National care, local power

The words ‘National Care Service' can make local government nervous. They are heard as shorthand for making social care more like the NHS: nationally designed, nationally managed, with councils left holding a diminished role.But that does not appear to be what Baroness Louise Casey or Prime Minister Andy Burnham have in mind. Both seem to be pointing towards something different – a stronger national guarantee, but care that remains locally delivered. That distinction matters because it could be the key to making genuine devolution possible.Social care needs a stronger national settlement. People should have greater certainty about what they can expect wherever they live: clearer entitlement, sustainable funding, stronger workforce and provider foundations and greater consistency in quality and access. Much of the foundation is already there in the Care Act. The task is to make its promise more reliable in practice, not to replace its emphasis on wellbeing, choice and local responsibility.The Social Care Institute for Excellence's work on national standards points in the same direction – a national floor can promote equity without prescribing every detail of how support should be organised locally. The principle should be simple: nationalise the guarantee, not the management.But stewardship only works if the centre can distinguish between assuring the national promise and controlling how places deliver it.A stronger national promise should make local control more real, not less. A national guarantee should enable devolution.That matters because social care is not simply another public service waiting to be organised like the NHS. It is part of a social ecosystem involving councils and providers, but also families, unpaid carers, housing, voluntary organisations, communities and the relationships that sustain people in everyday life. Whitehall cannot manage that ecosystem. But it does need to steward it.That means setting the national promise, distributing resources fairly and helping to secure the workforce and provider capacity needed to deliver it. It also means knowing whether the promise is being realised in practice and ensuring action is taken when persistent inequality, capacity failure or local failure puts it at risk.But stewardship only works if the centre can distinguish between assuring the national promise and controlling how places deliver it.England has a powerful habit of recreating central control even when policy says power is being devolved. Moving responsibilities from Whitehall to a mayor is not devolution if decisions that belong at council, place or neighbourhood level simply move upwards again.Devolution is not about where the headquarters sits. It is about where decisions are made. Greater Manchester shows both the potential and the limits.Its health devolution was never simply about handing the NHS to the mayor. The more important achievement has been aligning health and care with housing, employment, transport and the wider things that shape people's health. Yet much of the practical work of integration still happens at place and neighbourhood level.The lesson is not to ‘give social care to mayors', it is to put each responsibility at the level where it can best be exercised.Some things need strategic scale – workforce planning, market-shaping and resilience, specialist provision and connecting health and care with housing, skills and economic policy. Others depend on the relationships, accountability and local knowledge of councils and neighbourhoods.That matters when the maps of health and local government are moving in different directions. NHS commissioning is consolidating onto larger footprints while local government reorganisation could break up some existing social care systems. Care markets, workforces, families and communities do not reorganise themselves to fit new administrative boundaries.Local government should therefore stop asking whether a National Care Service threatens its existing responsibilities and start asking what powers it needs to make one work.If councils respond by demanding that adult social care stays where it is, they could miss the biggest devolution opportunity in a generation. But there is a larger possibility.For decades we have asked how social care can become more like the NHS. Perhaps it is time to reverse the question.Aneurin Bevan spearheaded the creation of the British National Health Service. He was right that a national guarantee should protect people from geographical inequality. But a national guarantee and national management are not the same thing. A National Care Service could demonstrate how to secure the first without requiring the second. And if we can do that for care, why not health?The NHS itself is moving towards larger strategic footprints while placing ever greater emphasis on neighbourhood working. A National Care Service built around a national guarantee, devolved responsibility and strong local delivery could offer the NHS something it has struggled to achieve – a genuinely national service that does not require national management.That does not mean giving every function to a mayor, nor pretending that structural reform substitutes for adequate funding. Genuine devolution requires capable institutions, mature relationships and leaders willing to tolerate local discretion rather than constantly pulling decisions back towards the centre.The task is not to build an NHS for social care, but to make the national promise clear enough, and the responsibility for standing behind it strong enough, that Whitehall no longer needs to run everything underneath it.Done well, a National Care Service could make social care more national and the NHS more local.Paul Burstow is a former care minister and MP who helped shape and steer the Care Act 2014. He later served for nine years as chair of the Social Care Institute for Excellence and is now chair of the Global Leadership Exchange

Title

SOCIAL CARE

National care, local power

By Paul Burstow | 04 September 2026

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