
The limits of structure
This brings the argument back to the question of structural reform.
The case for a more clearly defined national framework, including the idea of a National Care Service, rests in part on the need to address fragmentation and create greater consistency.
These are important objectives. But equity does not follow automatically from structure.
A more centralised or nationally defined system may clarify responsibilities and improve visibility. But unless it addresses the underlying conditions of delivery — workforce, funding, commissioning and provider sustainability — differences in access, experience and outcomes are likely to persist.
The question is therefore not only how the system is organised, but how it operates in practice.
From evidence to action
The final challenge is one of application. If inequities are known, and if evidence exists to explain them, why do they persist?
Part of the answer lies in fragmentation — of evidence, of responsibility and of decision-making.
Part lies in incentives — the way funding, performance measures and accountability structures shape behaviour.
And part lies in capability — whether organisations and systems have the capacity to interpret evidence, learn from it and apply it in practice.
Addressing inequity therefore requires more than identifying where differences exist. It requires:
- clearer visibility of those differences and prioritising their resolution
- stronger connections between evidence and decision-making
- and sustained attention to how change is implemented
Bringing it together
The argument across this series has been that social care reform is not simply a matter of intent. It requires:
- clarity about purpose
- alignment in design
- capability in delivery
This article adds a further dimension. Reform must also be judged by its outcomes. Not in aggregate, but in the lives of the people who draw on care and support.
The question is not only whether the system is coherent. It is whether it works fairly. Whether people can access support when they need it. Whether they are treated with dignity and respect. And whether care enables them to live the lives they want to lead.
