Policy can define direction, but delivery determines whether change takes hold.
11 June 2026
By Paul Burstow, Chair of the Board, SCIE
Core proposition
Reform depends not only on policy, but on the capacity to deliver and sustain change.
Previous attempts at reform have often focused on legislation or funding. They have tended to assume that once a framework is agreed, change will follow. In practice, the experience of social care suggests something different.
Change does not flow automatically from policy. Rather than being centrally directed, it has to be translated into practice — across organisations, professions and places. Within the social care system, that translation is complex, uneven and often contested.
The success of policy reforms depends on the infrastructure, capability and relationships that sit behind the formal system.
The reality of delivery
Adult social care is not delivered by a single organisation, or even by a single part of the public sector. It is delivered through a network of relationships between:
- local authorities
- independent providers
- the workforce
- people who draw on care and their families
Each of these operates under different conditions, with different incentives and constraints.
This matters because reform is experienced through these relationships, not through policy statements. The way services are organised, the way decisions are made, and the way people interact with the system are shaped by these day-to-day dynamics.
This is also where people’s frustration is often felt most sharply. Too often social care is experienced as a set of service transactions, when what people value most is the quality of relationships, continuity, trust and support that enables them to live their lives.
The provider landscape illustrates the point. Social care is delivered by a large number of organisations, operating at different scales, with different business models and varying degrees of financial resilience. Some are large and established. Others are small and locally rooted. All operate within a context of constrained funding and uncertain demand.
Local authorities commission services, but do not directly control how provision is organised or how it responds to changing pressures. Providers, in turn, respond to a combination of funding levels, contractual arrangements, workforce availability and regulatory expectations.
The result is a system that is diverse and adaptive, but also difficult to steer in a consistent way.
The question of a National Care Service
Recent debate has returned to the idea of a National Care Service as a way of addressing fragmentation and bringing greater clarity to the system.
This reflects a central insight emerging from the Casey Commission: that adult social care lacks a clear sense of ownership, accountability and identity. Responsibilities are distributed across multiple organisations, with no single point of leadership. For those who rely on care, this can feel like a system in which no one part is fully in charge.
In that context, the case for a more clearly defined national framework is understandable. A National Care Service could offer:
- greater visibility and public understanding
- clearer lines of accountability
- a more consistent approach to standards and workforce
These are important objectives, and they speak directly to the concerns that have been raised about the current arrangements.
But structure alone does not resolve the underlying conditions that shape how care is delivered.
Even within a more nationally defined system, care would continue to be delivered through:
- a diverse provider landscape
- a workforce facing recruitment and retention pressures
- local systems operating under different constraints
The question is therefore not simply whether to create a National Care Service, but how any national framework would engage with these realities. Without alignment between workforce, funding, commissioning, standards and delivery — and without space for local and provider innovation — structural reform risks reproducing the same patterns in a different institutional form.
Workforce as the foundation
At the centre of this landscape is the workforce.
Social care depends on a large workforce working across a wide range of settings, often in roles that are both demanding and undervalued. Recruitment and retention have been persistent challenges over many years. Turnover remains high in parts of the sector, and vacancies continue to affect service availability. Training and skills development are also challenging within these circumstances.
These are not marginal issues. They shape what is possible in practice. Where workforce capacity is constrained:
- continuity of care is harder to maintain
- services may be reduced or withdrawn
- opportunities for improvement are limited
Workforce pressures also contribute to variation. Areas with more constrained labour markets, or with lower levels of funding, may struggle to recruit and retain staff. This in turn affects access, experience and outcomes.
Workforce conditions therefore sit at the centre of system performance. They are not separate from design. They are part of how the system functions. They are also crucial to raising standards of care and improving outcomes for people.
Commissioning and market shaping
Between policy intent and frontline delivery sits commissioning. Commissioning determines:
- how services are funded
- what outcomes are prioritised
- how providers are supported or constrained.
In principle, commissioning provides a mechanism for aligning resources with need and shaping the development of services over time.
In practice, commissioning operates under significant pressure. Funding constraints, short-term planning horizons and administrative demands can limit the ability to take a longer-term view. In some areas, commissioning capability has been reduced or stretched, making it harder to engage with providers in a strategic way. The emphasis on managing today’s demands limits the scope for investing in prevention and early intervention.
At the same time, commissioning operates within a mixed market. Providers must balance the expectations set through contracts with the realities of financial viability. Decisions about whether to enter or exit a market, invest in services, or develop new approaches to care are shaped by these conditions.
This creates a persistent tension:
- between shaping services around outcomes, especially those that matter most to people who draw on care and support
- sustaining a market that is able to deliver those outcomes.
Reform cannot be implemented without addressing this tension. It is not enough to define what good looks like. The system must also create the conditions in which it is possible to deliver better care.
SCIE’s analysis of our recent national research has demonstrated a strong link between effective neighbourhood‑based commissioning and lower overall commissioned service costs, while improving outcomes, choice and independence. Therefore SCIE has launched a new commissioning product as part of our consultancy offer, designed to help reshape commissioning for better outcomes, stronger communities and long-term financial sustainability. Contact SCIE for more information about this.
Standards, guidance and learning
There is no shortage of knowledge about what good care looks like.
Over many years, work across the sector has developed a substantial body of standards, guidance and evidence. These describe effective practice, set expectations and provide a basis for improvement.
Work led by SCIE on national standards and guidance has demonstrated both what can be achieved in defining a clear account of good care, and the gap that often remains between that clarity and consistent delivery in practice.
The challenge is not defining good care. It is making it consistent. This depends on how knowledge is used in practice:
- whether guidance is accessible and relevant to front-line care
- whether organisations have the capacity to learn and adapt
- whether there is space for reflection and improvement
Standards can play an important role, but only if they are connected to practice. Where they are experienced as external requirements, disconnected from day-to-day realities, they risk becoming compliance exercises. Where they are embedded in practice, supported by leadership and capability, they can support meaningful improvement.
Leadership and culture
Reform is not delivered through structures alone. It depends on leadership.
Leadership in this context is distributed. It includes:
- system leaders working across organisational boundaries
- leaders within provider organisations
- managers responsible for frontline teams
- and those with lived experience shaping services and priorities
Leadership matters because it shapes how the system responds to pressure. It determines how:
- trade-offs are navigated
- priorities are set
- and change is sustained over time
It also shapes organisational culture — how people work together, how decisions are made, and how services respond to uncertainty.
Where leadership is strong, systems are more able to adapt, learn and improve. Where it is weak or fragmented, even well-designed reforms can struggle to take hold.
The role of co-production
A consistent finding from practice is that change is more effective when it is shaped with the people who draw on care.
Co-production is sometimes treated as an additional element of reform. In practice, it is a way of ensuring that services:
- reflect what matters to people
- are usable in everyday life
- and remain responsive over time.
For reform to improve people’s lives, it must be informed by their experience. It is not enough for the system to be coherent in design; it must enable personalised care in practice. That it is why it is central to everything the Social Care Institute of Excellence does.
Bringing it together
These elements — workforce, commissioning, providers, standards and leadership — already exist.
They are not new. Nor are they marginal.
But they are not currently organised as a coherent whole. They are shaped by:
- funding constraints
- institutional boundaries
- differing and competing incentives
- and varying levels of capability
The challenge is not to create entirely new structures, but to align these elements so that they support a shared direction. Reform, in this sense, is not a single act. It is a process of:
- aligning incentives
- building capability
- and sustaining change over time
It requires attention not only to what the system is meant to do, but to how it behaves in practice — and whether that behaviour improves people’s lives.
