Core system failures
This submission identifies six critical failures in the current system:
1. Invisible unmet need –there is no national waiting list or consistent measurement of delays across the care pathway.
2. Over-restrictive means testing – outdated capital thresholds that expose ordinary households to significant care costs.
3. Catastrophic financial risk – no lifetime cap on care costs, leaving individuals exposed to unlimited liability.
4. Hospital discharge bottlenecks – fragmented responsibility leading to delayed discharges and blocked NHS beds.
5. Chronic workforce shortages – insufficient domestic supply and constrained international recruitment options.
6. Underfunded provider market – commissioning rates that do not reflect the real cost of delivering safe care.
Priority recommendations and implementation plan
1. Make unmet need visible: establish a National Social Care Waiting List
Policy objective: Create a single, transparent national system showing demand, delays and unmet need across the entire social care pathway.
Implementation steps:
● The Department of Health and Social Care (DHSC)should mandate a standardised national data set covering all local authorities.
● NHS England and DHSC (jointly) should develop a unified digital reporting platform, aligned where possible with NHS waiting list infrastructure.
● Local authorities must report monthly data on:
● assessment waiting times
● care package commencement delays
● domiciliary care hours commissioned vs delivered
● residential and nursing placement delays
● hospital discharge delays attributable to social care
● The Care Quality Commission (CQC) should have oversight of data accuracy as part of its local authority assurance function.
● Data should be published quarterly at national and local authority level.
2. Modernise financial eligibility: raise the upper capital threshold to £100,000
Policy objective: Reduce exposure of ordinary households to immediate care costs and align thresholds with modern asset levels.
Implementation steps:
● DHSC should amend the Care and Support (Charging and Assessment of Resources) Regulations.
● The upper capital limit should be increased from £23,250 to £100,000 per person.
● Local authorities should be given a 12-month implementation window to adjust financial assessment systems.
● DHSC should issue statutory guidance to ensure consistent application across England.
● An evaluation of distributional impact should be conducted by the Office for Health Improvement and Disparities (OHID) within two years.
3. Introduce a lifetime care cap: £250,000 per person
Policy objective: Provide individuals with certainty over maximum lifetime exposure to eligible care costs.
Implementation steps:
● DHSC should establish a National Care Cost Cap Scheme, modelled administratively on existing pension or tax account systems.
● A centralised individual care account should be created for every eligible person, tracking cumulative eligible care expenditure.
● The NHS Business Services Authority (or equivalent national payment body) should administer the accounting system.
● Once £250,000 is reached, DHSC guidance should require:
● full state funding of eligible care needs
● automatic notification to the relevant local authority
● Implementation should be phased over 3–5 years, beginning with new entrants to the system.
4. Fix hospital discharge: establish a dedicated Hospital Discharge Service
Policy objective: Eliminate delayed discharge caused by fragmented responsibility and lack of rapid care coordination. Unlock at least an extra 20% bed capacity in NHS hospitals
Implementation steps:
● NHS England should require every Integrated Care Board (ICB) to commission a seven-day Hospital Discharge Service for each acute hospital.
● Services should be commissioned jointly by ICBs and local authorities, with pooled budgets under Section 75 agreements.
● Providers (which may include private, voluntary or NHS organisations) should be selected through competitive procurement.
● Each service must be responsible for:
● discharge planning from admission
● arranging home care, reablement or residential placement
● commissioning short-term packages within 24 hours of discharge decision
● Performance metrics should be set nationally by NHS England, including:
● average discharge time from “medically fit” status
● 7-day readmission rates
● patient experience outcomes
● CQC should inspect discharge services as part of system-level assurance.
5. Stabilise the workforce: controlled international recruitment with domestic expansion
Policy objective: Ensure sufficient workforce supply while maintaining quality, safeguarding and ethical recruitment standards.
Implementation steps:
● The Home Office, in consultation with DHSC, should reintroduce a Social Care Worker Visa route.
● Sponsorship should be limited to CQC-registered providers with a compliance rating above a defined threshold.
● Visa conditions should allow workers to bring up to two dependants, subject to financial and accommodation safeguards.
● DHSC should establish a National Workforce Strategy for Social Care, including:
● funded training expansion via Skills for Care
● minimum training and career progression standards
● retention incentives for experienced staff
● A national workforce dashboard should be published quarterly by DHSC and Skills for Care.
6. Fund care at true cost: introduce a National Social Care Cost Model
Policy objective: Ensure commissioning rates reflect the real cost of delivering safe, sustainable care.
Implementation steps:
● DHSC should establish an independent National Social Care Costing Unit, potentially hosted by an arm’s-length body.
● The unit should publish an annual National Care Cost Model, incorporating:
● National Living Wage and forecast increases
● employer National Insurance and pension costs
● travel time and mileage
● training, supervision and compliance costs
● inflationary pressures specific to the sector
● Local authorities and ICBs should be required to demonstrate that commissioned rates are aligned with or above the national cost benchmark.
● The CQC and DHSC should jointly monitor market sustainability risks, including provider exits and service fragility.
Strategic direction
These reforms are underpinned by a single principle: social care must become visible, financially predictable and operationally coherent across health and local government systems.
To achieve this, responsibility must be clearly allocated:
● DHSC – national policy, funding framework, financial eligibility and cost cap design
● NHS England / ICBs – hospital discharge commissioning and integration with health services
● Local authorities – care assessment, commissioning and delivery oversight
● CQC – system assurance, provider regulation and data validation
● Home Office – workforce immigration routes
● Skills for Care – workforce development and training standards
Without transparency, the scale of unmet need remains hidden. Without financial reform, families face unpredictable and often catastrophic costs. Without workforce and funding stability, services cannot expand to meet demand. And without a clear discharge system, pressure on the NHS will continue to intensify.
The Commission has the opportunity to establish a new social care settlement based on entitlement, accountability and sustainability, replacing fragmented provision and implicit rationing with a system that is transparent, properly funded and operationally coherent.
This would represent a decisive shift towards a system that is understandable to the public, fair in its financial design, and capable of meeting the needs of an ageing population.
Justin Jewitt
Chair ENHERTS PPG Network
CV :
Over 30 years experience in delivering healthcare at home and in residential homes
CEO Nestor Healthcare Group Plc 1994-2004
Chair Home Choice Care 2005-2012
Chair Hilton Nursing Group 2013-2019
Chair Chiron Healthcare At Home 2020-2025
07970 287743