Social care commissions: looking back to move forward

Adult social care is an essential public service, improving the lives of older people, disabled people and their carers. But England’s care system is in desperate need of reform and investment. Many people go without care they need and reliance on unpaid carers is high, partly since only the very poorest with the most significant care needs are entitled to any state support with care costs. Care work is underpaid and undervalued and there are chronic staffing problems.

Successive governments have promised social care reform but failed to enact meaningful change. Keir Starmer’s new Labour government has promised a National Care Service. So far, the government has provided little detail on what this might entail, when it might be introduced, or how it might be funded. It has also announced that it will not go ahead with the ‘Dilnot’ reforms to the charging system for social care, introduced in legislation a decade ago but repeatedly delayed. But the government is reviewing options for establishing cross-party consensus to inform a 10-year plan for social care, with reports it is planning a Royal Commission to do this.

Over the years, numerous commissions and inquiries on social care have offered proposals to tackle the problems facing the sector. This analysis looks back at government and major independent commissions on social care, government white papers and relevant select committee inquiries since 1997. It does so to understand what can be learnt today from the approaches and content of these previous reviews. Box 1 provides further detail on the scope of our analysis.

We begin by summarising previous reviews of social care policy and their range of approaches to developing reform proposals. We then set out the key proposals for reform made in previous reviews, highlighting notable gaps and areas of consensus, and evidence on their implementation. We conclude with the key takeaways for the current government as it develops its social care policy.

We identified 25 relevant social care commissions, select committee inquiries and white papers since 1997. Table 1 provides a summary of these reports, their central themes – for instance, whether their reform proposals mainly regard social care regulation or funding – and related legislation. A full list of documents included in our analysis can be found at the end.

Commissions are one-off committees with a chair-led group of commissioners advising on a particular policy area. Previous social care commissions include a Royal Commission appointed by government in the late 1990s, a government commission in the early 2010s and three independently commissioned reviews. They all reported within 15 months. These commissions ranged in size and scope: the Royal Commission had 12 commissioners, including the chair, whereas the Dilnot Commission had three; the Archbishops’ Commission looked at the broad ‘vision’ for social care, while others have had tighter terms of reference. 

They have taken various approaches to developing proposals but most drew on calls for evidence, commissioned research (to model future care costs or summarise public opinion research on social care, for instance) and existing evidence. Most involved some engagement with people with care needs, carers and the wider public: for example, the Royal Commission had a reference group of representative bodies and six public hearings, the Barker Commission drew on a panel of experts by experience and engagement events, and the Archbishops’ Commission included people with care needs and carers as commissioners and held engagement events.

Select committee inquiries bring together cross-party groups of MPs or Lords to examine and advise on a subject. Since 1997, there have been 11 House of Commons committee inquiries and three House of Lords committee inquiries on social care reform. To inform their proposals, select committees usually invite written and oral evidence, and draw on existing evidence.

White papers set out government proposals for future legislation. There were three social care white papers under New Labour, one under the Coalition government and one under the Conservative government. Their proposals have themselves been informed by commissions and parliamentary inquiries. The 2010 and 2012 white papers drew on extensive public engagement through the 'Big Care Debate' and the 'Caring for our future' engagement respectively.

Key proposals by theme

Five policy areas in social care have received particular attention: funding; the charging system; the workforce; approaches to delivering services, and integration with the NHS.

Funding

Government funding for social care is insufficient and insecure. Most commission and committee reports call for a sustained increase in social care funding – sometimes by a specific amount, for example to address unmet need or to restore funding to pre-austerity levels. Elsewhere, reviews recommend the creation of an independent body to determine the funding needed for social care. 

Analysis of potential sources for increasing social care funding is more limited. Some make specific recommendations – for example, Sutherland recommended that free personal care was funded through general taxation and Barker made a number of recommendations, including increasing national insurance contributions for people aged 40 years and older and means-testing winter fuel payments to fund social care. Other reviews set out principles for determining funding sources, such as fairness between generations.

Charging system

Currently, only the poorest in society with the most significant care needs receive any state support towards their social care costs. Most commissions – along with other reviews – have proposed reforms to better protect people against care costs and expand access to publicly funded care.

Charging reform proposals vary in their level of ambition. These range from making the existing system more generous by adjusting the means and needs tests for accessing publicly funded support to introducing universal access to social care, free at the point of use like the NHS. Several reviews propose that only some care should be free, depending on the type of support (for example, free personal care or nursing care) or who needs support (for example, free support for people with ‘critical’ needs or younger adults with care needs). Some have proposed limiting individual care costs by capping either the length of time or the amount that someone pays towards their care before the state steps in.

Often, it is recommended that these reforms are introduced in sequence (with the system becoming more generous over time) or in combination. For example, Dilnot proposed a lifetime cap on individual care costs, an increase to the asset threshold for accessing residential care and free support for people entering adulthood with care needs.

Workforce 

There have long been significant workforce challenges in social care, with high vacancy and turnover rates, limited career structure and progression, and poor terms and conditions. While commissions have largely focused on charging reform and funding, select committees have increasingly focused on the workforce.

Most committees make broad calls for a national strategy to recruit, retain and develop the workforce, often recommending that the government undertake this alongside NHS workforce planning. More specific recommendations largely fall into the following categories: 

• Targeted recruitment action, such as a national recruitment campaign for social care and lowered visa requirements for care workers to ease international recruitment.
• Measures to ‘professionalise’ the workforce, such as registration for care workers and senior care workers, and mandatory training and practice standards for different roles.
• Improvements to terms and conditions, such as aligning pay with the NHS, tackling underpayment, and offering workers more choice of employment contract types.

Service delivery

Older people and disabled people have often had limited choice over their care and support and whether they are supported to live in their own homes. Many reviews since 1997, including government white papers, have proposed national policy changes to support new approaches to care.

Reviews generally support adopting the principles of personalisation, choice and control, prevention, and (latterly) coproduction in organising and delivering care services. The Archbishops' Commission, for instance, sets out that the main principle for reform should be to ensure individuals are at the centre of decision making to shape their own support. Several reviews propose commissioning changes and national investment to support these approaches – for example, to increase the use of direct payments and individual budgets for people with care needs and their families, or to require local authorities to commission preventative services. Reviews have advocated for government to expand certain services, particularly in the community, by providing more home care packages, dementia-specific services and specialised housing options. Another recurrent theme is improving information about services, through national websites or requirements for local authorities to provide information.

Integration with the NHS

The NHS and social care are organised and funded in different ways, impacting people’s care. Most obviously, the NHS is a tax-funded system with services available to all residents in England, while social care is funded through a mix of public and private sources and access to publicly funded care is constrained. Several commissions and inquiries on social care have set out options to improve coordination and integration with health care services – often to tackle delayed discharges from hospitals into social care or in response to changing care needs as our population ages.

At their most ambitious, reviews propose moving towards a single health and social care system, with a joint budget and single commissioning bodies to plan and purchase local services. Other proposals support coordination between local authorities and NHS bodies, for example by incentivising or mandating pooled budgets, requiring joint workforce planning or expanding shared care records. Recent select committees have also included specific recommendations on the role of social care in integrated care systems – established in 2022 to support health and care collaboration.

Consensus and gaps among previous proposals

These reviews span decades and cross party political lines, but their proposals for reform overlap. Looking at recommendations from the many select committee inquiries on social care, for example, suggests cross-party consensus on the way forward in several areas:

• Set out a comprehensive long-term plan for social care reform, as opposed to tackling different policy questions and problems in silos. Both the timeline for reform and responsibility for delivery across government departments must be clear.
• Provide significant additional funding for local government to invest in social care, taking a more sustainable approach through multi-year settlements.
• Develop a national workforce strategy for social care, including action to improve pay, other employment conditions and career structure.
• Reform the charging system so that more people are eligible for publicly funded social care. Several select committees over the years (in 2010, 2012, 2018, 2020 and 2022) have supported the introduction of a cap on care costs, often in combination with other changes to create a more generous system.

Despite the abundance of analysis, some areas remain relatively underexplored. Relatively few previous reviews have focused, for instance, on improving support for unpaid carers, realising the potential of technology in social care or ensuring equitable access to care services. Important questions remain unaddressed, including about the purpose of social care in our society and how it aligns with other public services or the role of profit and market competition in care. There is no shortage of thinking in many of these policy areas – including by charities, local government leaders, academics, party political organisations and independent thinktanks – but they are conspicuous by their absence in commissions, select committee inquiries and white papers on social care reform.

Implementation of previous proposals

There have been significant challenges implementing proposals made in previous reviews of social care. Recommendations from both government commissions on social care did contribute to some legislative changes. The government did not accept the central recommendation of the Sutherland Commission to introduce free personal care due to its cost. But other proposals did inform changes, such as the establishment of a National Care Standards Commission in 2000 and more free NHS nursing care through the Health and Social Care Act 2001. The Dilnot Commission’s recommendations to cap care costs and extend the means test were introduced as part of the Care Act 2014, but implementation was delayed because of the cost. The Conservative government revived a version of these reforms after the COVID-19 pandemic, but it later diverted the funding for reform into system delivery and delayed them till after the next general election. After Labour won the election, it announced that it would not go ahead with the reforms because of costs.

Government proposals from white papers on social care have not necessarily led to change. For instance, the Health and Social Care Act 2001 extended the scope of direct payments from local authorities to individuals (so they can purchase their own support services), as promised by New Labour. But a mix of factors, including funding constraints and engagement from care professionals, meant that uptake of direct payments remained low. The Coalition government’s 2012 white paper formed the basis of the most significant legislative overhaul of social care – the Care Act 2014. But the ambitions of the Act to establish a clearer and fairer system of care and improve people's independence and wellbeing have largely been undermined by the approach to funding social care.

Some government proposals have not been implemented at all. In 2010, Labour set out proposals to phase in a universal National Care Service and began by legislating for free personal care in the Personal Care at Home Act. But plans were scrapped when the party lost the general election later that year and the Act was later repealed. The 2021 white paper set out a 10-year vision for social care funded through a health and social care levy, alongside the resuscitated Dilnot reforms. The levy was later scrapped in the face of rising inflation, reform plans were watered down, and the National Audit Office found little sign of progress after 2 years. 

The past 27 years have seen two government commissions, one shorter government-commissioned review, three independent commissions, five white papers and 14 parliamentary committee inquiries on social care reform. And there have been countless other policy papers and reports on social care. The new government is reportedly considering a new commission on social care reform.

Previous reviews of social care policy have had limited impact. Our analysis has illustrated how little progress has been made implementing the abundance of reform proposals – including from major reviews commissioned by government. Many of the problems in social care that existed at the turn of the century persist today. More broadly, available evidence suggests that government commissions generally have limited influence on national policy.

The government has emphasised that it wants to establish cross-party consensus on social care reform. A new commission may not be needed to do this. Drawing on previous cross-party committee inquiries into social care reform, we have pointed to some important areas where consensus already exists, including on taking a comprehensive, long-term approach to funding and reforming the care system. With a large majority won on a manifesto promising a National Care Service, this government has a strong mandate to reform social care. And an existing legislative framework for reform exists in the Care Act 2014, developed by the two other main political parties.

The government needs to be clear about what it would want a new review to achieve. In this context, any new work should: 

1. Avoid retreading old ground. Nearly all previous commissions on social care focused primarily on the charging system – an area where the options for reform are now clear. The Dilnot reforms even made it onto the statute books. But we have repeatedly seen politicians row back on promises to ensure that more people are eligible for publicly funded social care on the grounds that it is too costly. What is needed is not more analysis but sustained political will and commitment to funding a fairer and more generous social care system. Not repeating previous work may also help the government progress with necessary speed, given the urgent need for reform.
    
2. Focus on the gaps in previous government proposals. A preoccupation with charging reform has left other vital questions unanswered. We have identified some of these, such as options to tackle problems with the care market and support for unpaid carers – but we have also highlighted that there is existing independent analysis of these policy areas for a government review to draw on. Determining a funding source for social care has also been outside the remit of previous government commissions. While decisions on how to raise revenue and the right level of funding are ultimately down to the Treasury, these will be important questions for government in the context of current financial constraints.
    
3. Consider underused approaches to developing reform plans. For example, building public support for a long-term vision for social care was key to successful reforms in Japan and Germany, and it is not clear that previous reform proposals in England have commanded enough public support. There has been little public pressure when politicians have delayed reform – by contrast, government proposals for measures to fund social care led to significant public debate in 2010 and in 2017, before being dropped. Low public awareness and understanding of social care – including about who is responsible for paying for it – remain significant barriers to reform. Something akin to the public engagement exercise to shape the government's 10-Year Health Plan could help stimulate public debate on social care. 
    
4. Look at the care system in the round. The two previous government commissions were requested to focus on just a few aspects of social care policy. But many of the challenges in social care are interconnected. For example, increased costs resulting from the new government's plans to improve pay in social care will have implications for self-funders. A new commission or taskforce could aim to bring together existing reform proposals, along with planned workforce reforms, into a clear and comprehensive government-backed plan for the sector.

The government’s plans for social care, however they are developed, cannot come soon enough. There is already a clear policy direction for investment and reform in the NHS – not providing the same for social care will undermine plans to fix the NHS. Any review must be used as an opportunity to promote reform to improve the lives of older people and disabled people, their families and care workers – not an excuse to postpone it. Ultimately, whether a new commission or taskforce succeeds where previous reform attempts have failed will depend largely on political will and committing to providing the long-term investment needed. 

Acknowledgements

We would like to thank colleagues from the Health Foundation for their insights and contributions, in particular Sean Agass, Patrick South and Charles Tallack. Errors or omissions remain the responsibility of the authors alone.