A short series on reform
28 May 2026
By Paul Burstow, Chair of the Board, SCIE
Agreement on purpose has not translated into a system that can be delivered in practice.
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, without a single moment of design.
That observation is not new. What feels different now is the context in which it is being made. The Casey Commission has framed the current moment as an opportunity to ask more fundamental questions — about what social care is for, what people should expect, and how it should be funded.
For many years, the need for reform has been widely recognised. There is broad agreement about purpose: supporting people to live well, with dignity, independence, choice and control. That ambition is reflected in the Care Act’s focus on wellbeing, and in wider work that has sought to articulate, in more accessible terms, what people should be able to expect from care and support.
Yet reform has repeatedly stalled. The reason is not the absence of ideas, or even of shared intent. It lies in the gap between agreement and implementation.
The Care Act illustrates this tension. It provides a framework that is more adaptable than is sometimes recognised. It sets out not only duties and responsibilities, but an underlying proposition about what good care should enable — a focus on wellbeing, participation and individual control. In that sense, it can be read as an articulation of expectations as much as a piece of legislation.
But those expectations are not experienced consistently in practice. Access varies. Outcomes vary. People often encounter care at the point of crisis rather than through a coherent offer understood in advance. For many, social care remains something encountered late and under pressure, with choices often constrained by what is available locally.
This reflects a more general problem. The key elements of the current arrangements are not aligned:
- funding and entitlement
- workforce and commissioning
- national ambition and local delivery
- public provision and a predominantly independent provider market
A significant share of care is already funded by individuals and delivered by independent providers. Responsibilities — financial and operational — are distributed across the state, families and the market, often implicitly rather than by design.
The result is not simply variation, but a lack of clarity about how the different parts fit together.
In this context, reform is not simply a matter of policy intent. It requires working through how these elements relate to one another in practice. Developing a shared understanding of people’s journeys through the care system highlights the gaps, but also what matters most to people themselves.
That, in turn, brings trade-offs into view. Reform involves choices: between pace and affordability, national consistency and local flexibility, collective provision and individual responsibility. These are not constraints on ambition. They are how ambition becomes actionable.
They also surface a tension that has not always been addressed explicitly: between the aspiration for choice and control, and the constraints created by funding, workforce capacity and local variation.
Without clarity about those choices, government is presented with pressures rather than propositions. Different parts of the sector make legitimate claims, but without a shared account of how those claims can be reconciled.
The result is caution. Reform drifts. Incremental change becomes the default. The care sector, especially people who draw on care, are regularly dismayed and disappointed by the lack of progress.
There is also a more basic constraint. Public understanding of social care remains limited. Many people encounter the system only when they or a family member need support. The boundaries between health care and social care are not well understood. The financial rules are opaque. There is no single, visible institutional identity.
In these conditions, reform struggles to build a public mandate.
This matters because the questions at the heart of reform — what people should expect, who should pay, and on what basis — are not only technical. They are questions about the relationship between the state and the individual.
The Casey Commission has been explicit that a national conversation is needed to address them.
The effect is familiar. There is agreement about what social care should achieve. There is less clarity about how it is organised. And there is limited consensus about how costs and responsibilities should be shared.
Reform stalls not because the destination is unclear, but because the route has not been worked through.
The task now is not to restate the case for change, but to align the conditions under which change can be delivered.
