A ‘radically realistic’ vision for adult social care

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There has been a collective failure to deliver reform of adult social care in England for at least two decades. It has left a system struggling with a series of problems: an overly-stringent means test; catastrophic costs; unmet need; patchy care quality; poor workforce pay and conditions; a fragile provider market; disjointed care; and a ‘postcode lottery’ of access.  


Though there have been notable steps forward, most obviously the Care Act 2014, England remains without coherent reform. Governments have increasingly recognised the problems in adult social care but none has been able to combine a clear vision for social care with the practical reforms and funding required to bring it to life. 

If that depressing cycle is to end, it is essential to begin with a clear vision of what social care is intended to achieve, and the measures needed to implement it. The government plans to set out such a vision in its upcoming White Paper, which will develop the reforms it has already outlined. This needs to spell out the real potential value of social care – to people who may need to draw on it, to their families and carers, and to those working in it – and accept that this value cannot be consistently delivered while problems persist. 

This long read outlines what evidence says should be in that vision. We have resisted the temptation to create a vision of a perfect social care system because this too often creates expectations that cannot realistically be met. In policy, it may sometimes be worthwhile to think the unthinkable but there is no value in arguing for the undoable. What is needed instead is an ambitious but attainable vision for the social care system.

This then is a ‘radically realistic’ vision for adult social care. ‘Radical’ because it involves significant change and improvement that would mean many more people receiving better adult social care. ‘Realistic’ because it does not rely on wide changes to be implemented in society; it doesn’t expect more of individuals, families or communities (though it does acknowledge and draw heavily on them), and it requires no structural overhaul of how social care is commissioned or delivered.

Though this vision will immediately precede the current government’s planned White Paper, it is, nonetheless, a vision that any government, of any political persuasion, could buy into and begin to build. By limiting the degree of change required it reduces the time and cost of implementation, and it requires no fundamental reform of fiscal policy to raise the money (as would, for example, a move towards a social insurance model).  Movement towards it could begin quickly and progress at pace. While it would require more money to be spent on adult social care, the amounts of money involved are more than affordable for a wealthy nation.

The current system in England fails to deliver consistently on all these principles, yet that reflects a lack of policy follow-through and investment by successive governments rather than the fundamental impossibility of delivering them. 


The right services are available, in the right place

Availability means having an affordable supply of care that meets demand, and that care should be of the type that people most value, in the places that they most want it. It fundamentally requires a vibrant and dynamiccare market, with a wide range of services catering for different needs and ambitions. It is what a properly functioning social care market should provide, yet the current market fails to deliver. This contributes to a situation in which 1.5 million older people do not have their care needs fully met. 

For most people, the right place means in (or close to) their ‘home’ and ‘neighbourhood’. There is overwhelming evidence that people want to be supported to be independent in their own homes. This applies to working-age adults with disabilities as well as to older people: having your own ‘front door’ is key for many people who draw on social care. 

It is however important to qualify both the idea of ‘independence’ and ‘home’. Everyone is reliant, to one extent or another, on other people – people are ‘interdependent’ rather than fully independent. And the idea of ‘home’ may have to change with time and circumstance so a setting like a care home, a supported-living apartment or an extra-care unit must be able to be seen as a ‘home’ just as much as an owned or rented flat or house. 

Each of these settings has, in turn, to be embedded in a neighbourhood and community, within a network of family and/or other relationships and of local services, for it to be meaningful. Without this, ‘independence’ can easily mean in practice ‘isolation’. So we need to do more to support and empower unpaid carers – typically family members – who provide millions of hours of care each year so that people can stay living within their own homes, and harness the support of communities to ensure people stay connected and build mechanisms to ensure older and disabled people are able to work, volunteer and engage with their wider communities. Together, carers and communities put the ‘social’ into ‘social care’ and ensure that the strengths and assets of individuals and communities are recognised and appreciated.  

People also need these services to be integrated around them, to feel as though they are being supported by one service rather than many disparate organisations and people. This puts a heavy onus on organisations providing care to work together effectively for the benefit of the individual.


All care is personal to the needs, wants and ambitions of those who are drawing on it 

Personalisation has been a core objective of adult social care public policy since at least 2007, when ‘Putting people first’ – co-signed by national and local government, providers and commissioners – set out the aims of a ‘high quality, personalised system which offers people the highest standards of professional expertise, care, dignity, maximum control and self determination.’  

Underpinning personalisation is ‘choice’: to be able to find the care and support that best meets people’s needs rather than having to use the only service available. 

The 2014 Care Act set out to embed personalisation in social care but most accept that this ambition remains unfulfilled, a victim of both the strains of under-funding and the failure of the adult social care system to genuinely embrace its goals. However well-intentioned, consultation and engagement do not always involve full and equal participation – genuine co-production – alongside people who use services. 

However, it is not just in publicly funded care that the care is not meeting the expectations of its users. Consumer power in the self-funded market is weak as self-funders struggle to get information and have limited ability to change services, especially in care homes, for example. In 2017, the Competition and Markets Authority found that ‘those requiring care need greater support in choosing a care home and greater protections when they are residents’. 

Reform of social care therefore requires a redrawing of the power imbalance between users (whether publicly funded or self-funded), commissioners and providers. In designing and delivering services, we need to start from the basis that ‘those best-placed to understand what they need, what is working and what could be improved are the people using the services’. 

This means ensuring that   people using services have the levers to exercise control. People first need the information and support to make good choices; second, the right to make decisions; and finally, the individual and collective ability to challenge the poor services or decisions they do not agree with. 

With these levers in place, the market for social care will become a more reliable and effective mechanism for meeting the needs, wants and ambitions of people who use it. 


All care is high quality, and delivered by sufficient, properly trained staff, fairly paid for their work 

As we have observed elsewhere, the term ‘quality’ covers a wide range of perceived issues from concern about 15-minute care visits in home care to fundamental issues about the model of delivery itself, including reliance on institutional care and a lack of choice and control for service users. In that sense, all the sections in this long read are about ‘quality’. 

Nonetheless, measures to improve the quality of care should fundamentally involve two core elements: regulation and support to drive improvement in service delivery; and measures to increase the number of social care staff and properly train and develop them. These two issues are heavily interlinked: good-quality care simply cannot be delivered without the right staff with the right skills. 

Good management of care services is critical to quality (the lack of a registered manager is a key indicator of trouble for a care service) and will involve core management abilities alongside compassionate and inclusive leadership, and building the skills to listen more effectively to staff, service users and other stakeholders. There is also clear link between quality of care and wider staffing issues. Skills for Care finds that services with lower vacancies and lower turnover have higher Care Quality Commission (CQC) ratings, and those with more staff and higher pay also have higher ratings. Yet attracting and retaining a committed and skilled workforce is arguably the biggest challenge facing adult social care. Unless a service – and the wider system – can solve that problem, it will struggle. A wider strategy for recruiting, training, developing and retaining the increasing numbers of staff required to meet the population's needs is therefore essential. Better pay must be a cornerstone of any strategy because the evidence suggests social care will otherwise not be able to compete with other sectors to recruit. 

Giving users of care services the levers to challenge poor care and decisions, as described in the previous section, will help drive up quality but it needs to be supported by a process to benchmark care and encourage and support providers to improve. Ratings from the CQC suggests that overall quality of social care services is in fact good, with 85 per cent of services rated either ‘good’ or ‘outstanding’ (and the number of ‘outstanding’ services has increased more than ten-fold from just 77 in 2016). We should support more services to excel, while also tackling those that consistently fail to improve.  


Everyone can get the care and support they need to live a comfortable and independent life, with individuals contributing to the costs according to their income and assets 

This principle draws on the definition of adult social care created by Think Local, Act Personal partnership: ‘help that you need, such as personal care or practical assistance, to live your life as comfortably and independently as possible, because of age, illness or disability’.

This definition crucially recognises that adult social care is used by many different types of people, for a wide variety of reasons and with differences in expectation of outcomes. A vision for social care needs to be appropriate for everyone using adult social care– whether that be older people, disabled working-age adults, people with learning disabilities or those with mental health problems – and not just for one group.

The key question to be asked around eligibility is: who should receive publicly funded care and support? In answering this question, it is always tempting to start with a blank sheet of paper and work from there – why not, for example, replace the system in England with the free personal care model in Scotland, a social insurance model like that in Germany and France, or near-universal access, as in Denmark? Yet most countries in practice use some combination of four different approaches – free access, a means test, subsidy and a cap on costs – to decide who gets publicly funded adult social care. All these levers are available in England already and in combination they are highly flexible: it is perfectly possible, for example, to introduce free personal care using a means-tested system (by making the means test so generous for home care services that everyone qualifies for it). It makes sense, then to focus on the specific combination of levers to determine who gets access to publicly funded care rather than look for new levers to use.

Retaining but reforming the means test, including by the introduction of ‘cap’ on care costs, ensures there is better ‘risk pooling’ so that individuals who need more care do not end up paying very large costs individually. Instead, the costs of care are spread out more evenly across the population.

Means testing also allows retention of a key principle developed in earlier reforms that enjoys wide public support: the idea of a balance of responsibilities – a ‘partnership’ between the individual and the state - in paying for adult social care. Essentially this approach recognises that while the state should be responsible for a significant share of adult social care costs, individuals do have a responsibility too. That responsibility will be heavily tempered by capacity and circumstance – adults who develop a disability at birth or in childhood should not, for example, have to contribute from their assets towards their care costs in adulthood.

So it is important to accept that, while there are lessons to be learnt from other countries, none has a perfect social care funding system that England should aim to adopt wholesale. Instead, it is more pragmatic and efficient to reform the existing means-tested system in England to meet the goals set out in this vision, rather than to attempt to build a new system from scratch.  

Putting the vision into practice

The measures set out below are not a fully comprehensive programme to reform adult social care but nonetheless do set out some of main measures that will be needed to implement a vision of wider availability of services, greater personalisation, higher quality and greater eligibility to care. 

Ensuring the social care market works more effectively is key to increased choice and service availability for service users. Since most adult social care is publicly funded, local authorities play a key role in this, partly by using their commissioning power more effectively and partly by, as far as possible, devolving that power to service users. This means a requirement both for sufficient funding to ‘fuel’ the market and  for support for local authorities to put much greater emphasis on their duty to shape that market.

For this to happen, greater certainty is needed for providers about future demands, price and cost, to encourage investment and innovation. It points to the need for greater certainty about future levels of public funding too, so providers can look beyond the most immediate short-term survival towards innovation. It will also allow investment in technology, such as digitisation of care records and monitoring, that has the potential to help improve quality in the sector. 

A starting point for better availability of care at home is better homes. Housing in England is some of the oldest in the world. Action to improve the quality of stock is needed and, in particular, to ensure that it is easy for people to access simple aids and adaptations. 

Services need to be configured around homes so a home-and-neighbourhood-first policy fundamentally requires a strong, vibrant home care and live-in care sector.  That in turn requires more realistic fee rates for publicly funded home care. Again, funding local authorities to pay sustainable rates is essential. A similar situation affects care homes. The government’s fair-price-for-care initiative is intended to address this but as yet there is no detail of how it would work. 

Covid-19 has shown that there is also untapped potential for community support and mutual aid. Local authorities are well placed to support and nurture this, and the voluntary sector has a critical role in delivering it. 

Supporting people at home will often rely heavily on family carers. It is important to see carers and formal services as supporting, rather than replacing one another, and for support to be available to allow both individuals and their carers to remain independent, healthy and active in their community and wider society. 

There also needs to be s greater choice of what counts as ‘home’. There are gaps where the adult social care market does not appear to be meeting the needs and demands of people. One example is housing with care, where the UK has around a tenth of the provision of some other countries. Planning policy needs to address this gap and better advice and information is required to encourage people to think earlier about their future housing needs.

Partnership and collaborative working is necessary when arranging care around an individual. Though much of this will take place at neighbourhood or place level, integrated care systems (ICSs) will also be critical to this new way of working. They provide opportunities to improve people’s outcomes and experiences of care, particularly for those in contact with different services. However, what is made of these opportunities will depend on implementation. In particular, there is a need to ensure that local government generally, and social care specifically, has an opportunity to make its voice heard within ICSs. 

A greatly improved advice and information offer, provided as part of the offer on eligibility described earlier, is essential to ensuring that people can better understand, assess and exercise their choices. The introduction of the cap on care costs (described below), which will involve people contacting their local authorities to begin logging their care costs, offers an ideal gateway to this service. 

Personalisation also depends on availability of services: choice without options is no choice at all. However, for a market to work effectively it requires not just measures to improve individual choice and control but also collective measures to oversee and, if necessary, regulate that market. It also requires mechanisms by which individual users of services can seek redress. There are therefore good arguments for strengthening the hand of the ombudsman, which currently enjoys limited awareness of its functions, particularly among self-funders. 

For people drawing on publicly funded social care, there need to be more effective ways of holding commissioners and providers of service to account. There is therefore a good case for having at least one strong user-led organisation – one run and controlled by the people it serves, for example, people with disabilities or older people – operating in every local authority. 

The Equalities and Human Rights Commission is currently investigating the handling of social care complaints by local authorities. The results of the inquiry may lead to important recommendations about specific rights and local authority processes. More broadly, without long-term, sustainable funding that allows local authorities to pay decent fee levels and explore new service models, councils will struggle to deliver the degree of personalisation that is needed. 

There are approaches that local authorities can take that are less dependent on funding. One way in which they can shape the market for care services (see section above) is by giving users more power to decide which services they themselves want. This will help develop services that local authorities may not themselves have chosen to commission. 

Direct payments can be life changing for many people using services and should be a key offer, as intended by the 2014 Care Act. Oversight of council approaches to direct payments, if necessary through the new CQC assurance power, would be a logical step and should include not just how many people receive direct payments but – since many users complain of over-judicious monitoring of their use  – how local authorities audit and police them.  

Direct payments will not work for everyone, however, so there is also a need to explore and promote other methods of personalisation of care such as individual service funds, which can offer similar degree of choice and control but without as much demand on the service user. 

In quality improvement, the focus should be on getting all services to be reliably ‘good’. A critical factor is providing support to help providers improve - there is far less support for struggling care services than, for example, struggling NHS services. The CQC has a role to play as regulator – and its new strategic promise of doing more to drive improvements is welcome – but it is local authorities that are best placed to play this role consistently, because they are in regular contact with providers and, indeed, are often commissioning services from them. 

The Social Care Institute for Excellence identifies a number of challenges that local authorities face in driving improvements locally, including those around commissioning, data, management and leadership, and systems. It is clear that local authorities will need more support in these areas, within the context of stable funding, to improve quality. Provider associations can be critical allies in this work. Meanwhile, more care services should be supported and encouraged to step up to be outstanding. Support should include a dedicated fund to facilitate innovation and the spread of best practice across social care.

None of this will make the required difference without a stable, skilled workforce. Though it is not the only factor, better pay is critical to achieving this. Two factors need to be addressed to improve pay for care workers: lack of funding and uncertainty about the best mechanism by which pay of care workers – employed by 17,700 mainly independent organisations – can be uplifted. 

Registered managers are essential to care services, yet their vacancy rate is the highest of any job role in adult social care – more than 11 per cent. There needs to be greater focus on recruiting registered managers. Proposals to create a fast-track entry scheme for them, like Teach First, are welcome. 

Funding is dependent upon a realistic settlement for local government. The three -year 2021 Spending Round gives local government an increased spending power of 3 per cent a year, but this falls to only 1.8 per cent when new duties are taken into account, which is insufficient to meet both the increase in need and better reward care workers. Extra money will need to be found for this. If it is, the most effective immediate way of improving pay is through building uplift into commissioning practice by local authorities. The new CQC assurance powers in the Health and Care Bill offer an opportunity to monitor and assess the extent to which local authorities use their powers to improve the wages of staff employed by the providers they commission. 

However, while pay is critical, it is not the only factor. Skills for Care identifies that staff turnover in the sector is also affected by factors such as flexibility of employment, training and development, recognition and support for wider wellbeing. There is scope to do far more and, while it is encouraging that the government has committed £500 million over three years to support the sector and its workforce in these areas, this should be seen as an initial investment rather than a completed task

The starting point for increasing eligibility is a far clearer and wider non-means tested offer. This is critical to ensure that far more people feel that they get something out of the social care system and feel a sense of ownership of it. This offer should include much wider basic and preventive services, such as handyperson services and home aids/adaptations, and services tackling loneliness and isolation; significant expansion of advice and information for all users, whether publicly funded or self-funding; and an expanded reablement offer. 

The principle of a ‘partnership approach’ to social care funding means that most people would continue to contribute towards the cost of their care, and reform of the means test is therefore essential. The government already plans to introduce two measures to widen the scope of the means-tested system.  The planned extension of the current means test thresholds will see the upper threshold increased to £100,000 and the lower threshold reduced to £20,000. This is a good move but should be seen as only one step: the 75,000 people who will benefit are a relatively small number when compared to the 1.5 million older people who experience some degree of unmet need

A means-tested system inevitably involves some people paying for their own care so an essential additional element of a fair system – one that includes more ‘risk pooling’ – is a way of limiting the total liability of those people. The government’s plans to introduce a cap on care costs, set at £86,000, are welcome and will provide ‘peace-of-mind’ benefits to many. However, the cap is too high and will only directly benefit around 75,000 more people – we would prefer it set in line with the original Dilnot recommendation of £50,000. The government should also abandon its plans to make the social care cap less generous for people with low to moderate levels of wealth.  

It is also important not to miss out on the opportunity offered by introducing the cap. The contact that people have with local authorities when they initially register for the cap presents an ideal opportunity to offer the increased universal offer that is the cornerstone of reform. 

In addition to these headline measures, reform must also address raising of the minimum income guarantee. Currently, people using home care services are charged from their income and can be left only with a ‘minimum’ amount of money to live on. In the past, many local authorities set more generous levels that the statutory minimum but in recent years most have reverted to the lowest possible level. This particularly affects working-age adults on disabilities. Raising the minimum income guarantee would be an important recognition that adult social care should be fair for all ages and groups. 

It will be important that all these changes are future proofed by ensuring a regular uplift in line with inflation. In addition, for the needs test to operate as originally envisaged by the Care Act, it is essential that the adult social care system is properly funded. Without this, reform of social care will be reform in name only. 

Linking it all together – implications for national policy

Making the vision happen will require working across a broad partnership of different organisations, and some organisations will need to recognise there is need to fulfil different or expanded roles to lead and support the sector successfully. We focus here on examples of the types of national role that will need to adapt, rather than attempt a comprehensive analysis. 

The Department for Health and Social Care has traditionally viewed its role regarding adult social care as setting the legal framework for access, the regulatory framework for minimum quality standards and ensuring adequate funds for local authorities to discharge their duties. Beyond this, it has largely left the provider market to face alone significant structural issues such as developing a workforce of the future and investing in people, buildings and technology to improve care. 

The expectation that the market alone can solve these issues fails to recognise that government’s actions have substantial impacts on commissioners and provider’s ability to act themselves, including through the decisions central government makes about the level of funds available for adult social care. Given that the actions of central government determine much about the conditions of the market for social care, there are clear benefits if the Department of Health and Social Care takes on more of a leadership role in which it makes more active policy and implementation interventions across a much wider set of issues, addressing the market failures that its own actions often contribute to, be that with the workforce, improving services, or future investment in the sector. As well as the will to take on this role, it will require more and better data, available much more quickly than it has been in the past. This is a gap that the data measures in the Health and Care Bill aim to fill.         

Recently, central government support for improvement has been limited, with some small amounts of funding provided to the Local Government Association for sector-led improvement, and to the Social Care Institute for Excellence. But the level of funding has been marginal relative to the scale of the issue. As set out earlier, there is need for a much more active role for central and local government in supporting providers to improve, and it is clearly in the public interest to support a market that provides most of its services to the public sector. 

But this is not just about more funding for improvement, it’s also about how improvement happens. For example, in The King’s Fund report into social care leadership, we noted that supporting user groups and associations of providers pays dividends locally: ‘Some of the most encouraging accounts… were from user groups… and from associations of care homes and/or home care agencies closely engaged with their local authorities.’

A clear national-to-local improvement framework for both support and challenge to providers and commissioners is needed, with consequences for those which either don’t engage in improvement or fail to be able to demonstrate improvement.   

In addition to the Department of Health and Social Care taking a more active role, the sector would benefit from a more unified voice than that provided by the current myriad of provider and other representative bodies, and the role of the Association of Directors of Adult Social Services, in particular, could be strengthened.

These strengthened national roles are not intended to replace the key importance of local leadership and action by local authorities, providers and organisations engaging with people who draw on care and support. But decisions and action taken nationally set critical aspects of the environment in which social care locally can flourish or not, and as such a stronger set of national actions is required. These national roles should be closely connected to local insight and intelligence about the social care sector and the needs of people, and see their roles in a way that is local first, with national roles supporting and enabling local organisations to deliver. 


The government has promised to ‘fix’ adult social care. We argue here that to do this successfully it first needs to fix its sights on a picture of what a good system looks like, be clear about that in its White Paper and then set out the measures to achieve it. We set out here a radical but realistic approach to reforming the system. It would not be an ultimate ‘end state’ for social care but would nonetheless offer England a huge improvement on the current approach, which could (and should) be built on in the future. 

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Christopher Johns

Bath Institute for Rheumatic Diseases
Comment date
27 November 2021

My comments are more in a personal career based capacity although my role bridges health and social care through the work of the Charity.
I have followed the debates about Social Care policy and practice throughout a 45 year career in health and social care. I have been a practitioner, manager, leader, regulator ,academic and indirect user of services. Therefore my thoughts encompass viewing social care from a range of perspectives.
I fundamentally believe that the continued market approach, introduced in the early 1990s, will not ‘fix’ social care. It is noteworthy that the NHS and Government have at last accepted that the competitive market approach within the health service did not deliver improved outcomes for patients and have moved to a more collaborative model.
My leadership experience as a board member within the NHS confirms the negative aspects of the market competitiveness of so many years which had the result of limited creative service development in some areas real challenges in staff recruitment and retention by too much focus on contract costs rather than qualitative outcomes and patient benefit. My earlier leadership within both local authority social services in collaboration with the NHS ( through joint finance monies) delivered a variety of local person centred services in home care, very sheltered housing and residential care. This was alongside the growth of the not for profit and private residential care. These service developments provided real choice to users and increased options in support of the NHS at point of discharge. Some aspects were researched by external academics and the findings supported the service investments.
Staff development programmes leading to real external qualifications enabled both recruitment and retention within a difficult recruitment market at the time.
Experience as a Regional Inspector of the Department of Health Social Services Inspectorate enabled a strong translation link between the Centre and legislative based policy and local implementation and a broader inspection and joint review( with the regional office of the NHS) of each local and health authority area. This was much broader and policy linked than the role of CQC. This encompassed working collaboratively with diverse organisations such as the then ADSS now ADAS, private provider organisations of both home care and residential and nursing care which informed both policy development and review.
My viewing of the current landscape provides my concerns about the negative forces and big gaps which exist about the future of Social Care. I cannot see how integration with pooled budgets will be achieved when the market forces and spot contract culture which exists continue to push individual services apart rather look for opportunities for collaboration leading to more person centred service design, locally deliver through a professionally trained career focussed workforce rather than paid at basic retail part time roles.
My comments are part of a real reflection about a major service within the fabric of society and hoping that they can contribute to an honest debate about maximising the opportunities for the future shape and development of Social Care.
I am more than happy to contribute further if helpful.

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