FEATURE
ADESIGN MOMENT FOR SOCIAL CARE
England may be approaching a rare opportunity to redesign adult social care. Success will depend on how the sector responds, says Paul Burstow, Chair of the Board at the Social Care Institute of Excellence (SCIE).
Adult social care in England has never had a clear national settlement. Unlike the NHS or other parts of the welfare state, it developed incrementally rather than through a single moment of design.
Louise Casey’s speech at the Nuffield Trust Summit suggests that the country may be approaching such a moment now. Drawing on the first year of work by the Casey Commission, she described a system shaped by decades of partial reform but never fully aligned around purpose, responsibility or funding.
That may sound familiar. The need for reform has been widely recognised for many years. What feels different is that the conversation may now be shiſting from whether reform is needed to how it might realistically be achieved.
Two developments help explain why this moment may matter. The first is the government’s move towards a Fair Pay Agreement for the social care workforce. The second is the Casey Commission’s examination of the system as a whole.
Neither guarantees reform. But together they create a rare opportunity to revisit the design of the system itself.
REFORM IN STAGES
Adult social care in England was never designed in the way the NHS or other parts of the welfare state were aſter the Second World War. Instead, it evolved gradually through a series of partial reforms.
The National Assistance Act 1948 replaced the Poor Law framework but retained many of its underlying assumptions. Social care remained largely a safety net, with access shaped by means-testing and by local interpretation of eligibility. Over time, the legal framework became increasingly fragmented as new duties and powers were added through successive pieces of legislation.
A more coherent framework did not emerge until the Law Commission’s review of adult social care law, published in 2011. Many of its recommendations were implemented through the Care Act 2014, which consolidated decades of legislation into a single statute and placed the promotion of individual wellbeing at the centre of the system.
The Care Act created a framework that is more adaptable than is sometimes recognised. In effect, it operates like a balloon: the structure holds whether it is lightly inflated or filled more fully. The Act can support the constrained system that exists today, but it could equally accommodate a more ambitious settlement should government choose to expand entitlement, investment or prevention.
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The legislation, therefore, provides the architecture for reform, even if the system operating within it remains limited.
Yet none of these reforms fully resolved the relationships between the system’s key components: funding, workforce sustainability, entitlement, prevention and the balance of responsibility between national and local government.
Nor did they address the structural imbalance between health and social care. The NHS remains the dominant institution in the wider system. Part of that imbalance reflects scale and funding. But part of it reflects visibility. The NHS is a nationally recognised public institution, while social care is experienced as a complex set of local services whose boundaries and responsibilities are often unclear. The result is a system with strong statutory principles but persistent structural tensions.
The Casey Commission offers an opportunity to revisit those relationships. Not necessarily to produce an immediate comprehensive settlement, but to clarify how the system’s different parts should align.
THE REFORM WE ALMOST HAD
This is not the first time social care has come close to structural reform. In 2011, the Dilnot Commission proposed a cap on lifetime care costs. The proposal was not radical. It did not create a National Care Service or fully collectivise funding. But it would have changed the system in one important way: it would have made the state’s role more visible.
Care accounts would have tracked individuals’ progress towards the cap. Self-funders would have come into earlier contact with local authorities. The means test and the public safety net
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