Andy Burnham is back in the political headlines, and with him an idea that has long energised debates on social care reform. In 2010, as Health Secretary, Burnham proposed a National Care Service: a simpler, fairer system, reduced postcode variation, closer working between health and social care, and support that is easier to navigate.
Proposals to fund social care through an estate levy were branded a ‘death tax’ by Conservatives. The phrase cut through and weeks later Labour lost the election. England has spent decades agreeing social care needs reform, then retreating when the talk turns to money.
Fifteen years on, many problems remain. Families still struggle to know where to turn. People repeat their story to multiple organisations. Hospital discharge is delayed because support at home is unavailable. Preventative help comes too late, if at all. The instinct to integrate is understandable. But are we designing care around citizens or around institutions?
As a social worker said on LinkedIn, ‘People want the integration of support to be personal, directed and led by them with their families. No one ever asked for two broken pieces of state machinery to be fused together, founded on a belief that they would somehow mend each other and deliver for people.’
Integration should describe the person’s experience of support, not the merger of organisations. Institution-led reform starts with structures: who owns the budget, which bodies merge, who chairs the board, how NHS and council processes align. Citizen-led reform starts with people: what does this person need to live the life they want? How can support be simple, flexible and responsive? How do we help people remain well, independent and connected?
Greater Manchester has been one of England’s most visible experiments in health and care integration. If structural integration were the answer, we might expect consistently strong outcomes. Yet the Care Quality Commission’s (CQC’s) May 2026 assessment of Salford City Council raises questions.
Salford has had Section 75 arrangements delegating adult social care functions to NHS trusts since 2016. CQC nevertheless rated the council ‘inadequate’, identifying delays, weak governance, safeguarding concerns, unreliable data, poor communication and limited person-centred practice. No single assessment tells the whole story, especially in an under-funded system. But Salford reminds us that structural integration does not automatically create better care.
The NHS and social care are fundamentally different. Healthcare focuses on diagnosis, treatment and episodic intervention. Social care is about daily life, relationships, dignity, independence and continuity. If social care is absorbed into healthcare thinking, we risk solving the wrong problem.
Collaboration is still essential. People using homecare often need joined-up support from GPs, nurses, therapists, hospitals, councils and care providers. Fragmentation causes real harm. But collaboration is not institutional absorption. There is also a practical question about delivery. Burnham’s earlier vision reflected discomfort with market-based care provision and a stronger role for the state. Many people will sympathise with concerns about poor commissioning and unacceptable practice.
However, we should not confuse failures of system design and funding with failures inherent to independent provision. The independent sector delivers most homecare in England and forms essential national care infrastructure. Direct state delivery would require major public investment, workforce expansion, management capacity and years of transition. The useful debate is not ownership ideology. It is how to create high-quality, sustainable, person-led care, whoever delivers it.
A future National Care Service should begin with citizens, not organisations. It should offer clear routes to advice, transparent, equitable funding, genuine choice, stable neighbourhood care, fair commissioning and practical collaboration. The real divide is not public versus private. It is whether we design care around the lanyards or the lives. Get that wrong and no restructuring will deliver the care people deserve.
Dr Jane Townson OBE is Chief Executive Officer at the Homecare Association.
Email: [email protected] LinkedIn: @Homecare-Association