While lying paralyzed in a hospital bed, I have watched NHS nurses telling agency staff to just stand over there and do nothing, because they were so incompetent they were making things worse by trying to help. I’ve had the terrifying prospect of trying to explain to somebody who can’t speak English — and yet is working in a spinal unit in a hospital ward — in the middle of the night, why I desperately need them to get the nurse. Because if my autonomic dysreflection isn’t arrested, I’m going to have a stroke and then die.

I’ve had the rather different experience of returning to my ward to find a care worker asleep on the radiator. If the worst three words in the English language are “rail replacement bus”, then the most terrifying for a long-term hospital inpatient are “agency staff”. NHS rules dictate that a certain number of care staff have to be on the ward floor to support nurses as a legal requirement — even if the agency staff recruited to be in line with the law make the work of the nurses harder. When I learned that these agency staff were trained over Zoom before being sent into hospitals, I wasn’t exactly surprised.

Lying behind this sorry state of affairs is the uncomfortable fact that the British electorate wants to have its cake and eat it, three ways over.

There is, for one thing, growing awareness and concern that the social care sector is in crisis. But taxes are already at a historic high, and people don’t want them to go up yet further. And although this is not polling quite as highly as it was last year, there is a clear preference for reducing the level of immigration.

This is what pointy-headed academics like me call a trilemma; it is impossible to satisfy all three preferences simultaneously. If you want more care workers there are two options. You could make starting salaries a lot higher so as to encourage far more people from the existing British population to become carers. Or you can keep starting salaries pitifully low, so that the only people who will take these jobs are immigrants so desperate for the work that they will turn up anyway.

The problem with the first option is that the only way to do this is to raise taxes in order to directly fund social care. And given that it will cost literally billions, it really will mean putting taxes up. The problem with the second is that it makes reducing immigration levels particularly difficult, given how many immigrants will be needed to cover work in social care, especially with an aging population. And of course, if we halted immigration tomorrow, the entire NHS would collapse.

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But something has to give. My own preference would be to raise taxes and pay the care workers more. This isn’t primarily to reduce immigration at the net level (which I’m personally pretty relaxed about, because I’m a wet centrist of dad-age, and I think that the net economic benefits of migration outweigh the costs of cultural conflict that arise). It is because I think that if we pay carers more, we will get better quality carers — wherever they were born.

And I speak here not just as a pointy-headed academic, but also as somebody who has (to use the jargon that I hate) “lived experience” in this area. As regular readers will know, in 2023 I suffered a rock-climbing accident that left me tetraplegic — paralyzed from the collarbones down. Ever since, I have needed 24-hour, on-call care to help me with everything from going to the toilet, having a shower, preparing food, getting dressed, and making sure that if my body starts trying to kill me (which it very much can and does), somebody is close by to stop it doing that. I spent eight months in hospitals, four months in a nursing home in Enfield, and ever since I’ve lived independently, but with 24-hour assistance.

Now, before we go any further, an important point that must be emphasized. It is by no means the case that all nursing homes, and all care agencies in the UK are bad. Far from it. Indeed, I have been one of the lucky ones, who has received good care at all points.

The nursing home in Enfield was genuinely excellent — which of course is not the same thing as enjoying living there, but everything is relative in such cases. When I first moved back to Waltham Forest, I initially received care from a small-scale, locally managed agency, who did extremely well by me. I frequently spoke to the Managing Director herself, who went out of her way to make sure that her staff were not just looking after me properly, but helping me to adjust to the challenges of my new life. After about a year, we agreed that I would do better if I moved to a specialist agency that provides care only to people with tetraplegia. That is who I am with now, and it has allowed me to regain a level of independence I didn’t think would be possible.

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But it is important to emphasize that I am very much one of the lucky ones. Not least because my local authority has competent and empathetic NHS social care administrative staff, who signed off on a more expensive spinal agency taking over my care. This is not the norm. I have heard many horror stories, from others in my situation, about how their local authority basically wouldn’t agree to pay for appropriate care, usually through some mix of callousness, bean counting, and incompetence. But note: it is not an accident that the care I receive from my specialist spinal agency is the best available and the most expensive. They charge more, so they can pay their staff more, which means they can recruit better people. It’s also much easier for them to turn away candidates who are not up to scratch.

Now compare this to what most people, and their families, have to confront: the fact that vast numbers of social care workers in this country are not being employed directly by the NHS, but by unscrupulous private nursing homes and even more unscrupulous agencies.

We are not just talking about people with spinal injuries, but the huge range of conditions that require assistance for daily living: Alzheimer’s, strokes, advanced multiple sclerosis, severe learning disabilities, and a hundred other conditions that those of us who don’t suffer from them have probably never heard of. If you need social care in this country, the overwhelming likelihood is that you are going to receive it from an agency primarily concerned with one thing: extracting as much money from the NHS as it can, to feed back to its private equity masters.

The best way to do that? Pay staff as little as possible. Give them as little training as you can get away with. Don’t worry about the local authority kicking up a fuss; they can’t fully cover the cost of social care already after two decades of austerity, let alone check that you’re doing a good job. They’ll just give you the contract if you say you’ll cover it. Provided your staff don’t literally murder a client in front of the neighbors, you’re probably in the clear.

British people won’t take the work, because they have better options than the 12-hour shifts, low pay, and stressful conditions you are offering? No worries. Just exploit immigration visa exceptions for care work, and import low-skilled people from abroad. They can’t speak English? Whatever. Send them out to vulnerable people anyway. Money in the bank, Frank.

If you think I’m making this up, just ask anybody who has had to rely on one of the bigger agencies for social care provision. Like my friend from spinal rehab, who was injured at almost exactly the same time as me, with almost identical care requirements. Unlike me, however, he was not one of the lucky ones. In fact, he asked me not to use his name, because he’s scared of recrimination.

My friend has been shunted around large-scale care agencies for the best part of three years. He will tell you about the carer who ignored him as he screamed “Stop!” because his catheter was being ripped out through poor physical handling. He will tell you about the carers who don’t even try to understand what he’s saying to them (in English, which they can’t speak), and just walk away mid-sentence, before ignoring him for hours, alone in his own home. He will tell you about the one who refused to unblock his catheter, saying he was lying about experiencing autonomic dysreflexia — the life-threatening medical condition that if not resolved would have killed him. (That time he just about managed to manipulate the catheter himself. Next time, he might not be so lucky.) And yes, he complains to the agency. No, nothing ever changes. They just send fresh incompetents.

All of which makes me, I’m afraid to say, pretty pessimistic about Burnham’s promise to take the social care crisis seriously. For a start, he’s already ruled out raising taxes. And yet he claims to agree that social care workers need to be paid more. Well, Andy, how are you going to afford them?

The more fundamental problem is that the recent noise out of the new No. 10 about social care is all vibes and no concrete policy. And that’s because concrete policy is hard. In this case, really hard. As far as I see it, the only realistic chance of breaking the trilemma is not only to put up the wages of care staff (so that we get better quality people from the UK and overseas), but to remove from the equation the private equity funds that stand behind the large private agencies, more interested in their top line than you flat-lining.

This does not mean straightforward nationalization. There are huge pitfalls with doing that, and some private agencies deliver very good services: as a general rule, the ones who are smaller scale, both in provision and staff size, and not backed by private equity. Let’s not turn the need for reform into a case for demolition.

Burnham in his first week declared that he wanted to reverse 40 years of neoliberalism. There are good reasons to think he’s using the wrong word here: neoliberalism started to die in 2008, and has been dead as a dodo since 2016. What we currently live under is something worse. Zombie-neoliberalism: the legacy of Margaret Thatcher and Tony Blair fed through the meatgrinder of austerity. Indeed, the failure of Britain’s social care system is the archetypal case. We pay higher taxes, so that private actors can get rich, while providing substandard care to the most vulnerable people in society.

Our new Prime Minister is absolutely right to want to change this. The question is: does he have the courage of his convictions? Because the rich don’t like to give up their power and their privilege, no matter how many people with severe mental and physical disabilities suffer as a result. Those who gain from private equity’s deep reach into the NHS are going to fight him on this. And they are going to fight him hard. Will he stand up to them? And if he does, can he win? I’m not optimistic.

If we are reluctant to dwell on the reality of human vulnerability at either end of life, we are unwilling to give much thought to its corollary: that (somewhere safely hidden from the more exciting business of being healthy, youthful and autonomous) there must be people caring for those who are unable to do it themselves. Someone is wiping those bottoms.

Traditionally, this job of caring for the very old and the very young has been “women’s work”. To a great extent, it still is: the OECD reports that, worldwide, women do between two and ten times as much caring work as men.

In the UK, this tends in statistics to be framed as “unpaid work”, a sort of poor relation of the economically productive type that happens in workplaces and contributes to GDP.

Carers UK suggests there are around 9 million people caring for others in the UK part or full-time, of whom up to 2.4 million are caring for both adults and their own children. Women carry out the lion’s share of this work: 60% according to the ONS. Full-time students do the least and, unsurprisingly, mothers with babies do the most. Older working women carry the heaviest load of people in employment, with those in the 50-60 bracket being twice as likely as their male counterparts to be carers whether of a vulnerable adult, a partner or a child or grandchild.

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Second-wave feminism pushed hard against the pressure women experience to take on this work of caring. Within this variant of liberalism, caring work is routinely framed as a burden that imposes an economic “penalty” while harming the economy by keeping skilled women away from the workplace. The OECD report cited above states: “The gender gap in unpaid care work has significant implications for women’s ability to actively take part in the labour market and the type/quality of employment opportunities available to them.”

The implication is that, once freed of this obligation, women can then pursue more fulfilling activities in the workplace.

So what does this liberation look like in practice? According to a 2017 report by the Social Market Foundation, women in managerial and professional occupations are the least likely to provide care, as are people with degree qualifications. The number working in routine occupations who also donate more than 20 hours a week of care in their own homes is far higher than those in intermediate or professional occupation.

In other words, higher-earning women are to a far greater extent able to outsource the wiping of bottoms to less well-off people, who are themselves typically women: 90% of nurses and care workers are female.

These women are then too busy to wipe the bottoms of their own old and young, who are sent into institutional care. Such institutions are typically staffed by women, often on zero hours contracts, paid minimum wage to care for others all day before going home to do so for their own babies and elderly. The liberation of women from caring is in effect a kind of Ponzi scheme.

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This is a problem for our liberal society, for two interlocking reasons. Firstly, the replacement of informal family-based care with a paid, institutional variety renders caring impersonal, in a way that invites cruelty. Indeed, cases of care home abuse are well documented – see here, here or here – and the number is rising: the CQC received more than 67,500 in 2018, an increase of 82 per cent over the already too high 2014 figure of 37,060.

It is difficult to see how this could be otherwise. Caring for those who are physically or mentally incapacitated is emotionally testing even when we love those we care for. An exhausted worker on a zero-hours contract, paid the minimum wage to perform more home visits than she can manage in the allotted day, is unlikely to have a great store of patience to begin with, let alone when faced with a refractory “client”. The entire system militates against kindness.

Secondly, and relatedly, it turns out that the informal, traditionally female networks in which caring for the young and old once took place were actually quite important. Those networks also ran church groups, village fetes, children’s play mornings – all the voluntary institutions that form the foundation of civil society.

When caring is treated as “unpaid work” and we are encouraged to outsource it in favour of employment, no one of adult working age has time for voluntary civil society activities any more. If the number of people caring informally for relatives is waning, replaced by institutional care, so is voluntarism: between 2005 and 2015 alone there was a 15% drop in the number of hours donated (ONS).

The result is loneliness. Almost 2.5m people aged between 45 and 64 now live alone in the UK, almost a million more than two decades ago. Around 2.2 million people over 75 live alone, some 430,000 more than in 1996. In 2017, the Cox Commission on loneliness described it as “a giant evil of our time”, stating that a profound weakening of social connections across society has triggered an “epidemic” of loneliness that is having a direct impact on our health.

Several generations into our great experiment in reframing caring as a burden, we are beginning to count the cost of replacing mutual societal obligations with individual self-fulfilment: an epidemic of loneliness, abuse of the elderly and disabled in care homes, substandard childcare. A society liberated from caring obligations is, with hindsight, a society liberated from much that was critically under-valued.

What is the alternative? Some would prefer a more communitarian approach to caring for the old and the young. Giles Fraser recently wrote on this site that caring for the elderly should be the responsibility of their offspring:

“Children have a responsibility to look after their parents. Even better, care should be embedded within the context of the wider family and community. […] Ideally, then, people should live close to their parents and also have some time availability to care for them. But instead, many have cast off their care to the state or to carers who may have themselves left their own families in another country to come and care for those that we won’t.”

These are strong words and there is much to agree with, but the barest glance at the statistics shows that in practice what that means is “women have a responsibility to look after their parents”.

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If we are to count the costs of liberating society from mutual caring obligations, we must also count the benefits, as well as who enjoyed them. Society once encouraged men to seek worldly success, underpinned by the imposition of an often-suffocating domestic servitude on women.

Liberalism blew this out of the water by declaring that in fact both sexes were entitled to seek some form of worldly activity and fulfilment. It is not enough to point to negative side effects of this change and say: “Someone needs to be resuming these mutual caring obligations or society will disintegrate.”

To women well-accustomed to the widespread tacit assumption that it is they who will pick up those underpants, wash up that saucepan, pack that schoolbag and so on, this sounds a lot like a stalking-horse for reversal of societal changes that, on balance, most of us greatly appreciate. In truth no one, whether liberal or post-liberal, wants to confront the enormous elephant that liberal feminism left in society’s sitting room: the question of who cares. Who, now that we are all self-actualising, is going to wipe those bottoms? There are no easy answers.

Most care workers simply get on with this sort of thing. It is a basic part of the job, a bit like turning on the computer is for me as a writer. And besides, you don’t have time to dwell on feelings of discomfort or even nausea: the next client is invariably waiting.

The reality of the social care sector was aptly summed up to me by a fellow carer, who told me she felt like a “glorified cleaner”. This was not meant to be disrespectful towards cleaners. Rather, it was a pithy judgement on the way in which care workers – on whom thousands of vulnerable people rely for their most basic and intimate needs – are rewarded and remunerated for the work they do.

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It is quite easy to get a job as a carer – something I did as part of the research for my book, Hired – because few people stick around in the job for long. The turnover rate in the social care sector is 25%, compared to a UK average for all jobs of 15%. The figure is even higher in the private care sector and among home care workers, where around 300,000 people leave their positions every year.

According to a new report by the IPPR think tank, England faces a stark shortage of 350,000 care workers by the year 2025. Should freedom of movement end after Brexit, that figure could reach 400,000.

Crucially, the report notes that “chronic underfunding” of care, together with a “dysfunctional” social care system, has resulted in outsourced providers competing to minimise wage costs in a race to the bottom. With council budgets being cut by as much as 50% since 2010, there is less money with which to fund the private companies that are contracted to provide care, meaning wages are kept low. The IPPR report estimates that increasing social care wages to a living wage could cost the public purse as much as half a billion a year.

A great deal of what is wrong in social care boils down to money – or a lack of it. According to a 2014 report by the Public Accounts Committee, local authorities have cut costs in recent years “partly by paying lower fees to providers of care, which has led to very low pay for care workers, low skill levels within the workforce, and inevitably poorer levels of service for users”.

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In Blackpool, where I worked as a carer and where large numbers of low-income families have the cost of their care subsidised, the lack of cash makes a big difference in the level of care people receive. For obvious reasons, it also discourages people from working in social care, which in turn reduces care quality yet further. It’s a vicious cycle.

The deficit in the number of people working in social care is also indicative of the lack of dignity and respect afforded to carers, which in turn affects the quality of care vulnerable people receive. Rochelle, a care worker at a company similar to the one I worked for, succinctly relayed the process to me: “the care workers [are] working for way less than the national minimum wage, no travel time, fifteen to twenty two-minute calls back-to-back, rushing in and out, and not actually having the knowledge and skills required to deal with particular situations because you were thrown into places”.

And care workers are “thrown into a place” because companies are usually short staffed. I received just four days of classroom training before I was sent out on calls. With this modest instruction under my belt – which resembled the cramming I did back in university prior to an exam – I was expected to do everything from change pads, stomas and catheters, to administer medication and move disabled service users in a hoist, as well as prepare meals and visit the shops for groceries. All of this typically had to be completed within a twenty-minute window.

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Even a perfunctory care visit like this was more than many people were getting. According to Unison, three-quarters of English councils commissioned care visits of just fifteen minutes in 2014, up from 69% the previous year. Put another way, many of the people under my charge were receiving what has been accurately dubbed ‘clockwatch care’.

Officially, of course, we were paid the minimum wage. In reality, however, as Rochelle pointed out, it worked out at less once the unpaid time spent travelling from house to house was factored in. And then there was the cost of the fuel to get there. The company I worked for paid fifteen pence per mile towards your petrol costs, and you were entitled to claim another thirty pence back out of your tax. The rest you had to cover yourself, along with the depreciated costs associated with using your car at work.

As with many of the jobs I did while researching my book, it wasn’t just the lack of money that made the job unappealing. The sheer insecurity of care work caused just as much unease among the care workers I interviewed as the material poverty. Around a quarter (23%) of care workers in Britain are employed on zero hours contracts, meaning they have no guaranteed hours.

Several care workers I spoke to relayed stories about how ‘difficult’ care workers, those who blew the whistle on wrongdoing or tried to join a trade union, had been driven out of jobs in the sector. They had not been fired – that would almost certainly have presented legal problems for the company – instead they had turned up for work and found that their hours had been abruptly reduced to nothing, which was effectively the same thing.

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The constant lack of time prevents you from developing any sort of bond with the ‘service user’ (itself a cold term for another human being). According to research carried out in 2016 by the charity Age UK, half a million over-sixties spend every day alone. When a carer enters an elderly person’s house, whizzing past photographs of children, grandchildren, and long-dead spouses, they bring a little bit of the outside world in with them. I remember being peppered with questions: what was weather like? Who had won the football? Was that Tony Blair fellow still the prime minister? Because above all, what they wanted was company.

This would probably fall under the heading ‘social value’ – an aspect of care work that is extraordinarily difficult to measure in monetary terms. Yet it is arguably just as important as the physical aspects of the job, such as ensuring clients are clean and comfortable. And loneliness costs money too. Last year researchers at the London School of Economics estimated that an “epidemic of loneliness” was costing £6,000 per person in costs to health and other local services. The report calculated that for every £1 spent on preventing loneliness there are likely to be around £3 of savings.

In order to solve Britain’s care crisis – and to ensure that older people are treated with dignity and respect – government must reform the sector from the bottom up. This means understanding the link between the way we treat care workers and the quality of care they provide.

This is a moral imperative – it is simply wrong to leave vulnerable people to the whims of the grossly substandard system of care provision we have in this country. But it is also something that should concern anyone who looks at public policy through the lens of self-interest. Those of us lucky enough to live into old age will need a carer too one day. One care worker described the current status of Britain’s elderly to me as “units parcelled up and sold to the highest bidder”. None of us want to be treated like that.