Social care reform across the UK: why does it keep failing?

As we today kick off a new series of updated explainers looking at social care across all four countries of the UK, this blog from Camille Oung takes a closer look at why social care reform across the United Kingdom has proven so elusive.

Blog post

Published: 02/02/2023

All four countries of the UK are grappling with how to meet the growing need for care and support within a context of stretched budgets and a shrinking workforce. Squeezes to funding pots have been felt in each country and have contributed to a market for care provision that is unstable and insufficient. Difficulties in recruiting – and retaining – staff are acute, due to poor working conditions and uncompetitive pay, and as a consequence, unpaid carers often carry significant caring responsibilities.

Despite the differences in the UK’s four social care systems, and local dynamics and pressures, the fundamentals are largely the same. Social care, as it stands, is not delivering care that is of quality and which enables people to lead independent and fulfilling lives.

Shared challenges

Since devolution in 1998, the social care systems of the UK’s four countries have diverged, but one feature they share has been repeated attempts at reform – and these have proved similarly problematic across all countries.

2021 and 2022 heralded a glimmer of hope for social care systems across the UK, with promises of change with ambitious reform plans. But with the most recent Autumn Statement signalling delays to reform in England, Scottish parliament questioning plans to introduce a National Care Service, ‘critical’ workforce shortages threatening the stability of social care in Wales, and limbo in Northern Ireland over wider executive deadlock, the question is why, despite broad support for change, social care reform repeatedly fails to go the distance.

In this blog – which accompanies the start of our updated explainer series about social care in each country of the UK – we consider why this might be the case.

1. Financial uncertainty

Social care spending per head varies across the four UK countries, but agreeing how social care should be funded, and what it should deliver, has been a constant and common obstacle to reform. In England, Wales and Scotland, social care comes from a complex mix of local and national sources, but the responsibility for the commissioning and organising of care sits at local level. This means national governments have limited sway on how money is spent locally, and may therefore be reluctant to increase national funding. Added to this complexity, funding raised at local level (e.g. via council tax) is highly variable, which means more affluent councils are at an advantage compared to more deprived ones, as they are able to raise more.

In Northern Ireland, health and social care are fully integrated, with budgets for both sitting with health and social care trusts. Although this removes the complexity of a national/local funding dynamic, it is not clear that current spending is delivering good services. Indeed, it appears that health has taken the biggest share of the pie.

Local budgets are squeezed more than ever, with Covid, inflation and cost-of-living heaping on more pressure. As a result, funding commitments are struggling to keep pace with everyday demand, let alone being enough to enable reform. England’s last Autumn Statement delayed planned reforms to introduce a cap on care costs and to make the means test more generous by another two years, and instead reallocated the money for those reforms to addressing immediate inflationary pressures in the sector. To many, this will feel like a repeat of 2016, when plans to introduce a cap on care costs were put on hold indefinitely after similar financial concerns.

In Scotland, the Finance and Public Accounts Committee has recently (and unusually boldly) set out its concerns that plans to introduce a National Care Service are not fully costed, while also raising questions about whether these are “either affordable or sustainable” at a time of financial instability.

A failure to put in place a sustainable long-term revenue source to fund social care means that it will be dependent on sporadic injections of money that offer brief respite in a crisis, but do little to enable long-term strategic reform.

2. Political leadership and stability (or lack thereof)

A lack of political leadership and cross-party collaboration have also proved to be an obstacle for social care reform in the UK. In other countries, such as Germany or Japan, consistent political leadership across political divides has been necessary to embed long-term change. But while successive governments throughout the UK have made commitments to reform social care, these have often fallen whim to political point-scoring rather than cross-party agreement – with previous proposals in England being branded as “dementia taxes” or “death taxes” by opposing parties, for example.

With no consensus over long-term vision or strategy, social care has been susceptible to rapid shifts in government. Recent instability in England means we have seen, within a 15-month period, the introduction of a health and social care levy on national insurance to pay for social care reform under Boris Johnson, its revocation under Liz Truss, and delays to the reforms under Rishi Sunak. In Northern Ireland, the fall of government over wider political sharing disagreements has once again halted the steps taken towards reform.

Conversely, in Wales, it is the hope of possible continued cooperation agreements between Labour and Plaid Cymru that have led to shared ambitions to bring forward plans for a National Care Service free at the point of use by the end of 2023. The First Minister in Wales has claimed that U-turns in England have reinforced commitments to pressing ahead with these plans. Whether these political divides can be overcome to successfully move towards reform remains to be seen.

3. Comprehensive reform

While reforms to social care across the UK have taken the four systems increasingly further from each other, to date they have tended to focus on one narrow issue or area, rather than address the underlying issues that are facing the sector in a coordinated way.

Recent reform efforts have followed this pattern. For instance, England’s proposals were almost solely concerned with charging. The introduction (and subsequent delay) of the cap on care costs had the potential to expand the number of people with access to state-funded support, but with little else to expand capacity and improve quality of care. In Scotland, current legislation for a National Care Service will see a shift in accountability for social care from local government to Scottish ministers. But critics have questioned whether changing who is responsible for social care is just skirting around the problem, when there are very real issues facing the system now.

Countries such as Germany and Japan, where reform has been relatively successful, recognised that changing the funding requires changes to eligibility and access, with wider impact on the workforce and providers. While both countries are still working through challenges as their population grows and ages, political leadership and certainty in funding to ensure wholesale reform have taken these some way towards being sustainable care systems.  

Creating a positive framing

It's whether a social care system can support people to live better lives (brilliantly described as “gloriously ordinary lives” by the Parliamentary Adult Social Care Committee) that will ultimately be the test of successful reform. However, at present, attempts to reach this point are hampered by a reductionist political and media discourse that often portrays social care as a means to prop up the NHS, talked of as beds rather than people and a drain rather than an investment.

So it is positive that we are seeing countries in the UK, such as Scotland and Wales, giving an increasingly greater space to people who draw on care and support, staff and unpaid carers in the design of their reform. But, if the vision supported by the public is to be implemented to reform social care across the UK, it will need to be supported by political boldness, financial backing, and a comprehensive reform programme that can really take us from failure to success.  

Suggested citation

Oung C (2023) “Social care reform across the UK: why does it keep failing?” Nuffield Trust blog