On 29 July 2026, Prime Minister Andy Burnham gave a speech on his desire to reform  the adult social care system in England. As his first steps, he announced ‘cross-party talks’ with the leaders of the Conservative and Liberal Democrats, and prioritising reforms for improving the social care workforce. 

Burnham also confirmed that he will bring forward the government report on social care (led by Baroness Casey Louise) to 2027. The report was originally commissioned by Sir Keir Starmer to outline paths of reform for social care in England. This would aim to establish a ‘National Care Service’, which would make social care free at the point-of-delivery for everyone, along the same principles as the NHS.  

Social care reform has been attempted several times by past UK Governments to much public debate. In fact, since the original Royal Commission in 1997 that called for an urgent solution to the challenges of an ageing society, there remarkably have been 22 separate attempts at social care reform – many with limited success.  

At the London School of Hygiene & Tropical Medicine, multiple academic groups have been researching the problems with, and policy solutions for, adult social care in England. The Centre for Care Research and Policy (C-CARE) group is dedicated to long-term care throughout the world, with a big emphasis on social care in the UK. Similarly, NIHR Policy Innovation and Evaluation Research Unit (PIRU) hosted by LSHTM regularly advise the UK Government on new policies in health improvement, health care and social care and their possible effects on different communities. 

Professor Shereen Hussein, Professor of Health and Social Care Policy at LSHTM, Dr Josephine Exley, Assistant Professor at LSHTM and Dr Mirza Lalani, Assistant Professor at LSHTM from C-CARE and PIRU at LSHTM outline what they’ve found through their research and reflect on what needs to be done next to effectively reform social care in England.   

The Big Conversation on Care 

During his speech, Burnham announced the launch of the “Big Conversation on Care” to hear from people with lived experience, families, carers and the wider public. The engagement aims to allow people to give their views on the future of adult social care and the big questions that underpin its reform.  

Conversations like this have already happened. Professor Hussein highlights the findings of the Adult Social Care Staff Evaluation of Reforms to Training (ASSERT) study which captured what policymakers and national sector leaders expected of the 2023 social care workforce reforms before they were implemented. 

The study found that the policymakers and sector leaders felt the 2023 reforms would show “something was being done” but that without explicit regulatory and funding changes, on the ground reform would be minimal.  

In terms of asking the general public, Professor Hussein reflects that ASSERT’s limitation was in asking national level and senior figures which “captured organisational positions more than individual experience”. She stresses, to get on-the ground sentiment, a deliberate targeted engagement campaign is needed prioritising frontline workers and people using social care services, not just a public open invitation for conversation.  

More support for the social care workforce 

Burham’s announcement also highlights the need for change around the current social care workforce. Although not going into specifics, it does mention that the Government will look to “broaden the Fair Pay Agreement into a bigger reform to bring the workforce closer to NHS standards in terms of pay and progression routes”. Improving working conditions will be essential for successful reform, as the sector has struggled with workforce recruitment and retention. 

Professor Hussein notes that Burnham’s proposition, while ambitious, isn’t necessarily suited to tackle the current problems that adult social care faces. For example, the current gap in staff recruitment won’t be addressed by the Fair Pay Agreement on its own. International recruitment for care roles ended in July 2025 without a replacement plan, and while the Fair Pay Agreement takes effect in 2028-29, the visa transition ends in July 2028. This intervening period will essentially be a recruitment black hole, as the structural drivers of staff turnover will remain unaddressed. Any serious reforms will need to adapt to that reality first before trying to tackle workforce issues.

But what reforms do social care staff themselves want to see? The Developing a validated scale for Adult Social Care work-related quality of life (ASCK-WELL) study, developed in partnership with frontline care workers, provides some answers on care work-related quality of life. The study found that recognition, time and responsibility are areas that need to be improved.  

In terms of recognition, workers in the study drew a consistent distinction between recognition as discourse and recognition as material conditions. Appreciation, however sincerely meant, was valued but understood as insufficient on its own; as one participant put it, you can say nice things, but it is the actions that matter.  

The study shows clearly that where recognition is expressed symbolically without corresponding change to pay, security and protections, it widens the gap between rhetoric and experience and can intensify the sense of being undervalued. This underlines that, not only does the Fair Pay Agreement have to be reached, it needs to have more than just headline rates attached.

Time was highlighted as another area of concern. Social care delivery framework treats time in care as an employment standard, having enough time for training and delivering quality care, rather than a scheduling problem, fitting in as many tasks in the shortest time possible. Workers described completing training in their own time because it could not be accommodated within shifts and pay practices that deducted for minor lateness while declining to pay for time spent remaining with a client after a serious incident. A workforce offer built around training and wider support will not improve retention if protected, paid time to use it is not funded.

Finally, the study found that the current expansion of responsibility without corresponding authority needs to be reversed. Workers reported being held morally accountable for safety and dignity while having no control over scheduling, staffing or task sequencing. What needs to be done? Training, supervision, role clarity and protections have to expand at the same rate as accountability, not after it.

The missing piece: The National Care Service and devolution

The Prime Minister also outlined the core principles behind the future planned National Care Service:  

• The system must allow people to move seamlessly between hospitals, home care and community services.
• This service must be fully and sustainably funded
• The service must start with prevention, supporting people to live independently for longer
• Citizens’ needs must be at the heart of plans, removing budget battle lines between organisations and making sure local social, primary and community care works together effectively

On the surface, a National Care Service that is integrated nationally with the NHS and with a single workforce seems like a good idea. However, there’s an underlying tension: healthcare is delivered at local and regional levels. Adult social care is the largest, and costliest, task of local governments and it continues to grow. Under his plans, the burdens of responsibility and cost would need to be fundamentally reshaped to fit a national service model.  

This approach would not only radically change the current system, it could also present some serious questions about responsibility and governance. Dr Mirza Lalani, Assistant Professor at LSHTM summarises: “Adult social care is fragmented, as different regions vary considerably in how they provide care. Who can ultimately be held accountable for success or problems is also fragmented: the authority that determines funding sits at a different level to the regulators, or the companies that deliver social care. The fact that England’s social care is a mixed economy, where the system is partly ran by the government, the private sector, and the voluntary sectors, complicates the issue further”

“Implementing social care reforms means you have to navigate many different organisations, each with different structures and pressures. Reforms that are popular and seem coherent at a national level can encounter very different realities on the ground, and in different regions.”

There’s data to back up this viewpoint too, points out Professor Hussein, based on the findings of the ASSERT and ASCK-WELL projects. These projects found that the national level of governance would be best place to set common national standards, provide qualifications and establish entitlements for the workforce, and manage data infrastructure. Local governments would then be best-placed to commission and deliver the social care within their areas.

The hard question: Who pays?

Amongst all of demand for reform, there is also the thorny question of who should pay to fund the proposed changes – something LSHTM’s PIRU team has tried to get a better understanding of.

The need for social care and therefore the cost of providing more services, is only going to rise in future thanks to the UK’s ageing population. In England, it is anticipated that 50% of people aged 65+ will spend up to £20,000 on social care and that around 10% will spend over £100,000. Adding further complexity is the Government’s current means testing approach to allocating social care funding to individuals. This means most people who need social care, whether at home or in a care home, have to pay for it themselves (or get unpaid care from friends and family). Importantly, very few people plan for future social care needs either financially or in other ways. As a result, people can find themselves subject to unpredictable and potentially catastrophic costs.

Dr Josephine Exley acknowledges that while there is clearly a growing need for social care, there is poor understanding of how the social care system works among the general public; what social care involves, who receives social care, how it is paid for and how much recipients are expected to pay themselves. Few people realise that a large proportion of social care costs are paid privately by individuals their families and many only find out when they need to arrange social care for themselves or a loved one.

LSHTM’s PIRU team have conducted several studies to better understand what the public actually think. The team conducted a survey of 3000 people living in England between the ages of 18 and 75 to determine how they felt social care should be paid for. The participants were presented with different scenarios and asked to state what the split should be between Government and individual contributions in each scenario. Response options ranged from the “Government should pay for all” to “everyone should make their own arrangements”.  Nearly 60% thought costs of social care in older age should be shared between the individual and Government. However, compared with current arrangements, many believed the Government share should be greater and come into play before an individual has depleted their own financial resources.  

Digging deeper, the team also conducted focus groups across England to understand why people support sharing the costs of social care between individuals and Government.

The discussions showed that most participants supported shared funding because they believed that neither individuals nor the Government can afford to pay for social care on their own, s shared funding was seen as a practical way to spread the cost and share the financial burden.

Exactly where the split lies though, depended on how individuals framed social care in their minds. When the concept of shared funding was discussed in general terms participants discussed splitting it 50:50, with some arguing that given limited government resources, government funding it should only be used for care that is considered medically necessary.

In contrast, when participants were presented with specific individuals and situations, they favoured government paying a larger share of costs. The impact of individual stories even altered how people defined “medical need”, with many recategorizing the social needs of individuals as medical needs, for example the view that social loneliness kills. Participants also expressed a lot of concerns about individuals running out of money and not being able to access good quality care, so while they expressed support for individual contributions in theory, they also expressed a desire for greater risk pooling and collective provision.

Dr Exley admits that this leaves policymakers in a tough position on how to answer the question of who pays for social care. From PIRU’s studies, it is clear that most people have a very limited understanding of the social care system and often cannot sustain a single normative standpoint. This, argues Dr Exley, negatively impacts the level and quality of public debate possible  and raises questions about whether policy makers should be asking the general public to resolve the issue.

In her view, PIRU’s work highlights that in order to get a real gauge of public sentiment around who pays for social care, the public debate needs be human-centre, focusing more on people’s personal experience and values rather than the funding system itself.

The current state of play and where next

The debate around social care is clearly very complex and LSHTM’s researchers have provided evidence that not only highlight the sector’s existing problems and current public attitudes but also shine a light on the path ahead.  

In short, social care in England needs to be reformed, Dr Mirza Lalani said: “The sector’s core problems have been recognised for decades, yet successive governments have struggled to deliver reform.”

Dr Hussein said: “To meet this challenge, the government cannot rehash outdated analysis: it needs to engage with the current problems the social care sector faces. We need to have the best evidence and frameworks at our disposal for effective, evidenced-based reforms”.