Building a National Care Service: Six Essential Pillars
The government’s significant parliamentary majority presents it with a once in a generation opportunity to reform the adult social care system and build a National Care Service which is inherently enabling for the people drawing upon and working in adult social care services.
For decades, governments of various political persuasions have failed to deliver ambitious reform, and the last few years have been no different, with either delays to announced reforms or scaled back ambition.
Demographic changes in our society, growing unmet need and workforce challenges mean this is a policy area which needs an ambitious vision. The Health Foundation estimates that simply to meet the expected growth demand from an ageing population could cost an additional £8.3bn by 2032/33.1 More importantly, the full potential of adult social care to enable people to live life to the full, to unlock economic prosperity and combat social-economic and health inequalities, is a largely untapped resource and one which needs to be at the centre of conversations about reform. Care is the work that makes all other work possible.2
In building a National Care Service, the foundations of which is the ambition of the newly announced Casey Commission, the government should therefore recognise the potential of social care to achieve not only its health mission, but also its missions to kickstart economic growth, break down barriers to opportunity and move towards a net-zero and environmentally sustainable society. Within its health mission, a strong adult social care system is the key to achieving the shift towards improved population health and wellbeing. This has been described by Ministers as a three-fold shift from analogue to digital, hospital to community and sickness to prevention.
The government has said it will take 10 years to build the National Care Service and deliver its wider health plan, but much can be delivered before then, including short-term measures to stabilise the sector and enhance worker pay ahead of a fair pay agreement. Below we set out six essential pillars of a National Care Service that the government can begin to put in place now.
Click to read more about point 1
An effective National Care Service is only possible if there is a recognition that adult social care is a cross-government policy area and not simply one that is the responsibility of DHSC and MHCLG. In the same way we expect local government and the NHS to work together with providers at a local level to deliver social care services, we should expect central government departments to have joined-up thinking, rather than siloed working.
Social care is central to delivering the government’s wider policy agenda. Care and support services can be found in every community in the country, with a larger workforce than the NHS, making them a powerful tool in the delivery of the government’s missions. We urge the government to recognise how important the availability of and access to a diverse range of adult social care and support services is to the wellbeing and overall health of communities and enabling people to live their lives to the full. The sector offers a diverse range of care services, not just care homes, which form an ecosystem of care and support for many communities to draw upon. This includes supported living, supported housing, housing with care as well as home care, befriending services, day services, personal assistants, employment help, addiction and rehabilitation services, and services which overlap with homelessness, housing and mental health, as well as the wider VCSE sector. As such these services are strongly interlinked with range of other policy areas, such as affordable housing, benefits, economic growth, healthcare and employment among others. A National Care Service must recognise this diversity and potential for focused policy delivery.
The new government must:
- Commit to, and action, wide-ranging social care reform within the current parliament.
- Take a cross-government approach to the reform of social care, recognising the essential part social care plays in achieving other policy objectives.
- Make sure that the National Care Service offers a clear public identity for adult social care, as recognisable as the NHS and which helps people understand what social care is, does and how to get it.
- Create funded roles to enable the representation of adult social care providers on the membership of every Integrated Care Partnership.
- Require Integrated Care Boards to have an Adult Social Care Lead to ensure accountability and good governance, as well as correcting a tendency for systems to see everything through a healthcare lens alone.
- Create a duty requiring the government to lay before parliament annual analysis of current and future requirements for social care workers to meet the needs of adults of all ages, regardless of whether they fund their own care or not. This analysis should be used to inform workforce planning and wider policy agendas such as housing for workers, sustainable transport links, education programmes as well as social security and commissioning practice.
Click to read more about point 2
Without the workforce, the National Care Service cannot be built. There are around 1.59m people who work in social care, and we urgently need to improve their pay, terms and conditions. Currently, the skills, knowledge, and experience of social care workers are not reflected by the level of pay that they receive. Unfunded increases to the National Living Wage have meant that care workers with five or more years of experience in the sector can only expect an hourly rate which is 10p higher than a care worker with less than a year of experience. The median rate of pay for care workers sits at £11.00. Care workers therefore had lower hourly rates compared to NHS healthcare assistants who were new to their roles (£11.67) and those with two years of experience (£12.45).3
It is no surprise then, that recruitment and retention is one of the biggest challenges for the sustainability of adult social care and is contributing to unmet and under-met need across England. There are currently 1.705 million filled posts in social care but 131,000 vacancies in the sector.4 Unmet and under-met need are growing, there are now 5 million unpaid carers5, possibly reaching as high as 10 million6, and nearly half a million people are awaiting care assessments, care or direct payments to begin or a review of their care plan 7. It is also estimated that we will need 540,000 new social care posts to keep pace with demographic changes by 2040 on top of the current shortfalls.8
International recruitment has done a lot to stabilise the situation, with 185,000 international recruits between 2021/22 and 2023/24, but this is not a long-term solution. The same period saw 70,000 fewer British workers, and the flow of international recruitment has started to stop due to restrictions introduced by the previous government. 8,000 international recruits joined the workforce between April and June 2024, compared to an average of 26,000 per quarter over the previous financial year.9
The pressures on the workforce are largely being driven by the failure of successive governments to bring forward a workforce plan for social care or properly fund providers to improve workforce pay, terms and conditions. Attempts to introduce reformed career and development structures continue to fail because care and support providers are underfunded by the state for publicly commissioned care and support. This constrains their ability to offer more attractive pay, terms and conditions and maintain pay differentials which recognise and reward the attainment of additional skills, specialisms, and responsibilities. The journey towards a National Care Service could provide the political focus necessary to grapple these significant issues once and for all.
The government must:
- Bring forward funded interim measures, ahead of a Fair Pay Agreement, to boost the pay of care workers. Care workers should be paid at a rate according to their skills and competencies, at a level that is comparable NHS colleagues and ideally above the Real Living Wage. Action is needed now.
- Fair Pay Agreements should be underpinned by a reframing of the relationship between central government, local government and providers of care and support. The agreement can only be implemented if it is properly funded in recognition of the statutory duty to provide social care which is an essential public service. Sector trade associations will also need support to develop the infrastructure required to negotiate with Trade Unions and government through the Adult Social Care Negotiating Body.
- Adopt the Adult Social Care workforce strategy which has been developed by a wide range of organisations, people working in and people drawing upon social care.10 Use this to deliver a long-term workforce plan for adult social care which models future workforce requirements and seeks to diversify the types of roles available, as well as developing career structures and qualifications.
- Introduce professional registration for all adult social care workers and establish a professional body, such as a Royal College, to represent them. The establishment of this should be funded by the state.
Click to read more about point 3
Social care delivers public good, and much of it is funded by the public purse. If the National Care Service is to ensure that this public funding is used effectively and appropriately, it must invest in organisations that are financially responsible, have transparent ownership arrangements and have good governance. Not-for-profit models of care and support can provide these safeguards.
Not-for-profit care provision ensures that all the funding from either government or citizens is directed towards the delivery of care, so that money remains in the sector and is reinvested into the workforce and to improve the quality of their care and support, rather than leaking out of services and the public sector. This includes ensuring that care workers have improving pay, terms and conditions and learning and development/ training / career development opportunities
The not-for-profit organisations we represent are socially responsible and place a strong emphasis on the long-term sustainability of their care and support services in the local communities they serve, often having deep roots due to their origins and history in local areas, alongside their focus on person-centred care. As such, many are able to offer specialist provision for people with specific needs, such as people from different faith traditions, veterans, and the LGBTQ+ community.
Many not-for-profit organisations providing care and support are charities or social housing providers, meaning they are not just accountable to the CQC but also the Charity Commission and the Social Housing Regulator. As a result, the organisations we represent, by their very nature, have a very strong culture of accountability, transparency, governance, diversity and person-centeredness.
For these reasons measures to enable the growth of not-for-profit care provision should be part of the development of the National Care Service. This should include:
- The creation of a 10-year strategy to expand the proportion of care and support provided by not-for-profit organisations.
- The development of pathways to enable existing care organisations to adopt a not-for-profit care model.
- A greater focus on financial transparency to ensure confidence and accountability for commissioners and the taxpayer, and to ensure financial and social value for the public pound.
Click to read more about point 4
Adult social care is a key part of our nation’s infrastructure, with the potential to unlock economic prosperity and combat socio-economic and health inequalities in every part of the country. Care is the work that makes all other work possible.11 In order for the National Care Service to harness and unleash this potential, we need to see recognition of social care as a key part of the economy in the government’s Industrial Strategy.
Social care services are anchor institutions for their local communities – they generate spending which remains within the local community in which they exist and support a much wider ecosystem of community services and local businesses. Collectively, these services are some of the biggest employers across the country, and according to Skills for Care, contribute an estimated £68.1bn gross value added per annum to the English economy.12 For every extra £1bn in social care spending, an extra 50,000 jobs are created distributed across England, with the largest impacts felt in the North East and North West.13
Furthermore, the very nature of social care is enabling to people. As well as improving population health and wellbeing and creating new jobs, good social care enables some people in receipt of care and, crucially, their unpaid carers (often women) to join or return to the workforce if they would like to. It is a powerful tool in addressing inequalities.
If we want to maximise these benefits, adult social care needs proper investment to enable sustainable transformation with specific measures to encourage the building of new sustainable services, digital transformation, and new models of care to meet changing demographics and what people will want in the future. We also need investment in housing and technology enabled care to ensure people are able to remain in the community and independent for longer.
The National Care Service and Industrial Strategy must facilitate:
- Capital investment funds and grants to not-for-profit providers to develop and create new services and buildings, with a focus on new models of care, environmental sustainability and the introduction of new technologies.
- A funded national framework for the price of registered and unregistered care which ensures good quality, sustainable care wherever you live and removes the catastrophic costs providers, individuals and families are being expected to pay to subsidise the state.
- Zero-rated VAT for not-for-profit adult social care providers to enable VAT on operating expenses to be reclaimed.
- The establishment of new data infrastructures and a minimum data set for adult social care which allows insights about care to be harnessed. This could take the form of a Social Care Data Observatory. This must be co-produced with the sector and people, and it must balance data burden with data benefit and clarity on data ownership and access. Data is not free, so any strategy must ensure that it meets the costs of increased data reporting requirements.
- The creation of a strategy to develop and harness the transformative power of AI and other emerging technologies in the ethical provision of care and support, and in enabling people to live independently for as long as possible
- A new duty for CQC to promote innovation, improvement and economic development of social care services – the regulator should consider the role of Local Authorities and Integrated Care Systems commissioning in enabling this.
Click to read more about point 5
The government has made it very clear that one of its key missions is to decarbonise our economy and push for net zero and energy security in a way that promotes new jobs and industry and creates warmer homes and cheaper bills.14
This ‘mission-driven’ approach will need to work with adult social care providers for it to be successful – something the National Care Service could facilitate. Every day, millions of people draw upon care and support services – in their own homes, in community services and in residential settings – and millions of care workers travel to and from care services or between the homes of people. The transport infrastructure, built environment, digital technology and use of medical equipment that underpins all this will need significant investment and innovation to support a just transition to net-zero by 2050.
In the NHS, the Greener NHS Programme15 is grappling with these issues, but there is currently no equivalent for adult social care, resulting in very disjointed progress in the sector. Those providers who are also housing associations are more likely to have made some progress due to access to national funding and regulatory and legal requirements, but other social care providers, due to significant operational and financial pressures, simply have not been able to even begin their decarbonisation and retrofitting journeys. The creation of the National Care Service must have sustainability within its framework of standards, and these should be shaped as part of a centralised strategy for social care.
The lack of an overarching decarbonisation strategy in adult social care is compounded by the fact not-for-profit social care providers are unable to access national grant funding as they fall outside the eligibility requirements of the Public Sector Decarbonisation Fund and the Social Housing Decarbonisation Fund, as well as funding available for charities and not-for-profits.
There is untapped potential for social care to accelerate the government’s mission, as it touches millions of people lives, in communities across the country, every day. Properly invested in, social care is a tool that the government can use to improve access to high-quality green spaces, to create a stock of low carbon homes for people with care and support needs, to encourage greener transport options, to tap into community climate action and to influence the way millions of people think about net-zero, in their own homes and communities, and at work. Social care needs to be at the heart of policy development and delivery.
The journey towards a National Care Service should include:
- The creation of a ‘Greener Social Care’ strategy to help the sector meet net zero and environmental sustainability targets.
- The creation of capital investment funds and grants to enable not-for-profit providers to develop and create new services and buildings, with a focus on new models of care, environmental sustainability and the introduction of new technologies.
- Ensuring that not-for-profit care and support providers can access existing decarbonisation funds.
- Ensuring that care and support settings are properly considered during the formulation of energy and retrofitting policy and funding for domestic settings. The need for sustainable transport should also be carefully considered for home care and other community support workers.
Click to read more about point 6
A National Care Service will only work if it is able to guarantee the rights, fairness and choice of people in accessing care and support. To get there we need to give those with the biggest stake in the system working effectively, more power. People should be at the heart of their own care and empowered to shape the development of care services with commissioners and providers. To use the language of the Archbishops’ Commission on Reimagining Care, we need a ‘social covenant’ that underpins the National Care Service and which sets out the role and contribution of people, communities and government and clear expectations of what support should be available.16 This support needs to be universally accessible, rather than rationed due to the postcode lottery of funding and resources. It will also require a shift towards prevention and anticipatory care which ensures that resources and funding are in place to enable people to get care and support when they need it, where they need it. The underfunding of care and support has led to a reactive approach with the eligibility threshold to access support getting increasingly higher.
The dignity, independence and wellbeing of people and their families should be paramount. People who draw on care and support should have the same choice and control over their life as everyone else – a’ gloriously ordinary life’ to borrow the language of the House of Lords Adult Social Care Committee.17 People should be enabled to live in a place they call home with the people and things they love, in communities that look out for one another, doing the things that matter to them.18
For a long time, there has been an assumption by policymakers that family members will simply ‘step up’ to provide unpaid care. This is deeply unfair on both parties. Carers are left physically, emotionally and financially exhausted, while those receiving care are denied an ordinary relationship with friends and family. The assumption also fails to recognise that there are increasing numbers of people ageing without children or relatives.
We are calling on the government to:
- Underpin the establishment of the National Care Service with a National Care Covenant, as outlined in the Archbishops’ Report, which is co-produced and sets out clearly the mutual rights and responsibilities of the different parties. This would make clear the role of citizens, families, communities and the state in providing support and paying for it. Any cross-government taskforce or similar must seek this as part of its remit.
- Commit to a strong role for the National Care Service to guarantee universal access to care and support, security against the costs of care, and upholding people’s rights.
- Set clear requirements for commissioners to commission in partnership with care and support providers, unpaid carers and people who need services.
- Create an Older People’s Commissioner for England, along the same lines as in Wales and Northern Ireland.
- Ensure that people get the care and support in the right place at the right time in the community. In particular, we need to end the scandal of people with learning disabilities and/or autism being locked up in inappropriate NHS mental health units.
- Focus on the changing needs of people across all communities and ensure that care and support services are supported to shift and change the work they do to better meeting the needs of people in the future. This will involve the redevelopment of models of care, reshaping the workforce and developing new understanding of how to develop ever more person led approaches to supporting people.
1 https://www.health.org.uk/publications/long-reads/social-care-funding
3 The state of the adult social care sector and workforce in England, 2024 – Executive Summary
4 The state of the adult social care sector and workforce in England, 2024 – Executive Summary
6 https://www.carersuk.org/policy-and-research/key-facts-and-figures/
7 https://www.adass.org.uk/wp-content/uploads/2024/07/ADASS-Spring-Survey-2024-FINAL-1.pdf
10 https://www.skillsforcare.org.uk/Workforce-Strategy/Home.aspx
13 The Economic Value of the Adult Social Care Sector – England, ICF Consulting Ltd, 2018
14 https://labour.org.uk/wp-content/uploads/2024/03/Make-Britain-a-Clean-Energy-Superpower.pdf
15 https://www.england.nhs.uk/greenernhs/
17 https://committees.parliament.uk/publications/31917/documents/193737/default/
18 Adapted from Social Care Future’s Vison for Adult Social Care: https://socialcarefuture.org.uk/
How can you get involved?
NCF run a regular Policy & Public Affairs network for members. Any members who don’t currently attend the network and are interested in supporting our campaigning activities can register by contacting valeriia.zemtsova@nationalcareforum.org.uk
Download our Speak Up For Care campaigning and engagement resources and encourage everyone within your organisations, and those receiving your care and support to use them to engage with local MPs.
Contact us:
Vic Rayner, CEO – vic.rayner@nationalcareforum.org.uk
Liz Jones, Policy Director – liz.jones@nationalcareforum.org.uk
Nathan Jones, Senior Policy and Public Affairs Lead – nathan.jones@nationalcareforum.org.uk
