A National Care Service: Putting people and place at the heart of reform

We welcome the prime minister's commitment to a National Care Service, and will be watching the Budget on 28 October closely to see how it will be funded. But the hard part is turning two complex local systems, council services and the NHS, into one national service. Done well, this is a chance to change how care and health work together, which matters as much to the NHS as it does to local government. 

The prime minister has put the National Care Service for England at the heart of Labour’s offer for the next parliament, with changes to the pensions triple lock from 2030 to help pay for it. What has been announced so far sets a direction rather than a model: care that is free at the point of use, a report from Baroness Casey's commission on how to deliver it by summer 2027, and a phased introduction after the next general election. 

The pressures on the system are immediate and acute. Councils alone face an estimated £5.8 billion of additional adult social care cost pressures by 2028. They and their NHS partners will be looking for more than a restatement of the commitment in the Autumn Budget. 

What the sector is hoping for 

• Funding commitments to carry councils through to reform 

• A clear role for local government in shaping and delivering the new service, drawing on local knowledge and democratic accountability 

• Assurance that central government will meet the full cost of the fair pay agreement, beyond the £500 million earmarked for 2028/29 

• Action that doesn’t wait for the election, such as unfreezing the means-test capital thresholds 

• Long-term, flexible money for prevention and discharge in place of short-term pots 

For local government, the stakes are high. Adult social care is one of councils' largest areas of expenditure and greatest sources of financial pressure. In 2024/25,  English local authorities’ gross current expenditure on adult social care was £29.4 billion, an increase of 9% on the previous year. Behind that figure sit growing demand, more complex needs, fragile care markets and a workforce under pressure. 

Funding is only part of the answer. The rest of this piece looks at what it takes to turn two local systems into one national service: how care connects to health, housing and communities, who is accountable, what Scotland and the discharge fund can teach us, and what extra money can and can't do. 

Care is about more than care services 

Local government's experience is that people's needs rarely fit neatly within organisational or service boundaries. Whether someone can remain independent is influenced by much more than the formal care they receive. Their housing, physical and mental health, family circumstances, financial security, access to transport and connections within their community all play a part. 

Councils work across many of these dimensions, from social care, housing and public health to safeguarding and community development. They understand the very different needs of older people, working-age adults with disabilities, people with learning disabilities and those with complex, lifelong support requirements. That breadth is a real strength of the current system, even where the system itself is fragmented and under pressure. 

It is also what the NHS needs to deliver its own reforms. Each of the 10 Year Health Plan's three shifts, from hospital to community, from analogue to digital and from sickness to prevention, depends on social care and on the wider support that councils and local communities provide. The plan's neighbourhood health teams will include social care workers. 

The link is clearest in hospitals. In April 2026, people who were well enough to go home spent 408,350 days in hospital beds, nearly 15% of all bed days in hospitals with major A&E departments, at an estimated cost to the NHS of £229 million that month. With beds 92% occupied on average, delays at the back door of the hospital are felt at the front. In 2025/26, 74.9% of A&E patients were admitted, transferred or discharged within four hours, against a target of 85% by 2028/29. Full hospitals also make it harder to protect planned operations for the 7.2 million cases waiting for treatment earlier this year. And for older people and people living with frailty, every extra day in hospital risks a loss of strength and independence that is hard to recover. 

Not every delay is caused by social care, and many of the solutions sit within hospitals themselves. But the evidence points the same way: people get home sooner and stay well for longer when health, care, housing and community support work together around them. 

There is a risk that in seeking to create a more coherent relationship between health and social care, we inadvertently design a National Care Service that is better connected to the NHS but less connected to the communities in which people live. That would be a missed opportunity, for the NHS as much as for local government. 

We should be open to fundamentally reconsidering where responsibilities sit, how care is commissioned and how services are delivered. Everyone in the system understands that there is no benefit in retaining existing organisational boundaries if they are getting in the way of better outcomes. But whatever institutional arrangements emerge, the connections between care, health, housing, communities and the wider determinants of wellbeing must be strengthened, not weakened. 

Designing a system that works for people and places 

A National Care Service offers the possibility of clearer entitlements, more consistent standards and a more equitable approach to funding. These are the right ambitions, but national consistency need not mean uniform delivery. Rural and urban communities face different challenges, local care markets vary in capacity and resilience, and the support available through families, communities and voluntary organisations differs considerably. A national framework needs to recognise these differences rather than design them out. 

Several questions are still open, and they’re the ones council policy teams will have to work through. Who will be responsible for understanding local need, shaping care markets and ensuring that services respond to different communities? How will councils, integrated care boards and independent providers work together, and how will councils' income from charging be replaced? And how will people have a meaningful voice in the services on which they depend, particularly where they move between services, as young people and care leavers do when they move from children's to adult services at 18? 

Local democratic accountability is one way of connecting public services to communities, but it is not the only possible model. What matters is that any new arrangements provide clear responsibility for outcomes, meaningful public accountability and the flexibility to respond to local circumstances. The starting point should be the outcomes we want to achieve, followed by the capabilities, responsibilities and governance arrangements needed to deliver them. 

What has been learned so far 

Scotland's experience is instructive. Its plans to move social care into a new national structure were dropped in January 2025, after local government, trade unions and others withdrew their support, leaving a much narrower set of reforms on care home visiting rights and breaks for carers. The lesson for England is about sequence: agree accountability and build consensus before structural change, and make progress first where agreement already exists. 

England has its own evidence. NHS England's £1.6 billion discharge fund for integrated care boards and councils in 2023/24 and 2024/25 had only small effects, because the money was short term, narrowly focused on discharge and limited by poor data. Those running services pointed instead to long-term investment, joined-up care and flexible funding. 

Understanding the financial challenge 

The financial scale of reform is considerable, but so too is its complexity. Adult social care expenditure is not a single, uniform cost that can simply be managed more efficiently. Some of the greatest pressures arise from the increasing complexity of care needs, the costs of specialist provision and growing demand among working-age adults, who make up a little over 40% of people receiving publicly funded long-term care. These pressures will not necessarily be addressed by a policy focused primarily on financing personal care for older people. 

Nor can the financial opportunity be understood simply by applying an assumed efficiency percentage to national expenditure, although illustrative sums do help show its scale. A 1% improvement across council spending on adult social care would be worth about £294 million a year. At 3% it would be about £880 million, and at 5% about £1.5 billion. Even the higher figure would offset only around seven and a half months of the £2.3 billion growth in spending seen in 2024/25. Savings of this kind are worth having, but they buy time rather than resolving the underlying pressure. 

Health shows a different kind of benefit. Halving the delays faced by people well enough to leave hospital would free about 204,000 bed days a month, the equivalent of roughly 6,800 beds every day. NHS England's own costing would value that at around £115 million a month, but most of it would be released as capacity for other patients rather than as cash. 

Better commissioning, earlier intervention, effective reablement, assistive technology and more coordinated support can all improve productivity and outcomes, but the organisation making the investment may not be the one that receives the financial benefit. We need to distinguish between cashable savings, avoided future costs and improved outcomes. All are valuable, but they have different implications for public finances. 

There is also a potential tension between expanding entitlement and reducing expenditure. A more accessible National Care Service may bring previously unmet needs into the formal system. That may be an entirely desirable consequence of a fairer approach to care, but it needs to be understood and funded. The financial model must therefore look beyond the budgets of individual organisations and consider the costs, benefits and incentives across the whole health and care system. 

The hard part comes after the Budget 

The Budget on 28 October will show how far the government is prepared to back the National Care Service with funding, and whether councils get any clarity or money before the commission reports. It won't settle the hard part: turning two local systems into one national service without losing the local knowledge, relationships and accountability that make care work. When the Budget is announced we’ll be reading it against the hopes listed at the top of this piece. 

Over the coming months, councils and their NHS partners will need to interpret each announcement as it arrives, from the Budget on 28 October to the Casey Commission's recommendations. They will need to work out what they mean for their costs and demand, their care market, their workforce and their partnerships. We'll be publishing further insight after the Budget on what was announced and what it means for councils. In the meantime, we'd welcome conversations with councils and health partners who are thinking this through. 

The measure of success should not be the scale of organisational change, or the creation of a new national institution. It should be whether people can access support when they need it, avoid time in hospital they don't need, remain independent for longer, experience greater dignity and choice, and have confidence that the system will be there for them.