If Rachel Reeves wants some light reading to distract from difficult budget choices, then she probably shouldn’t read the pre-NHS hospital archives. They show a charged-for, means-tested system policed by almoners instructed to ‘eliminate… those whose circumstances do not seem to entitle them to treatment’, leaving many without support if they failed the test or were pushed to the Poor Law. Rules could be moral as much as financial: One medical aid society refused benefits if a sick member ‘visited a pub’ or ‘left their home during the hours of darkness’. The NHS replaced that discretionary charity with a universal entitlement.
It’s worth thinking about this pre-NHS landscape of health care in Britain, as we weigh up the dire state of social care and support for family carers today. Although health spending takes up an increasing amount of public spending – it was the main beneficiary of last year’s unpopular tax rises – few would openly call for the restoration of the pre-NHS insurance system (though read between the lines of Reform UK’s manifesto, and it’s a different matter).
Why social care never became a universal right
Back in 1948, the signal change was not so much money or a new name; it was treating health care as a public, universal right, one that was planned for and guaranteed to all.
Perhaps the reason that health care has remained publicly funded and largely free at the point of use is not simply due to nostalgia, but a shared belief that access should be a right; that care itself should not be monetised.
So it’s strange that social care and family care have never received the same recognition. Public ignorance may play a part – over a third of the British public believe that social care services are generally free at the point of need (like the NHS), while half of English adults say they have never thought about how they will pay for care when they get older. And politicians are loathe to talk about its costs too. The Dilnot Commission of 2011, which recommended a cap on total care costs was quickly shelved, while talk of such caps became political suicide for Andy Burnham as Health Minister in 2009, and Theresa May during her disastrous 2017 election campaign. Wes Streeting, the current Secretary for Health and Social Care, has said vanishingly little about the second part of his role. Louise Casey’s Commission on social care is due to report in 2028, perhaps after Prime Minister Starmer has been defenestrated – and it’s hard to see how she has the time when she’s often firefighting for the PM elsewhere.
The stark numbers behind unpaid care
The figures around unpaid care and long-term need are stark, and perhaps their appalling starkness makes them too awful to take in. Here are some, either in the public record or derived from our research:
- There are just under 6 million unpaid carers in the UK, who give care to relatives, friends or neighbours.
- The estimated cash value of unpaid care in 2021/22 was about £184 billion per year – equivalent to the annual spending on the NHS.
- Around 372,000 people are currently waiting for their local council to assess or review their needs or set up payments for care (down from half a million in 2022).
- Only 8 per cent of unpaid carers in England received a carer’s needs assessment in 2021/22. Only around 26 per cent of unpaid carers in Great Britain receive Carer’s Allowance, which is itself the lowest-paying form of social security. Of those, around 1 in 10 are now in debt to the DWP for mistaken overpayments.
- 1 in 7 carers reported using a food bank in 2022.
As our research shows, government policy in England on adult social care and family care has largely been 15 years of failure, with no sign of improvement. As needs have grown, levels of support have decreased. True, the Coalition government (under Lib Dem influence) introduced the 2014 Care Act, guaranteeing every family carer a needs assessment, but in practice, few receive these, and when they do, are often found ineligible for local support. Fifteen years of austerity have also hollowed out what local support might even look like – from reduced wellbeing grants, respite and replacement care to the gradual cutback and closure of community carers’ services and support organisations.
Yet it is not as if no money is being spent on social care; in fact, the opposite is true. Over 60 pence in every £1 of local government expenditure goes on children’s and adult social care; for some local authorities, this rises to up to 80p per £1. The crucial question to ask then is who benefits from this status quo?
Rethinking unpaid care: From pity to power
There are two things that Ms Reeves and others get wrong about unpaid carers.
The first thing we get wrong is the belief that care does not affect me. But the opposite is true: Most of us will give unpaid care in our lives (if we have not already). For some of us, this will be substantial – such as reducing or giving up work to care for a frail parent, unwell partner or disabled child. Recognising care as something universal and with legal protections (e.g. paid care leave) will help.
The second thing we get wrong is to view unpaid carers as objects of pity, not power. Most people choose to give care, and they do it with dignity, love and expertise. What’s needed is guaranteed protection for carers from poverty (therefore expanding Carer’s Allowance eligibility and payments), and universal access to a minimum standard of good community services and replacement care. Our new research sets out some ways forward, and our new special issue on ‘care, poverty and inequalities’ takes an international perspective. Care is inevitable; political failure need not be.
Dan Taylor is a Senior Lecturer in Social and Political Thought at the Open University.
Special issue: Care, poverty and inequalities. Guest edited by Dan Taylor, Jitka Vseteckova and Jodi Wainwright. Published in the International Journal of Care and Caring and is available on Bristol University Press Digital here.
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