How will Burnham "fix social care"?

Photo: Institute for Government

Andy Burnham’s promise to “fix social care” is welcome. His ambition for a system built on NHS principles, in which “everyone contributes, everyone is covered”, speaks to a failure that successive governments have acknowledged and then left unresolved. At last, a Prime Minister appears willing to say that England’s arrangements are unfair and that a lasting solution will require difficult choices.

That is a significant step, but a promise is easier to make than a service is to build. Social care is often discussed as though it were chiefly a question of protecting older people from large care-home bills but it is also about working-age disabled adults who need support to live independently, people receiving care in their own homes, unpaid carers and the workers whose pay and conditions shape the quality of care. A reform that answers only the question “How much might I have to pay?” will leave the core problem untouched. What is needed is structural and cultural change, alongside overdue ambitious thinking.

Burnham faces choices about who is entitled to support, what that support includes, who provides it, who oversees it and how it is paid for. England’s reforms would apply to England; social care is devolved elsewhere in the UK. Scotland’s experience nevertheless offers a useful warning. It has provided free personal care for years, yet its more ambitious attempt to establish a National Care Service ran into fierce opposition and was substantially diluted before eventually being ditched. The lesson is not that Burnham should lower his sights. It is that the details matter as much as the declaration.

A history of promising starts

In 2011, a commission chaired by the economist Andrew Dilnot proposed a cap on an individual’s lifetime contribution to eligible care costs. It recommended a cap of £35,000, alongside more generous means-tested support. Its estimated annual cost, depending on the level at which a cap was set, ranged from about £1.3 billion to £2.2 billion at the time. A cap would have offered something people badly needed - protection against the possibility of exceptionally high costs - but would have done little to offer meaningful social are reform.

The Conservative–Liberal Democrat coalition accepted the broad approach. But acceptance did not lead to delivery. After the 2015 general election gave David Cameron a Conservative majority, the government postponed implementation until 2020, citing pressure on the public finances. The first of several apparently serious solutions slipped away.

Theresa May’s Conservatives tried a different approach in the 2017 election. Their manifesto proposed counting the value of a person’s home when assessing eligibility for state help with care received at home, while allowing payment to be deferred until after death. It initially offered no lifetime cap, presenting this as fairer than Dilnot’s model. Opponents called it a “dementia tax”. Amid the backlash, May said there would be a cap after all, but the proposal was never realised. The government failed to build public confidence in what people would owe or what protection they would have.

Boris Johnson later proposed a higher asset threshold for means-tested help and a cap on eligible personal care costs, backed by a Health and Social Care Levy. The levy was reversed, and the charging reforms were subsequently abandoned. The pattern is familiar. Governments recognise that the existing system is difficult to defend; they announce a funding mechanism or a limit on individual bills; then cost, political opposition or a change of leadership defeats it.

Labour’s 2024 manifesto promised a National Care Service underpinned by national standards, but left fundamental questions about its scope and funding unanswered. As Prime Minister, Keir Starmer commissioned Baroness Louise Casey to examine reform. Her commission’s longer-term recommendations were originally due in 2028, a timetable that made it easy to suspect the problem had once again been pushed beyond immediate political reach. 

What Scotland can teach England

Scotland’s free personal care policy shows both the value and the limits of a universal entitlement. Adults assessed as needing personal care can receive it without being charged for those tasks. That includes help with such things as washing, dressing, eating and medication. The policy now extends to eligible adults under 65 as well as older people: a useful reminder that social care cannot sensibly be designed around retirement age alone. 

But personal care is not the whole of social care. Free help with specified tasks does not mean that accommodation, food or every form of daily living support is free. A person in a care home can still face substantial charges for the residential part of their stay. Nor does a legal entitlement, by itself, guarantee that the right service and enough skilled workers will be available when someone needs them. Scotland’s policy is an achievement, but it is not a complete answer. 

There was therefore merit in the Scottish National Party government’s ambition to go further. A National Care Service offered the prospect of clearer standards, greater consistency and stronger rights for people receiving support. it is important to point out that opposition parties initially shared much of the desire for change. But the Scottish proposal became caught between its sweeping promise and uncertainty about how it would work.

Local councils feared losing responsibility for services they understood and delivered. Trade unions raised concerns about shifting power away from local government and about what organisational upheaval might mean for staff. Providers wanted greater clarity about their roles. Questions accumulated about governance, delivery and cost. As the bill changed, support from opposition parties, councils and unions fell away. Scotland’s experience suggests that agreement on the goal of better care is no substitute for agreement on who will be responsible for achieving it and how the system will work.

Creating a national oversight body might help establish common entitlements and hold the system to account. It could also add another layer of administration while services remain dependent on local staff, buildings and providers. Transferring responsibilities away from councils would be an especially large undertaking. Burnham has the advantage of a substantial Westminster majority, which the SNP lacked. However, while a majority can pass legislation, it cannot supply missing care workers, settle disputed responsibilities or make an underfunded promise affordable.

Burnham’s choices

1. He could return to Dilnot. A cap, combined with a more generous means test, would protect people from the most extreme bills. It would give families a clearer sense of their financial exposure and might make private insurance or other planning easier. After so many false starts, implementing it would be a genuine improvement.

But what looked like a progressive breakthrough in 2011 would be a narrower answer in 2026. A cap concerns what an individual pays for eligible care; it is not a guarantee that suitable care is available, and living costs in a care home remain a separate matter. Its effect depends on the cap’s level, the means-test rules and what counts towards it. It would not, on its own, address low pay, uneven access, overstretched unpaid carers or the quality of provision. Burnham’s language points to an ambition much larger than limiting an individual bill, making a Dilnot-type solution unlikely.

2. He could borrow from May and Johnson. Their proposals should not be dismissed simply because Conservative governments made them. Raising the threshold at which people qualify for means-tested help has an obvious appeal. Johnson’s proposed levy, whatever its flaws, recognised that durable reform needs durable revenue. May’s plan raised a legitimate question about how housing wealth should be treated across different care settings.

Yet reviving either package wholesale would be politically and substantively unconvincing. Both failed to win a lasting settlement; Johnson’s levy was reversed and the charging changes were dropped. After promising a radical new social contract, Burnham would not want to be perceived as returnig to abandoned Conservative funding formulas. More seriously, neither package fully answered how care should be organised and delivered. He could use parts of them within a wider reform, but a revised means test alone would look like a small response to a much larger promise.

3. He could introduce free personal care on the Scottish model. This would establish a simple principle: someone assessed as needing intimate, essential help should receive it without a charge at the point of use. It would remove a painful distinction between medical treatment, which the NHS provides free, and help with basic daily tasks, for which people can face a bill. The Health Foundation estimates that introducing Scottish-style free personal and nursing care for people aged 65 and over in England could cost about £6.5 billion extra in 2026/27, rising to around £7.5 billion by 2035/36. That particular estimate covers older people, so it should not be mistaken for the price of a universal entitlement for all adults. 

However, the limitation is visible in Scotland. Personal care is only part of the support someone may need, and care-home accommodation and everyday living costs do not disappear. Burnham could introduce free personal care as a major step towards a fuller service. If he presented it as the completed solution, people would soon discover the distance between the promise and the bill they still had to pay.

4. He could build a genuinely comprehensive National Care Service. National standards and clear entitlement criteria could reduce the postcode lottery. Making eligible care free at the point of use would give practical force to the principle that everyone contributes and everyone is covered. A national framework could also set expectations for workforce training, fair pay, continuity of care and the quality of support.

That vision needs careful definition. Does “free care” include support for working-age disabled adults to participate in ordinary life, or only a list of personal tasks? What happens to housing and food costs in residential care? Who assesses need, and how can someone challenge a decision? Can people choose support suited to their lives, or will national consistency become a rigid menu? How will the NHS and social care work together without treating care simply as a means of freeing hospital beds?

National standards need not mean that a distant body makes every local decision. Councils have knowledge, democratic accountability and relationships with communities and providers. Burnham could set enforceable rights and provide national funding while keeping delivery close to the people receiving care. But he must specify where authority sits and who is answerable when a service fails. If national government promises an entitlement, it must ensure that councils are adequately funded to deliver it.

The workforce must be central to the design. A free entitlement is hollow if no one can provide the support. Better pay, training and career progression cost money, as do adequate fees for providers expected to meet higher standards. Care workers, disabled people, older people, unpaid carers, councils, unions and providers all need a role in shaping the service before its structure is fixed. Scotland’s difficulties show what happens when questions about control and delivery are allowed to remain unresolved while legislation advances.

Burnham should therefore publish a detailed account of eligibility, costs, funding, governance and implementation. A phased introduction might be sensible, provided the final destination and the timetable are honest. A National Care Service must be a workable plan developed with the people who will use and deliver it, not merely a compelling political slogan.

5. He could wait for Casey. Her commission should contribute evidence and test possible designs. Burnham has already accelerated its timetable, and he should use its work to improve his proposal. But waiting cannot itself be his policy. Having spoken so plainly about his ambition, he is unlikely to want social care remembered as a question he passed to someone else. The commission can help him decide how to act; it cannot make the political choices for him.

The question no Prime Minister can avoid

Every serious option costs money, but the figures often quoted in this debate describe different levels of reform. The Health Foundation estimates that a recent cap-and-means-test model could add around £4 billion a year by 2035/36. It estimates that having the state cover the costs of everyone currently receiving adult social care services in England could add about £18.5 billion a year by 2035/36. The latter is a much broader funding change, not simply a more expensive version of the same cap. Neither headline number is a complete, settled price for every possible design of a National Care Service, including any expansion of access or improvements to pay and quality. 

That distinction matters. A government could choose the cheaper cap and genuinely help people facing catastrophic costs. But it could not then claim to have created comprehensive, universal care. Conversely, Burnham could promise a service free at the point of use, but unless he pays for its staff and capacity, the costs will reappear as long waits, restricted eligibility or pressure on families. The real question is what he is willing to spend on the system he says England needs.

We also cannot escape the reality that social care has been underfunded for decades. The forecasts from the Health Foundation take into account the projected costs of funding the status quo via a new model, not an expanded and better-resourced social care system. The costs of a genuinely universal social care service are therefore likely to be higher.

The Prime Minister should be candid about how he proposes to raise the money. Will he dare to increase taxes or establish a dedicated contribution? Could he ask for greater contributions from accumulated wealth? Will he reconsider other expensive commitments, including the pensions triple lock? Each route creates losers as well as beneficiaries and changes to pension policy could fall heavily on people with modest incomes unless designed carefully. There is no reason to assume that the least politically painful way to raise money will also be the fairest.

Burnham has invited an honest conversation with the public. It must include the cost of inaction, too: unmet needs, exhausted relatives, workers leaving the sector and avoidable pressure on hospitals. Those costs may be less visible in a Treasury table headed “social care reform”, but they are paid every day. So is the uncertainty felt by people who cannot know whether an illness or disability will leave them facing bills they cannot manage.

My preference is clear. England should aim for a universal National Care Service, with free care at the point of use, dependable national entitlements and delivery shaped by local knowledge. It should serve people throughout adult life. That is a more fitting response to Burnham’s NHS principles than another adjustment to the means test. I am pleased that a Prime Minister has finally shown the courage to put the problem so openly. The test now is whether that courage extends to the detailed design and the funding decisions.

Can he create an equitable service while keeping taxes low, retaining every existing spending promise and avoiding a fight over who pays? Perhaps he will be tempted to tinker rather than be radical. But he should say plainly if a limited reform is what he chooses, rather than giving it the language of a universal service.

The fact that these questions are being discussed so openly is itself a huge step forward. In Scotland, though, we have been here before: there was considerable hope for a National Care Service but the attempt to introduce it, however well-intentioned, did not end well. Let us hope Burnham gets the detail right this time and creates a system that works for England—and might offer a basis for new approaches elsewhere.



Here is something I wrote three years ago, What should the future of social care look like?, which broadly supported the efforts to create a National Care Service in Scotland.