The work reform leaves behind

What did not follow 

Over the decade that followed, adult social care entered a period shaped by austerity, rising demand, workforce pressure, political instability and repeated disruption. The architecture of reform remained, but many of the conditions required to realise it weakened or disappeared. 

Funding pressures increasingly drove systems towards short-term crisis management. Prevention became harder to sustain. Workforce pressures intensified. Local variation widened. Public understanding of the system remained weak. And successive reform moments arrived and receded without a durable settlement. 

Looking back, I think we underestimated how difficult it would be to sustain alignment between policy ambition, operational reality and political attention over time. 

England has spent much of the last decade repeatedly rediscovering the same problems without sustaining the political and institutional conditions needed to address them. 

The greatest failure of the past decade has not been a lack of diagnosis, but the inability to sustain implementation. 

What reform taught me 

One of the lessons I have drawn from my nine years as Chair of SCIE is that social care reform succeeds or fails less through moments of announcement than through the slower work of translation, improvement and learning. 

Policy can establish direction. But systems only change when ideas are interpreted, adapted, tested and embedded in practice. 

That work is often less visible than legislation or funding announcements. It happens through guidance, standards, improvement support, evidence synthesis, leadership development and co-production. It depends on relationships across organisations and professions. It requires institutions capable of connecting national ambition with local realities. 

One example stays with me. 

As Care Minister, it was my decision to place responsibility for social care guidance and standards within NICE. At the time, this felt like the right institutional choice. NICE carried authority, permanence and statutory standing. The intention was to signal that social care deserved the same seriousness and infrastructure as health. 

In retrospect, I think I misunderstood something important. 

Social care improvement is not simply a technical standards problem. It depends much more heavily on translation into practice, co-production, implementation support and organisational learning across highly fragmented systems. 

NICE brought rigour and authority. But over time it became clear that the nature of social care required something different as well: institutions capable not only of defining evidence, but of helping systems apply it in practice. 

Ironically, much of that work continued to be undertaken by SCIE itself, including through guidance commissioned directly by government and broader improvement support across the sector. 

I have come to think that this reflected a deeper truth about social care reform. Systems do not improve through legislation, standards or structural change alone. They improve when there is sustained capacity to connect evidence, practice, leadership and lived experience over time. 

The missing infrastructure 

One of the weaknesses of adult social care reform has been the absence of sustained national improvement infrastructure — one that works with the whole complexity of the care system, across local places and communities, and with the multitude of care providers and their workforces. 

The NHS has developed institutions, however imperfect, that support evidence, improvement, leadership, data, guidance and implementation. Social care has never had equivalent infrastructure at the same scale or with the same stability. 

While I would not advocate replicating NHS infrastructure, that lack of investment matters. 

Without organisations capable of translating policy into practice, bringing evidence together, supporting improvement and grounding change in lived experience, reform remains dependent on short-term programmes, local capacity and brief periods of political attention. 

SCIE has often been asked to occupy this improvement role. 

Over the past decade it has supported implementation of the Care Act, developed guidance, advanced co-production, worked on safeguarding, contributed to standards, supported leadership and improvement, spread innovation and, more recently, created the Care Equity Evidence Hub. 

SCIE’s Covid-19 Hub demonstrated this role in practice, helping bridge the gap between national guidance and what people and organisations needed to do on the ground. 

The issue is not whether this work is needed. It plainly is. 

The question is whether it is recognised as essential infrastructure for achieving lasting reform, and whether our future care system provides sufficient investment to leverage this capacity to produce a care system the public will support and be proud of. 

Why institutions matter 

Some of the most important work in public systems is not about designing new policy, but about helping people make sense of complexity, learn from evidence and improve practice under pressure. 

That role can sometimes appear modest compared with the scale of the challenges facing the sector. But fragmented systems rarely improve through structural reform alone. They require institutions that help sustain coherence, learning and continuity over time. 

The recent development of SCIE’s Care Equity Evidence Hub reflects this wider challenge. One of the striking features of the current system is not the absence of evidence, but its fragmentation. We know a great deal about inequity in access, experience and outcomes. But evidence is often dispersed, inconsistently applied and weakly connected to decision-making. 

We are also better placed than in the past to understand what good care looks like, because we are increasingly able to capture evidence about people’s outcomes and experiences, not only service activity. 

The same could be said of reform more broadly. 

England has not lacked commissions, reviews or policy ideas on adult social care. Many of the central questions have been understood for years: how risk should be shared between individuals and the state; how to support a sustainable workforce; how to create greater consistency without losing responsiveness; how to shift towards prevention; how to support unpaid carers; and how to create clearer public understanding of what social care is for. 

The difficulty has been sustaining political and institutional alignment long enough to carry reform through. 

Reform without memory 

Too often, reform conversations begin as though history started yesterday. 

Institutional memory is lost. Previous learning is rediscovered rather than built upon. And implementation is treated as secondary to policy design. 

That matters because adult social care is not a system that can be reshaped quickly or centrally directed into coherence. It operates through a complex mix of local government, independent providers, unpaid carers, communities and public services, all working under different pressures and incentives. 

Reform in such systems is cumulative rather than instantaneous. It depends on sustained attention over time. 

The Casey moment — and a new political opening 

The Casey Commission now sits at the centre of a potentially much more consequential political moment. 

The possibility of Andy Burnham becoming Prime Minister gives the debate an unusual continuity. As Health Secretary in 2009 and 2010, he led work towards the creation of a National Care Service. His return to the issue creates the possibility that social care could move closer to the centre of government than it has for many years. 

That should be welcomed as a genuine opening. 

But the opportunity is not simply to revive a blueprint from 2010. It is to connect renewed political ambition with everything that has been learned since: the Care Act’s emphasis on wellbeing, prevention and rights; the importance of local government and a diverse provider sector; the centrality of the workforce and unpaid carers; stronger evidence about equity and outcomes; and a clearer understanding of the infrastructure required to turn reform into practice. 

Seen in that light, the Casey Commission could become more, not less, important. It could provide a bridge between renewed political ambition and a phased, credible and publicly legitimate programme of change: clarifying what a National Care Service is for, building consent around difficult choices and connecting structural reform with the conditions that determine people’s experience of care. 

There is now much wider recognition that the current arrangements are difficult for the public to understand and are often experienced as fragmented and unfair. The debate around a National Care Service reflects a legitimate desire for greater clarity, visibility and consistency. 

The context for reform is also changing. Workforce reform, the proposed Fair Pay Agreement, stronger expectations around standards, better data on outcomes and experience, and the growing role of lived experience all create fresh opportunities to think differently about what a future care system should achieve. 

But structure alone will not resolve the underlying conditions that shape people’s experience of care. 

Any future reform will still need to grapple with workforce capacity, provider sustainability, commissioning capability, uneven local resources and the wider care economy of families and unpaid carers that underpins the formal system. 

Nor will renewed political attention, however welcome, substitute for the patient work of implementation. 

The question is therefore not only what a future government or the Casey Commission might announce. It is whether political leadership, public consent, funding, sector capability and improvement infrastructure can be aligned long enough to make reform endure. 

That is where SCIE’s role matters. Not as an advocate for one institutional solution, but as a national improvement body for social care: independent, evidence-informed, grounded in practice and shaped by lived experience. 

Equity as the test 

It will also be necessary to confront more honestly the question of equity. This is partly why SCIE has made this the theme of this year’s Co-production Week, launching next Monday, 29 June. 

The central test of reform is not whether structures appear coherent from the centre, but whether people experience care fairly in practice. Whether they can access support when they need it. Whether they are treated with dignity and respect. And whether care enables them to live well and participate in their communities. 

That is ultimately the promise contained within the Care Act’s wellbeing principle and, more recently, within Social Care Future’s powerful articulation of what social care should make possible: “gloriously ordinary lives”. 

Many of the stories I heard as Care Minister remain recognisable today: people struggling to navigate services, families carrying too much alone, and support arriving too late. What has changed is that we now have stronger language, better evidence and more developed practice around lived experience. What has not changed enough is the consistency with which those insights shape the system. 

I have become increasingly convinced that this is the right way to think about reform. Not primarily as a debate about organisational form, but as a question about the conditions required for people to live decent, connected and meaningful lives. 

The work ahead 

That requires policy. It requires funding. It requires political commitment. 

The possibility of renewed political leadership on social care should therefore be welcomed. It may create the clearest opening in many years to move from repeated diagnosis towards sustained reform. 

But the lesson of the last decade is that an opening is only the beginning. Progress will depend on whether political ambition is matched by a clear account of what reform is for, honest choices about funding and responsibility, credible sequencing, and institutions capable of supporting learning, improvement and implementation over time. 

After nine years as Chair of SCIE, I leave more convinced than ever that reform is possible. But I am also more aware that progress depends less on moments of declaration than on whether systems develop the capacity to learn, adapt and sustain change. 

Another lost decade will not be avoided by diagnosis alone. The opportunity now emerging should be seized. Its legacy will be determined not simply by the strength of political commitment, but by whether we build the capacity to turn reform into better lives — and to sustain it beyond any one political moment.