Introduction

The COVID-19 pandemic threw into stark profile the multiple structural weaknesses in English adult residential care, particularly compared with health services. These weaknesses include: the chronic underfunding of care services; the prioritisation of health in national policy priorities, governance, and leadership; fragmented relationships between national and local government institutions and actors; fragmented relationships between acute health and long-term care sectors, nationally and locally; the complex relationships between local government and local private residential care home quasi-markets; and chronic shortages of paid care workers. All these weaknesses are well known, so the publicity they received during the pandemic was little surprise. However, since the initial crisis of early 2020, few steps have been taken to address them. From April 2022, an increase in payroll taxes will generate more funding that is, in due course, intended to be ring-fenced for adult care services; and there are plans to improve local joint strategic planning and service commissioning between National Health Service (NHS) and local authorities. Most other institutional and governance weaknesses laid bare by the pandemic remain unaddressed.

This chapter focuses on England (containing 84 per cent of the United Kingdom population). Within the UK, responsibilities for health and care services are devolved to the English, Scottish, Welsh, and Northern Ireland governments. There is increasing divergence between countries in the structures, funding, and governance of their services; differences were also apparent in how the four countries responded to COVID-19.