As we reflect on the Care Act's 10th anniversary, it's important to recognise the sector's journey since the NHS and Community Care Act of 1990. This legislation aimed to drive competition, efficiency and innovation in social care by enabling councils to outsource services to independent providers. It sought to shift power and resources closer to communities, reduce institutionalisation and build productive partnerships between the public, private and voluntary sectors.
In the three decades since, many providers have embraced this opportunity with creativity and commitment - developing new models of care, investing in facilities and technology, and driving up quality. At their best, they have combined an entrepreneurial mindset with a strong public service ethos.
The Care Act 2014 offered a transformative vision for adult social care in England, with high-quality, personalised support to enhance the wellbeing of older and disabled people. It recognised the value of a vibrant, diverse and sustainable market in fostering choice and stimulating improvement. The Act gave councils duties to shape local markets and ensure continuity of care if providers failed. It promised a fairer partnership between the state, individuals and families in sharing costs.
A decade on, it's clear that while the Act's principles were sound, the system has lacked the investment and policy architecture needed to realise them. Many of today's challenges - fragmented services, unstable markets, a struggling workforce - stem from failure to align resources and incentives with the Act's goals."
Instead of encouraging early support and preventative services in the community, the government has poured most of the funds into crisis management of hospitals. This has exacerbated demand, piling pressure on individuals, families, councils and the NHS, and trapping people in costlier services.
Meanwhile, spending on care has fallen by 40 per cent in real terms. Councils have had little choice but to squeeze fees, and short-term grant funding has failed to bridge the gap.
In many areas, the vision of a genuinely mixed market, with a range of quality options to suit different needs and preferences, has given way to a race to the bottom on price. The gulf between state-funded and self-funded care has widened to a chasm, worsened by a North-South divide in wealth, entrenching individual and regional inequalities.
Starved of resources, too many councils have fallen back on rationing, time and task commissioning, and buying care by the minute, rather than the outcomes-based, person-led support envisaged by the Act. To save money, some councils are encouraging use of unregulated care and ‘gig’ economy models, risking quality, safety, compliance with tax law, and employment rights for care workers.
Providers in the state-funded part of the market find themselves stuck on a treadmill of inadequate fee levels, high staff turnover, and compromised quality. Practices like "call clipping" in homecare – rushing calls to cover payment for travel time - have increased as providers struggle with low margins.
While the Act promised a well-trained, professional workforce, care workers remain undervalued and underpaid. Zero-hours commissioning leads to insecure zero-hours employment and a lack of investment in the pay, training, development and support needed to recruit and retain talent.
Most care workers love their jobs and the ability to improve lives. Too many, though, feel stretched by inadequate staffing and lack sufficient training to deal with increasing complexity of need."
As powerful monopsony purchasers, many councils are distorting care markets by failing to respond to rising costs, driving down prices, exploiting loopholes in regulations, and turning a blind eye to poor practice. This means we are not seeing the consistent innovation and efficiency gains that fair, well-regulated competition between high-quality providers should deliver.
In some places, cheap poor-quality providers are winning most of the work, threatening the viability of good quality ethical providers. This creates the conditions for labour abuse and modern slavery, as well as risking quality and safety. Commissioners and regulators, such as the Care Quality Commission, HMRC and UKVI, appear to lack the leadership, consistency, resources, or will, to enforce the rules and drive improvement effectively.
To reset the market and unlock its full potential, we need:
- A shift to outcomes-based commissioning focused on wellbeing and prevention, rather than a transactional 'time and task' approach. This would give providers more flexibility to innovate and tailor support, combining in-person care with technology solutions.
- Commissioning based on long-term value, not short-term price. Fees must cover the actual costs of good care and enable investment in staff, facilities and technology. A multi-year funding settlement is essential for market stability and planning, as well as workforce development.
- A comprehensive workforce strategy to make care an attractive career, aligning workforce growth and development with changing population needs. Care staff at all levels need fair pay and terms and conditions of employment, which reflect their knowledge, skills and responsibilities, as well as opportunities for career progression and properly funded training and development. Councils should reward the best employers with better commissioning terms.
- Genuine partnership between commissioners and providers to shape sustainable markets - moving away from the current dysfunctional 'buyer-seller' relationship. This should look 5-10 years ahead and aim for a diverse mix of provision to maximise choice, with a focus on outcomes, prevention and community wellbeing.
- A rigorous threshold for market entry and tougher sanctions for rogue providers and poor commissioners. CQC needs to work faster to identify and root out unacceptable practice. It should be unlawful for public sector commissioners to purchase care at fee rates which prevent compliance with care and employment regulations and undermine the principles of the Care Act.
- Capital investment to modernise facilities and introduce technology solutions, especially in less affluent areas. Pump-priming from central government should leverage private and social investment.
These building blocks need to be underpinned by action on the Act's unfinished business - implementing the cap on care costs to end the catastrophic bills facing many families. This will create a simpler, fairer system that protects wellbeing and dignity.
The Care Act, although excellent, still requires effective implementation. The 10th anniversary must be a catalyst for changes that are long overdue.
