Adult social care in England has spent too long in a holding pattern. The structural pressures are well understood, the reform agenda has been articulated many times over, and the consequences are being felt in every local authority area in England. Yet the gap between diagnosis and delivery remains.

That gap will not close overnight. But the decisions being made now, by government, by commissioners, by providers, will define the trajectory for a long time to come. As someone who works closely with local authorities and care providers navigating these pressures, I want to talk about what I see on the ground, and what I think public sector leaders need to be doing now.

Don’t expect the challenge to be solved for you 

Social care leaders I meet are passionate about delivering for their places and communities now, but a lot seems to be resting on expectations of answers from Baroness Casey’s review of care. The most damaging assumption I encounter is that we need to wait for answers, and that it is therefore worth holding off on difficult decisions until clarity arrives. I am hopeful that the work of Baroness Casey will lead to a renewed vision for care and reinvigorated delivery plans, but that is just the first step. The postponement of the Dilnot cost cap reforms is not an anomaly - it is a pattern, and one which could repeat. Structural reform of social care funding requires a level of political commitment that has historically evaporated when it meets fiscal reality and which is always subject to change in a volatile political context.

In any event, if we look at trends in social care reform, these are increasingly envisioned as exercised in subsidiarity, with neighbourhoods, local authority areas and regions increasingly empowered to do what is right for their place. The centralising tendency in England is a strong one, and so the implementation picture is more mixed, but if current trends continue then we should expect that a key part of a reform plan will be to create conditions for areas to make their own decisions as to how to deliver care that meets their population needs and priorities.  

That does not mean reform is impossible. It means that commissioners and providers who plan on the basis that a single model of reform with a comprehensive settlement is around the corner are taking a risk they cannot afford to take. The organisations navigating this best are those that are planning for a range of outcomes, identifying what can be done now to move along their own reforming pathway, with partners, and pursuing a vision which works for their place. 

This approach is also likely to support access to funding streams. Reform is not only achieved by the ‘stick’ of legislation mandating change. In fact, the current trend is legislation as a backstop, and reliance on authorities and regions to develop their own models for success, with access to funds for those who do. The recent announcement of funds for a further round of regional care cooperatives, with funding to support the transition is an example of this. The timeframe for applications and the criteria mean that prior planning and collaboration are likely to be a significant factor in terms of which application will succeed.

Authorities that have begun to envisage their own future arrangements and lay foundations, or have ‘oven ready’ projects identified and waiting for the right funding stream to come along are more likely to secure access to the resources they need to deliver change.  

Integration is an opportunity - but also a risk if you’re not paying attention

The push towards greater integration between health and social care is substantively right. Bringing services closer together, shifting towards prevention, easing access to the right services through a single ‘front door’ and reducing the number of times vulnerable people fall through gaps between systems: these are the right things to pursue.

But integration, in practice, is also a vehicle through which cost and risk can be quietly redistributed. Sometimes, the attraction of protecting budgets seems to be just too strong for organisations with scarce resource, and transfer of costs and risk becomes a driver of change, rather than outcomes for the system and the people it serves. At other times, the shift of cost and risk may be an unintended consequence of another objective, but is not factored into plans to ensure sustainable and genuinely collaborative working. Commissioning structures are redesigned, accountability frameworks shift, and providers find themselves holding responsibilities and liabilities that were not clearly allocated when the integrated model was agreed. 

The organisations and systems that work are those that engage in the governance design process early, have open conversations and ask hard questions about where accountability sits, and take legal and commercial advice before the model is locked in, rather than after.

The workforce is the system

No reform agenda succeeds without the people to deliver it, and social care is a service delivered by people, for people. Remarkably, policy discussion almost always starts with discussion of ‘the system’ and its structures, with focus on workforce coming later, sometimes almost an afterthought.  

The social care workforce is under extraordinary strain: persistent recruitment and retention difficulties, pay that struggles to compete with other sectors, a reliance on international recruitment now subject to significant policy headwinds, and a culture of expectation that care workers will absorb system pressure that should never have reached them. This adds significant direct costs of recruitment, temporary staff etc. Longer term it increases risk and cost through loss of the knowledge and relationships that make systems work.  

When system reform is on the table, workforce challenges multiply. Current discussions with leaders in relation to LGR frequently turn to the toll it is taking on people, the risk of senior staff being tipped into decisions that now is the time to retire or move on, and the lack of staff to replace them. 

This is why, in any change project, it is essential to treat workforce planning as a strategic priority from day 1, not an operational matter to be delegated when the system redesign is done. There will be change in care and workforce will need support through it. A workforce that knows its organisation and system has a plan with people at its heart is more likely to respond positively to change. We often talk about the Wigan deal in relation to community empowerment, but King's Fund research on the deal majored on the impact of workforce empowerment in the success of the project, describing a new sense of purpose and self-belief in staff, kindled by senior leaders giving them greater agency which had “rekindle[ed] hope among local professionals”.

What public sector leaders should do now

• Invest in integration relationships and design early: Establishing successful joint working arrangements with partners underpins system change, and the ability to develop the right local arrangements for collaboration. Early joint work builds shared vision and a real understanding of how to achieve desired outcomes. Once commissioning and governance arrangements have been agreed, unpicking them is costly and damaging to relationships. Get legal and commercial support at the design stage, not the dispute stage.
• Plan for scenarios, not a solution: Whether it’s about structures or funding, we have a clear direction of travel, but no complete roadmap, and future direction is unlikely to be prescriptive. Build financial and operational resilience across a range of scenarios, including those in which structural reform does not materialise in the near term. The organisations that will be in the strongest position are those that have not staked their viability on an assumption.
• Understand your provider market, genuinely: Contract compliance is not the same as market intelligence. Commissioners need a realistic picture of provider financial resilience. They need contingency plans that are ready before a provider exits rather than after, and in a time of changing needs and delivery models (including tech-enabled care) the ability to be agile as new solutions emerge.
• Invest in workforce, not just structure: Governance redesigns and new commissioning models will not hold if the people expected to deliver them are exhausted, underpaid, or leaving the sector. Workforce investment is not a cost, it is the condition for everything else working, and is essential under any future scenario.

The stakes are too high for managed decline

The social care system supports some of the most vulnerable people in our communities to live with dignity, independence, and connection. The gap between that vision and the current reality is not inevitable, it is the cumulative result of decisions deferred and reforms delayed. Structural challenges like funding and the absence of a national reform agenda are not in the hands of local authorities, providers and other system partners, but the choice as to how to act in this period is. 

We often see narratives of ‘managed decline’ in the economy and in public services, but I have yet to meet anyone in care who considers managed decline is right for their organisation, their workforce or the people that they support. All those I talk to remain passionate about making a positive difference. Many are doing it. 

Transformation will not happen overnight. But progress is possible, if those with the ability to act choose to do so with clarity and purpose rather than waiting for solutions that may never come.