At the start of 2025, Health and Social Care Secretary Wes Streeting announced an independent social care commission. The commission will take up Labour’s manifesto proposals for a National Care Service “underpinned by national standards, delivering consistency of care across the country” as a route to reform social care.
Exact details of what a National Care Service in England will look like are unknown and the commission won’t report until 2028. Amidst this uncertainty, Scotland’s evolving National Care Service proposals offer a guide to some of the pitfalls that officials will want to avoid.
As a devolved power, each of the four nations of the UK have different social care policies. Scotland is in the thick of establishing a National Care Service. Up until November 2024, legislation was passing through the Scottish Parliament.
After facing searing criticism from all quarters, the Scottish Government has announced they will not be pushing forward will the Bill in its current form and are considering how to progress the proposals. There are doubts that there was enough parliamentary support to pass the Bill.
Local authorities in Scotland withdrew their support for the reforms, as did several trade unions. Given the level of discord against the National Care Service in Scotland, it is difficult to see how the proposed reform will be delivered. However, the Scottish Government’s headaches may be to the Labour Government’s advantage, offering learning about how not to introduce National Care Service reforms in England.
Here, we reflect on our previous research with the Local Government Information Unit on Scotland’s proposed National Care Service and outline four areas of key learning for the Government in Westminster.
1. Work to bring everyone along with you
Instituting any reform depends on recognising the complexity of the social care system and its various players. Reforms will affect people who draw on services, local authorities and service providers. Getting the politics right is crucial – such a large-scale reform ideal needs cross-party support. If that isn’t possible then it needs to be delivered by a government with a sufficient majority and/or political capital to proceed anyway. In Scotland, the SNP Government lost political capital with the departure of Nicola Sturgeon as First Minister. Her successors have struggled to make progress on major reforms, and arguably the SNP no longer has sufficient momentum to drive through a National Care Service. Labour in England needs to learn from Scotland in terms of the timing of the reforms as well as the design.
Additionally, reforms will have wider ripple effects on other service areas which also need to be involved as proposals develop. Scotland’s experience warns us that meaningful co-production has to be embedded from the start and maintained as the proposals develop. Using appropriate and timely communication channels to update interested organisations is imperative to sustain engagement and strike the difficult balance between competing interests.
2. Clear proposals are needed from the start
The Labour Government should ensure that planned reforms are clear so that people can work out the implications of the proposals and know what they will be getting. In Scotland, the National Care Service Bill is framework legislation with details of the reforms introduced via secondary legislation. As the proposals have evolved, it has been difficult to keep track of where the boundaries of a Scottish National Care Service lie and what services will be included in the reform.
It’s to be expected that plans for an English National Care Service will evolve as part of the consultation process. However, proposals for an English National Care Service should be clear about how they fit within the current system, what will be changed and what continues. This allows local authorities and providers to understand the future demands that will be placed on them and plan accordingly.
The language of a National Care Service can trade on the goodwill directed to the National Health Service. However, under the Scottish reforms, service access wouldn’t be free at the point of use and a means test would remain with people paying for the costs of their care. Honesty and expectation management is needed about what the introduction of a National Care Service will mean for people drawing on services now and in the future. This is particularly important when we know people’s understanding of social care and its associated costs can be very limited.
3. Question if structural reform is really the answer
Proposals for a Scottish National Care Service have emphasised structural reform, with plans to introduce a new body to provide national oversight for social care. Initial proposals to establish care boards sharing responsibility with Scottish Ministers for the delivery of social care have been scaled back. The plan than changed to propose that integrated joint boards (IJBs) will be renamed national care service local boards and this will be the only permitted integration model.
The reforms have been challenged as over-emphasising structural reform without adequately explaining how this will generate improved outcomes for people drawing on services. Structural reconfiguration has been seen as an insufficient substitute for increased funding to existing bodies. Furthermore, new structures require the redirection of people and budgets and structural reform has been viewed as a potential distraction from day to day operations, increasing pressures. The National Care Service has been assessed by some as needless tinkering in a system that requires wholesale reform.
An English National Care Service should avoid reform for reform’s sake and be mindful of the drain on resources required by structural reconfiguration. Understanding how reforms generate improved services and outcomes is needed, as well as a clear explanation of how new bodies facilitate improvements that couldn’t be achieved within existing structures.
4. A national and consistent approach may not lead to better outcomes
The idea behind a National Care Service is to improve the consistency of care services across the country. However, national standards do not necessarily result in improved outcomes. Some have welcomed the proposed national approach in Scotland, however others have emphasised that local government has to be able to develop community-based solutions responding to local need. While consistency can address concerns around possible postcode lotteries, services need to be built around a person. What is right for one person won’t be suitable for another and consistency should not be pursued at the expense of developing approaches that are right for the individual.
An English National Care Service needs to find a balance between centralised and local approaches to the design of social care services. Local authorities are well positioned to work with communities to understand the needs of their local populations. The availability of high-quality services allows people to live the life they want. Local authorities should be able to develop whole-place approaches designed to meet the specific needs of an area.
Conclusion
Any social care system reform requires old approaches to be unpicked to make way for new ways of doing things. For the Labour Government, developing a National Care Service in England should be built on a clear rationale demonstrating how the changes lead to better outcomes. This has often been missing from the Scottish Government’s approach and has led to over-promising and dashed hopes for some groups. A National Care Service will have implications for providers, local authorities and people drawing on care and support. The Labour Government should learn from the experiences of the Scottish Government and work to build consensus across the different parts of the system. However, it also needs to get the timing of reform right, and avoid squandering the political capital that came from its 2024 election win. The lesson from Scotland is that the policy needs to be right, but also that the politics needs to be right. Wait too long and a National Care Service will look too risky for politicians contemplating the next election.
About the authors
Emily is based at the University of Birmingham where she is focusing on exploring the application of systems thinking to the analysis of social care. Prior to this role, Emily was part of a National Institute for Health Research (NIHR) funded project at the University of Birmingham exploring local authority market-shaping activities in social care and how these facilitate the development and access of personalised care and support.
Catherine Needham is Professor of Public Policy and Public Management at the Health Services Management Centre, University of Birmingham. Her research focuses on adult social care, including personalisation, co-production, personal budgets and care markets. She has published a wide range of articles, chapters and books for academic and practitioner audiences. Catherine led the Care in the Four Nations work package within the ESRC Sustainable Care team. She is now leading research on care systems as part of the ESRC Centre for Care and is also a member of IMPACT, the UK centre for evidence implementation in adult social care. She tweets as @DrCNeedham.