Since taking office as Prime Minister, Andy Burnham has made one thing very clear: he sees it as his personal and political priority to succeed where predecessors have failed to finally address how England should reform social care. His speech yesterday at Labour Party Conference was, therefore, hotly anticipated as a first indication of his vision of the system and intentions for reform.
The Prime Minister’s passion and determination shone through as he described his intentions for a “National Care Service”, “free at the point of use”, and it is refreshing to see this level of personal commitment after decades of neglect. But the speech also raised further questions about what he actually meant. Although the speech itself repeatedly described a care system “free at the point of use”, further details published by the government in fact refer to free personal care for the over-65s.
These terms are often used interchangeably by politicians, journalists and commentators, yet have very different implications for the extent to which this new offer can tangibly meet the needs and preferences of people who draw on care. While much will need to be defined by the government following the outcome of the Casey Commission, we can look to Scotland’s experience, where free personal care has been in place for the last 25 years, which demonstrates how important it is to be crystal clear about what exactly the offer is.
When Labour last proposed free personal care in the run-up to the 2019 election, we highlighted the importance of being clear about terminology, which we explore again in this updated blog.
What does personal care actually mean?
Current Scottish legislation provides us with the best indication of what could be covered under Burnham’s new offer for England. In Scotland, ‘personal care’ includes personal hygiene, support with mealtimes, immobility problems, medication and general wellbeing. The ‘national’ care service the Prime Minister aspires to implies some level of consistency across the country, and therefore some clarity over the offer and definition.
In Scotland, this consistent definition was not established until 2005/06, before which there was wide variation across local authorities in the interpretation of what personal care actually meant when it was first introduced in 2001. Even with some nationally set criteria for personal care, research in Scotland has suggested that differences in interpretation by local authorities persist, accompanied by confusion among the public as to whether other services are provided free of charge or if they are subject to the means test.
In the diagram below, we map some common social care activities under some broad types and settings, following Scotland’s example. Only the ones that fall under personal care are currently free in the Scottish model. Other main types of social care can include activities to help with daily living, such as shopping or laundry, and support and preventive activities that enable people to go about their daily lives. In Scotland, any state support to help fund these is subject to a means test. For residential care, anyone with assets above £36,750 must fully pay for non-personal care costs themselves – this threshold is set at £23,250 in England.
But in the real world, people’s needs and preferences often fall across these boundaries. For instance, under Scotland’s model, a free personal care offer could fund time to help someone get out of bed, get dressed, and eat breakfast, but not to go down to the shop to get the food to make said breakfast.
What are the pros and cons of free personal care?
The introduction of free personal care is estimated to cost £7.5 billion by the end of the next parliament, and would provide everyone with assessed needs to a universal entitlement to a set package of care. It would bring England closer in line with other countries, being one of few countries that currently restricts access to any social care based on people’s finances.
While there are some clear advantages to a universal personal care offer, it may not benefit everyone equally. For a person living with advanced dementia, personal care is likely to form a small – albeit important – part of what their daily care and support needs look like. They may, for instance, require one-to-one or frequent assistance to prevent them from encountering harm. This can prove very costly without protection against catastrophic costs. In Scotland, despite the funding of personal and nursing costs for people living in a care home, people living in residential homes still pay £1,160 a week towards non-personal care and living costs, rising to £1,410 in a nursing home. Some – particularly those with higher needs – face bills in excess of £2,000 a week.
If the Prime Minister is serious about protecting “people’s homes and their savings”, he will need to think about how free personal care can be coupled with a mechanism to protect people’s assets in the long term, or move towards a more comprehensive free offer.
From what we know so far, Burnham’s plans for a National Care Service currently only focus on delivering free personal care for the over-65s – leaving questions unanswered about how a reformed system will work for the 300,000 people under the age of 65 who also have care and support needs.
Scotland chose to expand the remit of free personal care to people under the age of 65 in 2019, which was hailed as a victory for equity and fairness. Commentators at the time pointed out that as many as two-thirds of people under 65 would stand to benefit very little, although more recent analysis suggests a moderate increase in the number of people accessing personal care since the expansion of the offer.
Scotland’s 2021 independent review into social care identified that the implementation of free personal care was not sufficient to fully meet people’s needs and preferences, and recommended removing all charging for non-residential care. It also found that access to free personal care was also, in many parts of Scotland, only available to people with high needs – missing opportunities to prevent crisis.
The Prime Minister has repeatedly described an aspiration for the National Care Service to be preventive. The level of needs at which entitlement to free personal care is set in England will be crucial to the success of his vision, but may have implications for how much the policy costs in reality.
Why do definitions matter?
The Prime Minister has explicitly called for a new social contract for the 21st century, backed by the British population, which can build a social care system that delivers “person-centred, high-quality care”. We have long called for bold political leadership to lead to real change, and there is a real chance that this can now happen.
Baroness Casey’s Big Conversation on care is underway, and is a critical part of successful reform. The basis of that conversation needs to start with a clear articulation of what social care is really for and what we, as a society, need and expect from the state. What’s in and out of a new state-funded offer may appear arbitrary, but will have tangible consequences for people who draw on care and support, and how well they are supported. Free personal care could be a positive building block for a reformed social care system that is fit for our future. But if our national conversation is to be honest and transparent, we all need to be on the same page about what we are talking about.
*Please note this is an updated version of our blog published in October 2019 titled “What might Labour’s free personal care pledge actually mean?”
Suggested citation
Oung C (2026) “What does the Prime Minister mean by a National Care Service?”, Nuffield Trust blog