For years, the debate about social care reform has been dominated by the question of who pays for it. That is understandable. The costs can be substantial and unpredictable, placing enormous strain on individuals and families. But people need to know what support they can count on and how much control they will have over it.
As care minister, I established the Dilnot Commission and began the work that led to the Care Act 2014. A cap on eligible lifetime care costs was legislated for but never implemented. While the act gave wellbeing, prevention and personal control a statutory footing, people’s experiences of care still too often falls short.
Labour’s commitment to free personal care for older people is an important step towards greater financial security. Its proposed National Care Service must now address five key questions.
- What kind of care are we building?
Much home care is still commissioned as short visits for specified tasks. Reliable personal care matters, but a rigid timetable can leave someone unable to get to work, collect a child or see friends. Making personal care free could reinforce a narrow understanding of what social care is for: help with washing and dressing may be free while support to participate in ordinary life remains chargeable. We could end up funding more generously the very model the Care Act sought to change.
People need a genuine say in what support achieves, who provides it, when it happens and how their care budget is used. An accessible bathroom can enable independence; rehabilitation can restore skills. Voice-controlled equipment can make a home easier to manage, communication aids can help people express choices and digital tools can sustain relationships. Technology can reduce paperwork and travel for workers too. Its value lies in what people can do and decide, not just hours saved.
These changes need investment and evidence. They must not justify withdrawing wanted human contact or expecting relatives to fill gaps. Better care may initially cost more, especially where needs have gone unmet.
- Who carries the costs?
Dilnot sought a fairer sharing of care costs and risks between individuals and the state. Alongside a cap on unpredictable lifetime care costs, the Commission proposed a more generous means test and greater protection for people whose care needs began earlier in life. Free personal care would tackle everyday charges differently, but the two approaches need not be alternatives. The detail of what qualifies for free care remains to be settled, while accommodation and living costs in care homes would remain chargeable. The question is how the different protections fit together to provide a fair and dependable settlement.
Disability can also turn an ordinary expense into an unavoidable additional burden. Labour has understandably put older people first. Yet a younger disabled adult may also need support to work, study, raise children and sustain relationships before older age, with little chance to build savings. The Care Act already provides a common framework across adult life. Phasing new protections may be necessary, but ministers should explain how comparable needs will eventually be treated fairly, whatever the age at which they arise.
From April 2030, the government proposes to adjust state pension uprating and use the savings to fund care. That raises questions of fairness between and within generations. So does unpaid care. When a daughter cuts her working hours because support is unavailable, the cost appears in lost earnings, pension savings and independence. The public should know which risks taxpayers will share, what people may reasonably contribute and what families may choose, rather than be obliged, to provide.
- Where will the workers come from?
Deliverability is the next test. Skills for Care, a planning body for adult social care in England, records care vacancies falling to 96,000, but also notes slower workforce growth and declining international recruitment. Its demographic model suggests we will need 410,000 additional social care posts by 2040.
The government says the National Care Service will be introduced from the next parliament, in phases, as funding, workers and provider capacity grow. But phasing is not a workforce plan. Without a credible assessment of labour supply and ways to expand and reshape services, a stronger entitlement may leave people with no better prospect of receiving support.
- How will contracts change?
Better pay, pensions, secure hours and training are essential. Skills for Care finds lower turnover where employment conditions are favourable, yet 44 per cent of care workers in home-care services are on zero-hours contracts. Some value that flexibility, but council funding and commissioning help determine whether providers can offer stable jobs and reliable support. The planned Fair Pay Agreement must be backed by sustainable council fees and provider funding. Nor should ministers assume that technology and prevention will remove the need for substantial recruitment.
- Who is accountable?
Finally, who is answerable when promised care is unavailable? Councils already have duties to meet eligible needs in defined circumstances and powers to respond urgently. A finding months later will not help someone whose care breaks down tonight. Councils should assess immediate risk, arrange interim support where necessary and explain when adequate care will resume.
When shortages persist across areas, national decisions on funding, workforce and provider markets may be responsible. A National Care Service should identify those patterns and require government to address their causes. That need not mean Whitehall managing local services. But a national promise cannot become a local problem when it proves difficult to deliver. Otherwise, ministers could take credit for a new entitlement while councils manage the failures and families bear the consequences.
Louise Casey's Independent Commission on Adult Social Care, due to publish its report next year, can help settle these choices. Before each phase, ministers should say who is covered, what changes, whether workers and providers are ready and who must act if care fails. Parliament and the public should be able to test the plan before the promise takes effect.
