• The government must recognise the significant under-investment in care and support services and commit itself to making good the substantial shortfalls year on year. This needs to be at least as much as the investment in the NHS.

• Continued development of direct payments. This demands a more pro-active approach by the Department of Health (DoH), local authorities and care trusts in encouraging take-up and giving service users the training and skills they need to become their own service commissioners and care managers.

• Commissioners of care and support services must encourage the development of a wide range of services to meet the diverse needs of different communities. The DoH should pay adequate attention to raising equalities issues within the emerging national minimum standards agenda.

• The commission for health improvement and the social care institute for excellence should address genuine involvement and empowerment of service users.

• The Department of the Environment, Transport and the Regions, the audit commission and the national care standards commission should review guidance on best value to ensure there is adequate recognition that improving service quality is not always synonymous with driving down cost.

• The DoH should issue new guidance to local authorities, primary care trusts and care trusts on best practice in commissioning with a focus on promoting the development of high quality, responsive and creative services.

• The DoH must take responsibility for appropriate governance arrangements for care trusts.

• An immediate review of care NVQs and work by the Training Organisation for the Personal Social Services (TOPSS) and Healthwork UK to improve the quality of work-based assessment.

• TOPSS and Healthwork UK should urgently ensure all training builds on the skills of staff and focuses on the development of competence.

• Councils must work with providers to raise the skills and standards of all care staff.

• The DoH should raise the status of care work.

• The national workforce development board in the DoH should take responsibility for identifying and disseminating examples of successful recruitment and retention strategies in health and care that might be more widely adopted.

• Measures to encourage volunteering need to recognise the role volunteers play and not treat them as substitute labour.

• The general social care council should adopt a revised timetable for the registration of care workers that does not rely on qualification alone.

• The DoH should take the lead in developing management training across the public and independent sectors of care and support.