England’s “creaky” adult social care system is confusing and impenetrable for the people who rely on it and are held together with “band-aids and glue”, the head of a government-commissioned review has said in a withering critique.
Louise Casey said the country was facing a “moment of reckoning” over its failure to effectively and fairly meet the needs of its aging population and the growing number of people with chronic diseases such as dementia and Alzheimer’s.
In a frank and often impassioned speech, Casey said society needed to confront the great challenge of reforming an underpowered system in which “some needs are barely met and others are met late and in a fragmented and random manner.”
Casey, who has been tasked with giving political substance to the government’s manifesto commitment to establish a national care service, said her review was examined through “the lens of the adult and their family who need social care”.
“The challenge for all of us is to get this right and it is collective. How do we ensure that care and support are available to those who need it in a fair and dignified way that reflects the nation and the values we hold dear today? It is a time of reckoning. It is a time of renewal,” he said in a speech Thursday.
In January 2025, Casey, a former social activist and senior civil servant best known for chairing national inquiries into issues such as homelessness, the Metropolitan police and grooming gangs, was commissioned by the government to carry out a major two-part review of adult social care.
He said adult social care had never had a “Beveridge moment” – a reference to William Beveridge, the architect of the post-war welfare state – and that the nation had never had an honest debate about how it could provide support and care for an older, sicker population.
Despite at least 22 major reviews of welfare over three decades, welfare reform had never had the political backing it needed, he added.
Years of fragmented change and underinvestment had left adult social care underpowered and fragile, delivering often inconsistent services that left people and families needing help confused and anxious, he said in a speech to health and social care leaders on Thursday.
Services had been cut during years of austerity, while provision depended on what she called the exploitation and underpayment of care workers. Social care was the poor relation of the NHS and the two services often failed to work together.
In diseases such as dementia and Alzheimer’s, artificial definitions of which services counted as healthcare and which were social care had led to institutional “fights” over who footed the bill, he said, “and families footed the bill.”
This division between care and health “does not exist for the public,” he said: “It is based on our division, on definitions and categorizations that satisfy each institution. Not the public. It is not about what is best for the patient or the person.”
He contrasted the failure of the NHS and social care to respond to the “seismic challenge” of dementia and Alzheimer’s with the “brilliant determination and energy” those services had brought to the fight against cancer.
He urged health secretary Wes Streeting not to wait for his report but to invest immediately in dementia trials, create a full-time “dementia tsar” and speed up care for people diagnosed with motor neurone disease (MND).
The first phase of Casey’s review, due this year, will set out plans for a national care service. The second phase, expected to be reported in 2028, will examine how to build and finance a system to address the country’s care needs.
A spokesperson for the Department of Health and Social Care said it had accepted Casey’s proposals on dementia and MND. “It’s about moving faster, reducing delays and building a social care system that works for everyone,” they said.
Caroline Abrahams, charity director at Age UK, said: “This is possibly the first time that someone as senior, respected and independent as Baroness Casey has been prepared to tell the truth about the state of social care in our country.”
Nuffield Trust deputy director of policy Natasha Curry said: “As the clock ticks for this government, the commission must act quickly and seize the momentum for change.”
