Fixing Social Care: The Announcement Is the Easy Part

What a National Care Service would actually require of the workforce built to deliver it

The Centre for Workforce Intelligence and Planning | July 2026

A seventeen-year homecoming

Andy Burnham has now been trying to fix social care for longer than some of the sector’s newest recruits have been alive. As Health Secretary in 2009, he published a Green Paper, Shaping the Future of Care Together, setting out three funding options for a new National Care Service and launching what became England’s largest-ever public consultation on care and support, the “Big Care Debate” (Department of Health, 2009). A White Paper, Building the National Care Service, followed in early 2010, weeks before the government that commissioned it lost office (Department of Health, 2010). The service was never built.

Seventeen years and several Prime Ministers later, Burnham is back at the same desk, in a considerably bigger office. As Prime Minister, he has pledged “substantial change” to social care, telling the BBC that without reform the NHS “will collapse” under the weight of people who should not need to be there (Nursing Times, 2026). Days later, reflecting on nearly thirty years of governments failing to act, he put it more bluntly still: “it is indefensible” (Document News, 2026). Sector bodies broadly welcomed the intent. The Royal College of Nursing’s Nicola Ranger said the Prime Minister was “right to highlight how the fortunes of social care and the NHS are inextricably linked” (Nursing Times, 2026).

Few would seriously dispute that a Prime Minister who first sat with this problem in 2009 has earned the right to be taken seriously on it. It takes a peculiar kind of stamina to fake interest in social care funding formulas for a decade and a half; most politicians can’t manage the enthusiasm past a single Parliament. What seventeen years of thinking does not do, however, is answer the practical questions a policy like this raises the moment it meets an actual rota.

What’s actually on the table

The shape of the plan, as reported ahead of the Prime Minister’s speech, is for personal and nursing care to become free according to assessed need, funded nationally rather than rationed by 153 different local means tests, broadly in the spirit of what Burnham first sketched in 2009 (Document News, 2026). What it does not appear to cover, at least initially, is what the sector bluntly calls “hotel costs”: the rent, food, heating and other daily living costs facing the roughly 400,000 people in residential care. That is not obviously mean-spirited by international standards; Nuffield Trust analysis of eleven comparable health and care systems found that almost all of them draw the same distinction between paying for someone’s care and paying for their rent (Oung and Curry, 2026). As the report’s authors note, “you would not expect the state to pay your rent if you were living at home” (Oung and Curry, 2026). Analysis reported ahead of the speech put the cost of free personal and nursing care at around £18.5 billion a year; including daily living costs for everyone in residential care would roughly double that figure (Document News, 2026).

None of this is a criticism of the ambition, and it is not this paper’s job to relitigate it. It is, however, exactly the kind of detail a workforce and planning organisation exists to sit with rather than skate past. Commentary elsewhere this month, notably Roy Lilley’s widely read nhsManagers.net newsletter, has pressed the obvious questions a genuinely universal entitlement raises when it replaces a means-tested one: what precisely becomes free, who qualifies, and who pays. All three matter. This piece is about a fourth question, the one a funding formula cannot answer on its own: who does the caring?

The workforce Burnham would be building this on

Whatever settlement emerges from the Casey Commission and the Fair Pay Agreement negotiations, it will be built on a workforce that is, by most available measures, closer to breaking than to expanding. Median care worker pay stood just 39p above the National Living Wage in December 2025, and the April 2026 wage floor rise pushed roughly 48 per cent of the independent-sector workforce, around 495,000 posts, below the new statutory minimum overnight, requiring an immediate correction simply to remain lawful (Care England, 2026b; Care Management Matters, 2026). The reward for staying in the job has all but disappeared: the pay gap between a care worker with five years’ experience and one with under a year in post has collapsed from 33p an hour in 2016 to just 10p today (Community Care, 2026).

The consequences show up in people’s lives, not just in pay scales. Health Foundation analysis finds that around one in five residential care workers live in poverty, roughly twice the rate of the average UK worker, and that 15 per cent rely on Universal Credit to make ends meet (Health Foundation, 2025). The Care Workers’ Charity’s 2025 Wellbeing Survey found 72 per cent do not feel financially secure, and more than a quarter had used a food bank in the past year (Care Workers’ Charity, 2026). For those already claiming Universal Credit, the system does not reward the extra hours a growing care service would need: once tax, National Insurance and the taper are combined, a claimant keeps as little as 32p of every additional pound earned (Institute for Fiscal Studies, 2026). For the 1.5 million unpaid carers the House of Commons Health and Social Care Committee identifies as effectively propping up the system, the barrier is sharper still: Carer’s Allowance operates on a hard cliff edge, not a taper, so earning a single pound over £204 a week costs a carer their entire £86.45 weekly payment, not a proportion of it (House of Commons Health and Social Care Committee, 2025; Assured BID, 2026).

Set against demand rather than just cost, the picture is no less stark. The Committee found that two million people aged 65 and over, and a further 1.5 million working-age adults, are not getting the care they need, even before a universal entitlement widens who is eligible to ask (House of Commons Health and Social Care Committee, 2025). A workforce recruited and retained on today’s terms was already struggling to meet yesterday’s demand.

Care England’s own scorecard on the government’s progress, published this week, is a useful reality check on how quickly good intentions translate into delivery. Grading two years of manifesto commitments as “requires improvement”, it notes that there is still “no social care workforce plan, no national standards”, and that the Fair Pay Agreement is backed by £500 million of funding against an estimated £1.4 billion the sector will lose to frozen tax thresholds over the same period, a promise that works out at roughly £393 per full-time worker a year (Faragher, 2026). Care England’s chief executive, Professor Martin Green, put the gap between promise and delivery plainly: “too much of what was promised exists only on paper” (Faragher, 2026). It is a fair description of every social care reform since 2009, not just the most recent one, and precisely the trap a National Care Service announcement needs to avoid repeating.

What a National Care Service would actually require of its workforce

Government has, to its credit, built some of the legal architecture reform needs. The Employment Rights Act 2025 establishes the sector’s first negotiating body for a legally binding Fair Pay Agreement covering pay, terms and conditions, and a new Adult Social Care Negotiating Body is due to be established by the end of this year (King’s Fund, 2026; Faragher, 2026). The difficulty is timing: the first Agreement is not expected until 2028, the same year the Casey Commission’s own deeper structural work is due to conclude (Care England, 2026a; Care and Support Alliance, 2026). If free personal care according to need is genuinely the direction of travel, waiting for both processes to land on their existing timetable risks a National Care Service being announced years before it has a workforce able to deliver it at scale.

At least five things would need to move well ahead of that timetable, or alongside it rather than after it.

Pace. An interim, funded pay uplift ahead of the full Fair Pay Agreement, and a credible parity anchor, most plausibly NHS Agenda for Change Band 2/3, which the Health Foundation has already costed at around £2.3 billion for the sector (Health Foundation, 2025; Homecare Association, 2025).

Progression. A funded structure tied to qualifications and specialisms, so the reward for staying and getting better at the job stops being a rounding error, currently just 10p an hour (Community Care, 2026).

Benefits reform. Without changes to the Universal Credit taper and the Carer’s Allowance cliff edge documented above, additional hours and additional entrants into paid care work remain financially irrational for exactly the people best placed to provide it.

Role redesign. England does not need to start from a blank page here. The Netherlands’ Buurtzorg model organises small, self-managing teams that combine nursing and personal care around a person rather than splitting them into separately commissioned visits; an independent KPMG evaluation found it delivered shorter overall episodes of care and lower total cost than conventional home nursing, alongside high patient and staff satisfaction (Drennan et al., 2018). Sweden’s undersköterska, a single regulated occupational title spanning hospital, primary and elderly care, has been a legally protected profession since 2023, giving roughly 180,000 staff a visible career ladder that runs across, rather than stops at, the boundary between health and social care (Nordic Labour Journal, 2020; LikeSweden, 2026). Germany has gone further still on training, replacing three separate qualification routes for elderly, general and paediatric nursing with a single standardised pathway since 2020 (Noracares, 2026). As Dr Anna Dixon MP put it in a recent Fabian Society collection on building the National Care Service, a Fair Pay Agreement “must be about more than pay”: it needs to address career progression and the ability of staff to move between the NHS and social care, and a ten-year NHS workforce plan needs a ten-year social care workforce plan running alongside it (Dixon, 2026). None of these examples is a template to import wholesale; evaluations of English pilots of the Dutch model found that some of its core features, particularly the professional autonomy Dutch nurses exercise over scheduling and clinical decisions, proved hard to replicate inside NHS regulatory and cultural norms (PMC, 2019).

The migration pipeline. This one rarely gets the attention pay reform does, and it may be the fastest lever available. Care England has warned that tighter immigration rules, including proposals under which migrant care workers could wait up to fifteen years for settled status, have not been matched by funding for domestic recruitment and training, “carving out a huge hole in our workforce with no plan to fill it domestically” (Faragher, 2026). Reports suggest Burnham is weighing an exemption for some care roles from the earned settlement proposals (Faragher, 2026). Compared with a multi-billion-pound funding settlement, that is a remarkably cheap thing to get right, and a remarkably expensive thing to get wrong twice in the same policy area.

The elephant in the care home: public purpose, private delivery

There is a structural question underneath all of this that is rarely said aloud in the same sentence as “National Care Service”, and it deserves a mild note of caution before it is dismissed. Whatever “national” ends up meaning, it will not mean publicly delivered, at least not in the way the name might suggest to anyone unfamiliar with how the sector actually works. In 1979, 64 per cent of residential and nursing home beds in England were provided by local authorities or the NHS; by 2012 that had fallen to 6 per cent (Hudson, 2018). Domiciliary care moved even further, from 95 per cent directly provided by councils in 1993 to just 11 per cent by 2012 (Hudson, 2018). The most recent workforce data confirms how deeply that trajectory has embedded: in 2024/25, around 84 per cent of the adult social care workforce sat in the independent, private and voluntary, sector, against roughly 7.5 per cent directly employed by local authorities, with most of the remainder employed via direct payments (Skills for Care, 2025). The care home sector alone spans around 11,300 homes run by roughly 5,500 different providers, a level of fragmentation the Competition and Markets Authority itself flagged as a barrier to consistent standards and effective oversight (Competition and Markets Authority, 2017).

That is not, on its own, an argument for renationalisation, which even critics of the current model tend to regard as neither feasible nor obviously desirable given how deeply embedded and fragmented the market now is (Hudson, 2018). The NHS itself, despite the name, has never been a single monolithic employer either; it has relied on independent GP contractors since 1948 and on outsourced clinical and non-clinical services for decades since, and still manages to be experienced by most of the public as one coherent, national service. What makes that possible is not who signs the payroll but whether the standards, training, pay architecture and accountability sit above the level of any individual provider. A National Care Service could plausibly follow the same logic: national terms, national training standards and a national pay architecture, delivered through a still-mixed economy of providers held to those standards, rather than a wholesale change in who owns the buildings.

That said, the case for asking the ownership question more openly than current policy debate tends to is stronger than it looks. Providers, unions and Care England itself have been explicit that pay compression is not employer reluctance but “commissioning arithmetic”: local authority fee uplifts have not consistently tracked statutory wage rises or employer National Insurance increases, leaving providers with “nowhere else to go” once they have met the legal minimum (Care England, 2026a). Around 70 per cent of the adult social care workforce is, in that sense, already publicly funded even though it is not publicly employed (Faragher, 2026); the state is, in practice, the dominant customer of a market it does not directly run. A structure built around 5,500 competing providers, many operating on thin margins set by the same local authority commissioners under fiscal pressure, has limited capacity to absorb a step-change in demand without either a much larger funding transfer or a genuinely different commissioning relationship, one that rewards providers for workforce stability and ethical employment practice rather than simply for lowest cost (Hudson, 2018). Sector leaders pressing the case for a National Care Service would do well to be equally precise about which “national” they mean: national standards within a mixed market, or something closer to the NHS’s own blend of public commissioning and increasingly mixed delivery. Burnham, who has spent a career defending the NHS’s public character while accepting its reliance on independent contractors, is arguably better placed than most to hold both ideas at once. Whether his government says so explicitly is a fair thing to keep asking.

The real test

Burnham deserves genuine credit for refusing to let this issue disappear into the long grass that has swallowed every predecessor’s attempt since 2010, his own included. But an announcement, however overdue, is not the same as a plan, and a funding formula is not the same as a workforce. Care England’s own scorecard on the last two years is a warning of how easily one gets mistaken for the other. The evidence above suggests a settlement that survives contact with an actual rota will need pace ahead of the Fair Pay Agreement’s 2028 timetable, a funded progression structure, reform of the benefit interactions that currently make working more hours irrational for many of the people the sector most needs, a serious look at how care and health roles are organised and trained, a domestic and migration workforce pipeline that isn’t quietly working against the policy’s own ambitions, and honesty about what “national” is actually going to mean for a market that has spent thirty years becoming almost entirely private.

None of that is a reason for cynicism about the ambition itself; if anything, it is a reason to take it seriously enough to ask the harder questions now, while there is still a genuine political window in which the answers might change the outcome. The funding announcement, when it comes, will make a good headline. Whether there is still someone available to do the caring is the test that actually matters.

References

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