The social care system lacks ‘clear stewardship’ according to a report on governance of the sector from the Independent Commission on Adult Social Care, published today.
Commission chair Baroness Louise Casey is expected to use her speech at the National Children and Adult Services conference today to warn that “no one is in charge” of England’s adult social care system which the report warns operates as a fragmented patchwork, lacking clear leadership, accountability and long-term direction.
The new report, produced by the Nuffield Trust for the Commission drawing on a range of research including a round table with sector leaders including care providers, explores how governance could be redesigned as part of a future National Care Service.
Here’s everything care environment leaders need to know:
What is the central message of the report?
The report argues that England lacks clear ‘system stewardship’ of adult social care, with no single organisation clearly accountable for overall performance, workforce planning, market development or improvement as responsibility is spread across central government, local authorities, regulators and thousands of independent providers.
The authors suggest these governance weaknesses are contributing to persistent issues around workforce shortages, inconsistent access to care, variable commissioning practices and market instability.
The report offers an effective blueprint of governance options available to Baroness Casey and ministers to underpin any future National Care Service, focusing on national approaches to eligibility and access, care home fees, commissioning consistency and market oversight.
What’s the impact of this governance issue?
Significant challenges beset the sector because of a lack of clear accountability and governance, according to the report. These include:
- Wide variation in local authority fee rates
- Inconsistent commissioning approaches across 153 councils
- Workforce shortages and weak workforce planning
- Limited oversight of market sustainability
- Insufficient support for innovation and improvement
- Opaque accountability structures during periods of crisis or market disruption, such as the situation that emerged during the Covid pandemic, which Baroness Casey described as a “national shame” in a letter sent to the Covid inquiry chair Baroness Hallet today.
Does the report support a National Care Service?
The report concludes that if government wants a genuinely national service, it will be difficult to maintain today's level of variation in eligibility, access and commissioning.
However, it underlines that governance structures should follow policy objectives rather than being introduced due to reorganisation - warning against the creation of new organisations before government decides exactly what a National Care Service is expected to achieve.
Should provider ownership structures change?
The report examines international examples where governments have taken stronger positions on ownership models, profit-making and market entry requirements. It raises concerns over highly leveraged business models and references previous failures involving major care providers including Southern Cross and Four Seasons.
As a result, it asks whether government should become more explicit about the balance between public, not-for-profit and for-profit provision in adult social care.
The report also suggests stronger national signals could help shape provision in priority areas such as dementia care and specialist services, and includes examples from countries that impose stricter design standards, operational requirements and market entry criteria on providers. It adds that 'provider representatives' at the roundtable session for the report said there 'could be greater scope for the government to set a clearer expectation of the types of provider that should be providing services – or rather, whether any types of provision would be undesirable'.
Should commissioning structures be changed?
The report stops short of recommending national commissioning but examines international models where governments take a stronger role in:
- Setting fee schedules
- Defining commissioning standards
- Planning future capacity
- Shaping provider markets
- Establishing national eligibility criteria.
Should a national care home tariff be considered?
The report analyses national pricing mechanisms, showcasing examples from Germany, Japan and Australia, where governments operate national fee systems for care services, and from Scotland and France, where minimum tariffs or national contracts establish baseline rates.
The authors suggest such approaches can provide greater market stability and predictability for providers, although they also warn they may reduce local flexibility.
What does the report say about self-funders?
The report highlights ongoing concerns about transparency, with self-funders typically paying 40 per cent more than local authorities for comparable services, and argues there may be a stronger case for greater visibility around provider pricing and fee structures.
What are the report's strongest recommendations?
Although the report avoids formal recommendations, it does identify workforce planning and innovation and improvement as areas where it concludes action is needed regardless of wider reform decisions.
It says workforce planning should be placed on a much more stable, strategic footing, warning that the lack of a mandatory care worker register and a long-term workforce strategy in England means a stronger national infrastructure is needed for workforce planning, recruitment, development and professionalisation.
The report also points to growing concerns around:
- Persistent vacancies
- Recruitment challenges
- Retention pressures
- Immigration policy impacts
- Leadership succession
- The implementation of the Social Care Fair Pay Agreement.
Meanwhile the authors argue support for innovation has become fragmented and under-resourced, and that organisations such as SCIE and Skills for Care need greater long-term stability.
The full report is set to be published on the Casey Commission website at 11:30am today.
