In the UK, we don’t do well by our elderly relatives. We make their final journeys about ourselves: the financial toll of their care, the grief we’ll feel when they’re gone. We infantilise them and dismiss them. Yet, they’ve lived through more than we can imagine, often adopting a resigned kindness to ease our discomfort at their lingering burdensome presence. Privately, many carers admit to feeling bittersweet relief when a loved one dies, unaware that the elderly know better than anyone the sacrifices made on their behalf.

As a nation, though, we struggle with the concept of mortality. Whether due to a misplaced cultural stoicism or sheer discomfort at the thought we all die one day, we shy away from discussing death. While we celebrate long lives well lived and mourn the departed with ease, the difficult liminal space between life and death often goes unexamined. And the elderly serve as an unspoken shorthand for the fate that awaits us all.

And so, rather than facing the fact of death head on, we render it an abstraction. Those miserable, lonely deaths happen to those people over there who are just unfortunate; that could never happen to us. We can’t get old people out of our sight fast enough and into our crumbling care system. The unsustainable, fragmented and means-tested care “system” offers little in the way of dignity. Local authorities provide support only to those with minimal assets, and private care is prohibitively expensive. While some nations integrate elderly care into community life, Britain isolates its ageing population in underfunded institutions, often reducing their final years to a slog of survival.

Our European neighbours put us to shame: Germany, France, and many Nordic countries provide extensive support with innovative systems that do more than delay death. The aim is instead to enhance life by reducing isolation, preserving dignity, and recognising every older person still has something of value to offer their community.

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Britain is haunted by Dickensian ghosts

By Darran Anderson

Earlier this year, I glimpsed what a more humane system could look like when I visited the House of Generations in Aarhus, Denmark, for my BBC Two series, The State We’re In. This residential project fosters connection between people of all ages, offering 304 rental units for families, young people, and seniors, alongside shared facilities including a library, workshops, and gardens. I joined a community sing-along where children played with seniors, highlighting the joy and dignity possible in later life. These people were old, yes, but they were vibrant and curious and keen to contribute. Thanks to their high quality of life, they were also more independent and less prone to mental health problems, and therefore able to support their neighbours, whether visiting other elderly folk or looking after young kids for a couple of hours.

This joyous scene starkly contrasted with the isolation I witnessed in Britain. Many elderly people I met here seemed resigned to a slow and painful decline, counting the days until their passing. The UK tolerates such indignities because we collectively deny that we too, will one day face them. If we admitted that such a bleak end likely awaits us too, we wouldn’t stand for the pathetic health offer currently made to the elderly in the UK. Truth be told, I came away from my many encounters with these beautiful old souls certain that a faster life would be no bad thing.

One man I visited sat alone in a cold kitchen, staring at a TV he couldn’t move to turn on, in a puddle of his own urine. Another woman, a full-time carer for her disabled husband, came alive when talking about her love of music and theatre, which she could no longer pursue due to her life-limiting devotion to her partner. One woman, grappling with terminal cancer and early dementia, seemed energised when asked about the meaning of her life — a rare reprieve from being treated solely as a patient. She confessed her fear she was going to hell for her sins, but also that she awaited death with anticipation — quite a purgatory.

No one expects that one day they’ll end up spending Christmas day alone. What starts with a random fall, followed by a routine hospital admission, ends in institutionalisation by the dysfunctional health service and alienation from society. A once-capable human being is reduced to a growing list of ailments, waiting lists, and financial costs. And before you know it, there’s no one to pull a cracker with. This comes as an immense shock precisely because the truth of what awaits us in our third act is never broached in our cold statistical discourse. The process of collective denial that passes for “debate” about social care in the UK rarely touches upon the reality that we will one day become these “bed-blocking” old people. Instead, death is firmly put out of mind for as long as life allows it. Then one day, we are suddenly forced to realise just how old we really are, not necessarily because of the date on our birth certificate, but because society, configured for the economically active, begins shuffling our fragile frames out of view — making greater space for the productive among us.

Oddly, this approach is actually more expensive. Loneliness and neglect accelerate mental and physical decline, complicating care needs. The elderly wither away not from age itself but from the absence of community. The recent debate over assisted dying illustrated just how little we offer those nearing the end of life. Instead of providing compassionate care, we debate helping people end their lives as if this is the pinnacle of ethical progress when, in truth, that entire debate arises in the context of a dire social care system that should shame us all. We must shift the conversation about ageing and death from mere survival to dignity, community, and respect. Unless we do, many Brits will continue to face their last Christmas alone and isolated — a bleak fate that you, too, may one day endure.

Yet even though she was prepared, her death would still be messy: both for her and the family she left behind. Tensions between my siblings had escalated over the months, as we negotiated a difficult and stressful process. Let down by the officials who were meant to help us, it would be fair to say that assisted suicide killed my family along with my mother. 

Mine isn’t just a personal tragedy. As euthanasia inches towards legality in Britain, with a private member’s bill on assisted dying potentially being debated in the Commons this month, we must think seriously about the logistics of death. Ignore it and we risk wreathing a nation in trauma — long after bereaved families leave their loved ones behind. For whether a longed-for release or slow and painful menace, death is a painful business. 

The protocols, though, are simple enough. Following the Oregon Dignity in Death Act, passed in 1998, the Volunteer Assisted Dying Act in New South Wales encompasses 11 distinct steps and a host of safeguards. It is only available to over-18s who have an illness that will cause death within 12 months, or is causing suffering that cannot be relieved. Patients must undergo three assessments and write a declaration of their intentions.

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'I was offered assisted dying over cancer treatment'

By Ian Birrell

Beyond these tight theoretical rules, however, the practicalities of VAD are less proscribed. For one thing, unlike in the US, assisted dying is free. And therefore more accessible. But far more important is the way in which amateur family members are roped into the protocols. My mother, as part of the process, nominated one of my sisters as her Key Person who would help her navigate the path to euthanasia.

This, though, was a difficult emotional burden for my sensitive sister, who struggled with poor health. To make matters worse, she was estranged from my other siblings. My mother selected this sister simply for her own ease. Another, more pragmatic sister had long been Evelyn’s Power of Attorney, but when new papers were drawn up, her name was misspelled and Mum wouldn’t sign incorrect legal documents. Instead of having the papers corrected, and waiting until her daughter could make the six hour-return drive to sign them, Mum was impatient.

Instead, she defaulted to the most convenient solution: her most available child. KP worked part-time, due to her health issues, while my other siblings work full-time. For my part, I live in the UK. At any rate, the newly bestowed Power of Attorney laid the groundwork for my KP sister being named as the primary support person. It was treated as a coup against my other sister who mum had always sought advice from on important matters or during a family crisis. In fact, that sister was the family vault on all serious matters. The animosity from one sister to the other was established years before my birth.

So I was commissioned as an intermediary, offering updates from my mother and KP to the other side of the family. I had also been passing along the various visiting times and dates of my siblings, so they could avoid each other at the care home. It was exhausting.

In theory, this muddle shouldn’t have mattered. After all, the rules also provide each family with a so-called VAD “coordinator”. These professionals are there to guide and support families through the challenging process. Empathy, it goes without saying, is key. 

Alas, these theoretical safeguards were inadequate. After attending a couple of assessments, my sister was struggling to cope. Even the most resilient adult will find it challenging to accompany a parent who is arranging their own death. My mother, for her part, made the process trickier. Evelyn’s dark humour — once funny — was now hurtful as she took to saying that she was “being put down.” 

That ominous sign would soon be echoed elsewhere. In January, Evelyn passed her third and final medical assessment, and was formally granted permission to undergo euthanasia. She was elated. “I feel like a huge weight has been taken off my shoulders,” I remember her telling me, “I haven’t felt this free in years.” She sounded so relieved and happy that of course I wondered whether she would go ahead with it. But the date was set. February 22, 2024, the wheels were set in motion — and the trouble really started. 

In January, I took a flight from Heathrow to Chicago for a research assignment, in the belief that she would not go ahead with it. Between long flights and epic time differences, my role as intermediary collapsed, as my sister refused to share information with the other side of the family. Soon enough, I received frantic phone calls from other siblings desperate for crucial information. It seems that information is power and that information was being tightly held.

Now, my KP sister and one of her adult children had started to tell me when I could and couldn’t call my mother. They had established themselves as Mum’s guardians. Of course, I ignored their instructions, and Evelyn was annoyed by their interference — but ultimately did nothing to intervene.

I know, of course, that many families are dysfunctional — and VAD can’t be blamed for our internal squabbles. Yet the shallow, inflexible support offered families makes a miserable process far worse, triggering sleepless nights and agony for all of us. 

Then, on February 15, just a week before she was due to die, staff shortages meant the date had to be postponed. A tough woman, not given to weeping, she crumbled. She could not stop crying. She was terrified of dying and had psychologically prepared herself for it, only to be undone by a bureaucratic bungle. Again, I asked her on the telephone why she was going ahead with it when she was clearly afraid. “I’m more terrified of living,” she told me. 

The delay, though, did offer me the opportunity to say goodbye. So I flew out with my daughter, Ava, to Sydney. And my mother was fascinated by the granddaughter she hadn’t seen in so many years. I sat on the bed watching, mesmerised as they laughed and exchanged ideas. The deep interest Mum showed in Ava’s life made it even harder for me to reconcile her decision to be injected with a lethal dose of barbiturates the following day. The notion that she would be dead in 24 hours had not landed. It would not land.

But my mother was determined. And on February 23, we arrived at the hospital early in the morning. A social worker was assigned who, after a whispered conversation with my KP sister, promptly left the room and didn’t reappear. Unable to sit still, I roamed the sterile corridors until I noticed one of my nieces sitting alone in the public waiting area. Such was her distress I hardly recognised her. The social worker, though, was nowhere to be seen. 

Evelyn arrived at midday, dosed up with painkillers, awake and chatting. Only now did it seem real. When we all entered her room, the VAD coordinator was there, having suddenly reappeared after weeks of silence. There she was at Evelyn’s bedside, acting like nothing had happened. Speaking only to my KP sister and Mum, she merely offered a nod of acknowledgement to the rest of us. As so often, our apparent invisibility felt crippling.  

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The assisted-dying lobby has already won

By Kathleen Stock

My mother was oblivious. And after she had whispered a private message of farewell to each person in the room, an anaesthetist ended her life. Just after 1pm on February 23, 2024. Nothing in Evelyn’s life became her like the leaving of it, such was her grace and courage. 

In 2018, my father-in-law died a merciless death in England. The former country GP had Parkinson’s disease and had been in residential care for several years. When he could still make decisions, he made clear that he did not want to live if he could not eat or drink. Specifically, he refused a feeding tube.

When he was no longer able to swallow his death began. It took five days for him to die of thirst. I remain haunted by the harrowing nature of his departure.

So beyond the beauty of her passing, what have I taken from Evelyn’s death? Would I recommend it? Yes, in a sense I still would. I firmly believe NSW Health has opened a much-needed service for the terminally ill. But the system has a long way to go if it isn’t to destroy an ocean of other families. Even the most cohesive units can fracture under such immense strain. The trauma for our family will never be healed. My KP sister didn’t come to the scattering of my mother’s ashes. And none of my other siblings is in touch with her. Going through the VAD process has turned a once close sisterly bond into something uncomfortable and unwanted.

So as Britain begins its serious discussions over assisted dying, it must obviously consider ethics and morality. But equally important is to create an intelligent, reactive system of euthanasia, which cares for both individuals and their families. Failing to create that risks causing even more suffering — which would be an irony indeed. 

In stark contrast to this beatific moment, the 90-year-old’s life before her exit had been “long and tormented”, according to her daughter. Factors that led to her decision to end things included “deafness, incontinence and many other conditions”, as well as a “lack of mental resilience” to cope with the suffering. One wonders what the deceased would have felt about such frank disclosures. While dignity in death supposedly now requires control over the precise timing of your demise, a discreet silence from relatives about the embarrassing details beforehand seems to have become optional.

Campaigners for assisted dying seek to eliminate messiness of various physical and emotional kinds, and their language is adjusted accordingly. At times, it can sound as if one is being offered a particularly relaxing spa treatment. With a pleasing ring of supportiveness, you are now being “assisted” in achieving something, rather than killed by a doctor or killing yourself. In van der Zee’s piece, the lethally toxic sedative given to “the patient” was merely a “drink”, and its administration a “procedure”, after which her mother “fell asleep”. Also in the past week, Scottish politicians sponsoring a new bill legalising voluntary euthanasia have stated that, once legalised, resulting deaths will be recorded as “natural” rather than as a result of suicide, with the suggestion that this will reduce the “stigma” around assisted dying. In other words, moral qualms will be framed as bigotry. (Then again, perhaps bureaucrats are just looking for a respectable cover story for Scotland’s ever-decreasing life expectancy rates.)

And alongside the sanitised language, there’s a tendency to place large amounts of trust in the future judgements of relevant unidentified authority figures, even in the face of blatant legal and medical failures of the recent past. Many activists seem convinced that any UK pro-assisted dying law will contain enough safeguards to avoid people being bumped off for the wrong reasons. And perhaps they are right, as far as the first iteration of any such law goes; but they are bound to be wrong about later extensions of it. Changes in social norms tend to roll down slopes rather than hurtle off cliffs; but either way we can all easily end up at the bottom.

Canadians, for instance, used to reject assisted dying, but now significant numbers would agree to expand the existing programme in order to include as respective qualifying reasons, “inability to receive medical treatment” (51% of respondents), and “homelessness” (28%). In the Netherlands, euthanasia is permitted on the basis of “hopeless and unbearable suffering” rather than fatal illness and is sometimes allowed for psychiatric illness alone. Given the degree of concept creep endemic to modern society, as we collectively grow yet more anxious and neurotic, who knows what mundane aspects of modern life will end up counting as “hopeless and unbearable” too?

I am using the future tense here deliberately, for it seems clear that such legislation will pass in the whole of the UK sooner or later. Its arrival has been heralded for a while now, not least by the safe, agent-approved involvement of TV personalities like Dame Esther Rantzen — herself now in the grip of Stage 4 lung cancer and apparently keener than ever on personal choice in this area. (Presumably she has forgotten saying that unvaccinated Covid sufferers should be left to expire on their own, wholly untreated by the NHS.) Other celebrities have been doing their bit by offering personal anecdotes of heart-rending suffering too, including some from beyond the grave.

The main tool their opponents tend to wield in response to such campaigning is a list of potential adverse consequences to society generally, should legalisation happen: for instance, that it might lead to martyr-ish types being guilt-tripped into taking up the option against their own best interests; or that its real appeal to economists is the cost-efficient dispatching of those who disproportionately drain health and social care resources. Indeed, the latter was actually positively embraced by Matthew Parris in his Times column last week. But really, either way, how can such abstractions compete, faced with the visceral power of a story about Dame Prue Leith’s brother’s agonising death from bone cancer? It is not that we care so much about what happens to celebrities and their families, but rather that, in a vacuum of personal experience where most of us have yet to see a dead body, their stories can act as psychic proxy for what we imagine or fear might happen to us.

Since Parris’s article, some Christian commentators have argued that his chilling reasoning about the social utility of assisted dying has starkly exemplified how the value of individual human life can become negotiable in a post-God world, as we move instead to prioritise the good of the collective in utilitarian fashion. Yet the example of the many Canadians now willing, in principle, to see a painless death available for those poor and homeless people who convincingly say they want one, reveals that the good of the collective is far from the minds of many in contemplating such matters. In fact, society’s trajectory away from God and towards legalised euthanasia is less direct, and also less altruistic, than both Parris and his critics seem to think. It is not that an increasingly secular outlook directly causes us to prioritise collective benefit over the individual, but rather that it paralyses many of us intellectually, and means that a selfish mental focus upon alleviating future personal suffering is the only cause we can really get behind.

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The cruelty of Canada's euthanasia policy

By Lionel Shriver

Or to put it another way: the real reason why the activists’ rhetoric eventually will prevail is that, without prior commitment to some deeply felt theological or philosophical principle about the intrinsic value of human life, all that is left for most of us are vague intuitions and orphaned remnants of moral reasoning inherited from a formerly Christian outlook. And these are no match against the powerful lure of a vision of preventing personal physical suffering in future, or the suffering of loved ones, via the offering of a serene and painless death.

This is what gives the edge to emotive anecdotes like those offered by van der Zee and Rantzen. Sure, to most of us, on the face of it there seems something wrong with doctors killing off the old and the sick even if they are mentally competent to assess the situation and fully acquiescent; but what is it, exactly? Lacking a convincing reference to God or some other organising value system, many will struggle to articulate the problem. They will naturally wonder: wouldn’t any harms caused be offset by the massive reduction in hideous, meaningless suffering? Back and forth the non-committal reasoning will go, leaving the argumentative field open to those with more immediate and self-interested emotional reactions to take the win.

As a matter of fact, though I myself cannot manage it, a full-throated and enthusiastic endorsement of utilitarianism and of the cumulative value of the collective over that of the individual might well knock the arguments of both Parris and Rantzen on the head. For, once introduced at scale and firmly embedded into existing social systems, the constant presence of the psychological possibility of assisted dying might easily wreak more quantifiable havoc than it prevents, in exactly the ways anticipated by critics: guilt-tripping those who feel like burdens into premature endings; tempting the already depressed towards easy oblivion, and so on. But to make this case convincingly would require a positive belief in something; and for many of us, real ardour for the principle of utility is just as hard to conjure up as a sincere belief in a Christian God. Those who want to see the back of assisted-dying laws had probably better start praying harder, though I wouldn’t hold out any hope.

Yet still it hurts. He’d also developed a moisture lesion, the start of a pressure sore, on his lower back — a consequence of not being repositioned regularly. Joseph’s death wasn’t caused by anything we did, but what we were unable to do. Had we had our full team of staff, I’m sure that we could have moved him more regularly and perhaps have prevented the lesion, which no doubt hastened his decline.

One of us could have sat with him and fed him, listened to him and held his hand. But we simply don’t have the time. The loss of one permanent member of staff a few weeks ago because she refused to be vaccinated, and the resulting reliance on agency staff, has had a devastating impact on the standard of care in our home. When it becomes compulsory next April for staff to be jabbed unless they have a medical exemption — at the moment care homes can decide their own policy — the situation will only deteriorate. Some estimates suggest more than 100,000 unvaccinated care home workers could be forced to quit.

Tonight’s shift is intensely busy, as always. We have 30 residents in our private care home in Sheffield. They all need feeding, washing and changing — and I don’t stop for a moment. It’s six hours into my shift when I’m stopped by my colleague Lisa. Grabbing my arm, she practically throws me into the room and onto the sofa and tells me to sit down for five minutes.

“You’ve not stopped,” she says. “Eat something!” I check the clock. She is right. It is almost 1.30am and I haven’t eaten a thing since I clocked on at 7pm. The only time I’ve stopped is to pop to the toilet and take a few sips of cold coffee. It is time for a quick break.

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I sit down to eat a sandwich, but a pile of paperwork sits on my desk and I can’t ignore it. As the senior member of staff on duty that night, it’s my responsibility to be in charge of the medications, so I might as well audit the drugs paperwork while I eat my dinner. It will save time later.

Barely five minutes have passed when another colleague, Sheila, asks for some help moving one of our residents, Anne, who has soiled herself. Many of our residents are incontinent and accidents are common, but it’s often impossible for care workers to move residents on their own, particularly when they’re only 5ft 2ins like Sheila. If we don’t clean and move them swiftly, bed sores can develop and that’s when residents are at risk of infections which can be fatal.

We find Anne in some discomfort and distress. Who knows how long she’s been lying in her mess? The staff tonight are spread even more thinly than usual: Clare, one of the younger members of the team, called in sick and no agency nurse has turned up. We clean Anne up and make her comfortable and she sleeps.

It’s a small consolation. I have worked in the care sector for ten years and while we’ve always been busy, it’s becoming clear that things are dangerously close to breaking point now. The pandemic was stressful but now we have the added burden of being short-staffed. Carly, the unvaccinated nurse, left a fortnight ago and we are unable to find a permanent replacement.

Carly is one of many careworkers who refuses to have the Covid vaccination. She’s not what you’d call an ‘anti-vaxxer’ because she’s had other vaccinations such as flu; she simply didn’t trust this one. She felt it hadn’t been tested rigorously enough and could harm her health in the future. I’ve no idea why. The rest of us tried to persuade her that it was safer — for the residents, herself and us. It felt like another level of protection.

But for whatever reason, Carly was adamant she didn’t want it. She initially thought the Government might perform a U-turn but when it became clear they wouldn’t, she looked for a new job. She’s working in a school now.

Of course, it’s a shame. She loved her job and she was good at it. But if she’s going to put others at risk, I can’t blame the Government for wanting her out.

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Yet her departure leaves us in the lurch and it makes me nervous about what lies ahead. Although I have a 36-hour-a-week contract, I’m regularly working up to 60 hours — all for £9.60 per hour and I’m exhausted. There’s no bonus for overtime. I suppose I should count my blessings. I know of another home that has lost four members of staff who refused to have the vaccine.

Once Anne is cleaned, I return to the staffroom to finish the drugs paperwork. I’m always terrified of making a mistake when I’m tired. Only two weeks ago I’d been so busy rushing from room to room that I’d forgotten to give someone his epilepsy drug. He ended up having a seizure and although we found him in time and he was fine, I felt dreadful. I held my hands up. I knew it was my fault. But with so few staff, mistakes are going to happen. Not long ago a lady fell in our lounge area and broke her hip. I watched it happen, almost in slow motion but I couldn’t get to her in time. Would that have happened if we’d had enough staff members? Possibly. But I couldn’t help but feel she might have been saved if someone had been able to keep a closer eye on her that day.

I thought things might improve when the pandemic started to subside this spring. Like many frontline workers, we had little in the way of PPE at first and had no idea what we were dealing with. Watching people deteriorate when they got the virus was horrific. I’ll never forget them desperately gasping for breath, as if they were drowning. We couldn’t do anything except prop them up on their side or turn them over onto their fronts. That seemed to help. But we lost seven of our residents and there would be many nights where I’d go home in tears.

The terror and paranoia of bringing the virus home has never really left me, even now. After my shift ended, I would undress at work and put my uniform in a tightly sealed bag to take home and boil wash. But when I got home, I was fearful that I still had the virus on me, so I’d strip off in the hallway and rush up to the shower to scrub myself clean before I went anywhere near my daughters. My husband would grab the bag, put the uniform in the washing machine and then thoroughly scrub his hands.

When the vaccine arrived, it felt like we’d been saved. I managed to have mine early in the year and I’ve now had all three. I don’t think anyone should be forced to have the vaccine, but I still can’t understand how people in our sector are reluctant to get jabbed. We have people in our homes in their 90s who are completely bedridden with dementia. Even though they’ve been vaccinated, they will be among the most vulnerable if this new Omicron variant takes hold, as it looks like it will.

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For the moment we’re relying on agency staff to plug the gaps but this is never ideal. Although they’re competent enough, the people who need the care can become upset if they see a face they don’t recognise. There’s no continuity of care. Last week, one of our more vocal residents got spooked. She doesn’t speak much English and was screaming and crying about the new staff member.

And so I feel pessimistic about the next few months. We are currently Covid-free in the home but I don’t expect that to last. Our residents have all been vaccinated so we know they have some level of protection and that’s reassuring. But it’s the ‘stepdown beds’ — people who arrive in the home for temporary care straight from the local hospital — who we constantly worry about. Although they are tested before they arrive and they’re put in isolation and tested again on Day 5 of their stay, we’re all worried that one of them will bring in the new variant.

Then what do we do? Will it mean another lockdown? Families unable to visit their loved ones again? Although I hope it doesn’t come to that, we are all expecting it.

Don’t get me wrong: I love this job and I don’t want to leave. But there have been many nights where I’ve come home — sometimes after 16 hours on my feet — and I wonder if it’s worth it. We are all scrambling. And things are only going to get worse.

“I don’t want you to come,” she told me on the telephone.

“But I’ve had coronavirus recently Daphne. I can help you.”

“Yes, but I don’t want you to see me like this. I want you to come when I’m back to normal. I’ve not told you what happened after I left 16th Searchlight Company.”

I am an oral historian. I turn old women’s stories into books and in the process sometimes I cross the professional line. It is hard not to during a pandemic working with 17 isolated veterans all of whom served in the female army (Auxiliary Territorial Service – ATS) during World War II. The youngest is 96. Our conversations are often the only meaningful communication they have from one day to the next. After pleasantries and a quick health check, I ask these women to channel their younger selves.

Returning to her restorative tonic — the war — puts the mettle back in Daphne’s voice. She is quick to remind me that she only accepts guests when her hair is fresh set and coloured (soft chestnut). “In the army they encouraged us to take care of ourselves, that was very important.”

But taking care of herself in this new ‘war’ has proved almost impossible: cut off, alone and now suffering with Long Covid, Daphne is miserable. “I’m doing my best to stay alive for you. I want to make it to the book launch, but sometimes I wish I wasn’t here.”

Army Girls is my third project involving the extreme elderly and the first written during a pandemic. My newest friends are society’s exceptional outliers, with all the research suggesting that reaching a great age takes much more than good genes. Longevity requires optimism, ambition, and multi-generational friendships. Try retaining just one of those criteria with no technology (is your great-granny on Zoom?) and no visitors, while facing down what might well be your last year on earth.

Between the first waves of Covid-19 I visited my oldest friend, Ann. She is 107, lives in a care home and is (more or less) ‘compos mentis.’ By her own admission things have slipped a bit recently. Being alone hasn’t helped. Ann was born before the start of World War I; she can still recall Union Jacks spread out in her Buckinghamshire garden on Armistice Day, 1918, flirting with communism in the Thirties and counting bacon in World War II, but she has never experienced anything like this pandemic. “I just have to accept it, what choice do I have?”

During last year’s visit, our conversation was monitored (a carer kept guard in the corner) and timed. Ann struggled to hear what I was saying, (masks are deafening when you’re old). She stared blankly at my obligatory disposable apron and muttered “it’s time they uninvented plastic.” Post-vaccine, the process of visiting remains cumbersome. For some it is a deterrent. I am shooed out of communal areas despite swathes of impersonal PPE and a negative test. Ann shrugs, “I am currently working hard on forgetting the last 18 months.” Dig deep and Ann is still there but Covid has diminished her. She’s become the personification of our reduced humanity. She can’t wait to get to the end.

Marino Plata, Ann’s care worker who is full of love and song, shakes his head. “It was too sudden; the lockdowns were too much with too little explanation.” Marino is one of the thousands of experienced health care workers who have noticed an accelerated decline in their elderly residents during successive lockdowns and restrictions. “Ann at least understood what was happening, others didn’t. They were confused and desperately missed their visitors and activities. They died sad.”

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By Timandra Harkness

Adam Gordon is a Professor of the Care of Older People and President Elect of the British Geriatrics Society. He saw Covid-19 wreak its worst. “At the beginning of the pandemic even for an experienced practitioner like me, I was affected; early on we weren’t sure how to treat patients with the virus. I still have flash backs, I’ll spare you the gruesome details.”

Adam reminds me that when coronavirus first came knocking, Britain was shamefully unprepared. Between 20,000 and 30,000 of our vulnerable elderly died unnecessarily and horribly. This nightmare scenario led to hastily revised practice: better PPE, strict lockdowns, no visitors. Britain could not keep climbing up the Covid-19 league of shame. And sure enough, fewer very old people have subsequently died. But has their last year of life been worth living?

Do not go gentle into that good night. The prophetic words of Dylan Thomas have proved almost impossible to live up in Covid times. Old age should burn and rave at close of day. Not a chance if you’ve been locked up in your care home (or your own home), with no visitors and, crucially, no voice on the public stage.

“There’s the tension” admits Professor Gordon, “the competition between protecting people from the virus and their other needs was underestimated. It is nuanced.” And modern debate doesn’t like nuance. I was blocked and shouted down on Twitter by several influencers for querying their calls to extend the lockdown last summer. Too many only see one side of the ‘tension’ the professor talks about. After a terrible start, the restrictions Britain’s elderly had to endure were dehumanising to the point that many no longer wanted to live. ‘Deconditioning’ is the word he uses to describe their accelerated cognitive and physical degeneration.

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The new public health despotism

By Matthew B Crawford

“It’s dreadful to be alone and old,” explained another Anne. She was 96 years old and a former WWII junior commander in the ATS. Like 107-year-old Ann, she too had lived through an era when duty was the nation’s watchword; the press was censored, the people were conscripted, and hundreds of thousands of her generation died. It is that generation who have once more been in the firing line, but this time their duty was to be solitary and still. Pride is harder to wear in private. For the first time Anne watched Remembrance Day in November 2020 on television, rather than celebrating it with friends in her local church. It was a disappointing replacement. She sighed, “I wish someone would rub me out, I wish I could disappear.”

Anne was a Norfolk County Vice President of the Guide Association and mid-pandemic she reckoned that “the reason why Guiding has been so successful is that we were all involved together in our activities. Humans are built to be together.” Anne died in July 2021, most of her last year lived alone.

Professor Gordon admits that data has not been collected to track the unprecedented deconditioning that’s taken place over the last 18 months. Daily we are assailed with graphics charting Covid-19 cases and death rates, but there is no equivalent measure for the impact of loneliness, suicidal thought, feelings of abandonment and physical deterioration that the restrictions have induced in the extreme elderly. As 107-year-old Ann pointed out “I have terrible forgettery, this won’t be remembered.” Perhaps society is banking on that. When judgement day comes it will ask whether our very oldest, most precious citizens were ‘protected’ from Coronavirus. But who will ask if their last year (or two?) was worth being saved for?

Public health concerns over the spread of the virus have seen the human right to safety bulldoze other basic needs. Rectifying this imbalance is crucial as a second Covid-19 winter looms with large sections of the public already demanding increased restrictions. What will they mean for the extreme elderly? The average care home inhabitant is over 85, with a life expectancy of just two-and-a-half years, many won’t live to see the end of the winter. Has anybody asked them what they want? Do we really want to condemn yet more to a lonely death?

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When I met her in the summer of 2020 Beryl may well have been the last ATS WWII Physical Training instructor alive and aged 99, with swollen legs in a heat wave and a pandemic, life was hard work. She worried about the modern world — “I think there’s more wrong today. It’s harder for you lot.” Things were certainly harder for Beryl who was struck by the contradictory game of national statistics: “In the Second World War in order to win they didn’t talk about death tolls, but in this current battle it is all we focus on.”

She wasn’t killed by Covid-19, but in February this year Beryl died, and her close friend sent me a message: “She rarely complained and she didn’t give up, but sadly, her last year was more like imprisonment since she was unable to see her friends thanks to coronavirus.” Like so many others, Beryl’s last months were collateral damage in Britain’s war against the pandemic.

As an NHS practitioner, Professor Adam Gordon has lived both sides of the problem. Given all he’s been through I’m embarrassed by my visible emotion during our conversation. In less than 12 months five women I work with have died. I managed to say goodbye to one and I’ve been to just one non-virtual funeral. The Professor confirms that Britain is sitting on a pandemic of grief; hundreds of thousands of people could not see those they loved most before they died and then were unable to give them an affirming send off among friends and family.

It is not just old people who have experienced depression; minus our elders, Britain has struggled with feelings of guilt and loss.

Yesterday Daphne, one of the 17 women featured in Army Girls who we met at the beginning of this article, left me a message. “I can’t get an appointment with my GP. I can’t work the new system.” But she has not given up. “When I get through, I am going to ask them to give me a pain shot so I can come to the book launch.” Many of her contemporaries haven’t been able to ‘rage rage against the dying of the light’ and aged 98, a Covid-19 survivor who is fully vaccinated, Daphne is determined to be the exception.

Unless, that is, a fresh wave of winter restrictions pin her and us down. Then we will need to push back and ask: who is really afraid? The very old? Or those seeking to control them?

An Evening with the Army Girls is at 6.30pm, 10^th November, National Army Museum, London. Tickets are £10. 

Army Girls: The secrets and stories of military service from the final few women who fought in World War II by Dr. Tessa Dunlop is available to pre-order here. 

I hurry to my consulting room and briefly go over my schedule for the day — one morning clinic from 8.30 to 12, an afternoon telephone clinic from 2 to 5, and an hour for admin from 1 to 2. I have two scheduled coffee breaks as well, which I won’t use for coffee: I always try to schedule them after my trickier patients, so that when they inevitably overrun, it is not into another patient’s time. I am a trainee doctor, having qualified from medical school two years ago, so my appointments are 15 minutes long rather than 10 minutes, and I have time at the end of my day to debrief with a supervisor.

At 8.45, I go to the waiting room to call my first patient, Mrs Smith. She is hard of hearing and I don’t know what she looks like, so it takes a minute for her to acknowledge me. It takes a further two minutes for her to walk to the consultation room, because her ankles are swollen and she walks with a stick. By the time she has managed to sit down in the chair and remove her coat, nearly half of the appointment time has gone.

Mrs Smith starts to talk about the weather. I interrupt and remind her we need to keep on topic. As a medical student, I watched qualified doctors talk over patients in this way and thought naively that I would never be so rude. But it only took a few weeks of working in General Practice to realise that being brusque and firm is essential, unless you have hour-long appointment slots. Mrs Smith looks crushed. I suddenly remember that she recently had an appointment with my colleague following a bereavement, and that I am perhaps the only person she will speak to today. I constantly feel pulled in two different directions — forced to choose between doing the best for the patient in front of me, and doing the best for the patients waiting for me.

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She eventually tells me that she has come to see me about breathlessness. When I hear that word, a list of potential diagnoses pops into my head: infection, lung disease, fluid overload, cancer, or perhaps a more niche disorder I’ve only seen in a medical school textbook. To determine which seemed more likely would require me, at the very least, to take a 20-minute “history”, but if I want to examine her, that would leave us with around three minutes, not including the time required to write out any prescriptions and refer Mrs Smith, if necessary.

Mrs Smith seems slightly annoyed when I ask about her medical history: “Isn’t it in my notes?” She’s right — it probably is somewhere in her electronic record, but I haven’t had a chance to click through its entirety, and long gone are the days when GPs know each individual patient. On average, there is one qualified GP for every 2087 patients.

This ratio is worsening year on year, partly because the population is increasing, but also because the pool of full-time GPs is shrinking. It’s not surprising. In the UK, the average full-time employee works 35.7 hours a week; 48 is the statutory maximum. General Practice is often seen, even among doctors, as the ‘easy’ way to practice medicine: the equivalent of a 9 to 5. But full-time GPs work 48 hours a week, while “part-time” GPs work 35, not including the unpaid hours when clinics overrun, or the time spent on admin at home.

No amount of time ever seems to be enough, though. I was reluctant, for instance, to examine Mrs Smith on the bed, rather than letting her remain in the chair, because I knew it would take at least five minutes to get her on and off it. But my conscience got the better of me. As I assisted her onto the trolley, I mentally readied myself for complaints about waiting times later in the day. I can deal with angry patients; Mrs Smith’s health cannot deal with a misdiagnosis.

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Mrs Smith’s breathlessness, I decide, is most likely related to her heart failure, and that the best course of action would be to increase her diuretic dose to try and get some of the fluid off her lungs. But Mrs Smith has chronic kidney disease — which is common in the elderly — and increasing the diuretic dose might exacerbate it; I want to schedule her a blood test for the next week, to check. She takes out her diary, which I cross check with the phlebotomist’s diary — which feels like a bad use of my time. I find myself becoming frustrated.

As I begin teeing Mrs Smith up to leave, she bursts into tears and says it’s just so hard without her husband. Perhaps, I think guiltily, the breathlessness was just an excuse to talk about her bereavement. But I have seen one patient and I am already running 30 minutes late: I cannot comfort her now but offer a follow-up appointment to talk about how she’s coping generally. I have a free slot in 2 weeks. At the end of this consultation, I don’t feel like a good doctor; I feel like I rushed a grieving old lady with complex health issues. I tell myself to think about it later, when I have time.

By the time Mrs Smith leaves the room, my next three patients are already waiting, but I need to wipe down the chairs, bed and door handle: Covid is still with us after all. My next patient is Luke, a young man I have been seeing regularly due to his deteriorating mental health. He is unemployed, in serious debt and has recently split up with his girlfriend and moved in with his alcoholic father. We are both aware that his low mood and anxiety are mainly down to these circumstances — but I cannot fix them, so I have prescribed him an antidepressant and referred him for counselling.

Today, Luke is agitated. He tells me he is having serious thoughts about driving his car off a bridge. I screen for protective factors — a support network, a hobby, any hope for the future — but find none. Luke accepts my concern and agrees to be referred to the mental health crisis team. The person who answers my call is a trainee and wants to discuss the case with her boss. I am aware that the mental health team is as stretched as we are, but I can’t help but feel frustrated: it takes thirty minutes for her to call back. During this time, I do not feel comfortable asking Luke to leave my room, so we make awkward conversation as my patient list builds up.

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When the phone eventually does ring, I speak to a mental health nurse who insists that, because Luke has had previous suicidal ideation that he has not acted on, his latest symptoms don’t constitute an acute change. Luke does not need to be reviewed by their team, she tells me. I need to take responsibility for discharging him. I don’t feel comfortable doing this, so we go back and forth until she eventually agrees to contact Luke later that afternoon. As Luke grunts a thank you and leaves the room with his head down, I am not sure that I have helped him at all.

There is no time to dwell, however: I need to write a detailed entry in Luke’s notes. In theory I am doing this to provide an accurate history of his condition to help him get the best treatment possible from subsequent professionals. In reality, I am doing it to protect myself in court should harm come to him.

Fortunately, the rest of the morning’s cases are simpler: a child with a urine infection, a man with a fungal rash, a woman who wants a repeat prescription of her contraceptive pill. I rush through them, grateful both that I have a chance to catch up and that, if the patients are angry about their wait, they do not show it.

I finish my morning surgery at 1.15, over an hour late. As usual, I will have to eat as I go through my admin. Patients often wonder what I do when I am not actively seeing them. They don’t realise that I have to sign every repeat prescription request, even if the patient has been on the medication for years. I can do this well, or I can do it badly.

If I do it well, I will read through their entire list of repeat medications, making sure that another doctor hasn’t started them on any drugs that might inadvertently interact with the ones they’re already taking. I will check that they haven’t been on a medication for years that should have been stopped after a certain period of time. I will see if any checks are overdue. If any of those things are the case, I need to ‘action’ them — by sending a letter to the patient to ask them to come in for a check-up, or by writing to their specialist consultant about changing their medication.

If I did it badly, I would just sign.

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Next on my admin to-do list is to read through letters sent from secondary care. Today, I note that Mrs Jones, who I referred a few weeks ago with a breast lump, has been diagnosed with cancer. I call her to schedule an appointment to talk through everything. Finally, I catch up with my admin from the morning clinic that I didn’t have time to do during the appointment — like sending Mrs Smith’s referral.

The afternoon clinic is a telephone surgery, for which I am grateful. It means that patients won’t be getting agitated in the waiting room if I have another Luke or Mrs Smith, but can instead get on with their days as they wait for my call. I can also choose the order in which I call patients: I scan the afternoon’s list, scheduling simple prescriptions for acne and leaving a young woman with a recurrent sore throat until later in the day. I know that she is becoming fed up with the GP management of her condition and that the phone call is likely to be a difficult one.

Because it’s easier to read the guidelines for a condition during telephone surgery, by the time I phone her I am able to apologetically inform her that she does not meet the referral criteria for a tonsillectomy. The patient is angry. Her affliction is interfering with her job and private life; I know she cannot understand why the people who are meant to help her will not. I understand, but I am also affronted. It would be much easier if I could pass her on to the hospital, instead of prescribing another packet of throat lozenges, but I know that the referral will be instantly rejected. Of course, this is as much to do with the risks of surgery as the pressures on secondary care, but the patient does not care about that. As her anger dies down and she says goodbye, I find myself hoping she will eventually get fed up of calling. I admonish myself and decide to refer the patient anyway. At least then I can tell her I tried my best.

My final phone call of the day is with a patient who has some sort of pain somewhere, but it’s hard to work out where because there is a significant language barrier. I get put on to someone — a nephew, I think — who tries to explain, in slightly less broken English. In the end, I make the patient a face-to-face out-of-hours appointment with a colleague, and add a warning in her notes that it is not suitable to offer her a telephone appointment in the future.

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Before I leave, I have a debrief with one of the GP partners. I hover outside his door, listening for a gap between his phone patients. When I eventually enter, he has his head in his hands, but quickly springs to attention when he sees me — he is keen to train more doctors after all, and tries his best to shield me from the pressures, and focus on the positive aspects of a job he once loved.

But I know that he has stayed late each night this week and that in his spare time he obsesses over the — increasingly negative — Google reviews of the practice. I don’t want to take up his time, but if something goes wrong with one of my patients after I had chosen not to discuss their case with a senior, I could end up in hot water legally. So I rattle through my day while he nods and occasionally interjects with suggestions.

Once I get home, I try to relax, but thoughts continually flash into my head: didn’t you rush those “easy” patients a bit? Are you sure the diagnoses weren’t actually urosepsis and a malignant rash? If harm comes to them, they will blame me, and I will blame myself.

My phone buzzes with messages from colleagues from my previous rotation, a surgical job. They joke that I am living the dream, working 9 to 5 — that I spend most of my time sitting down and refer any real problems onto the hospital. I turn off my phone and head to bed. I have decided not to apply for GP training.

Some will call this progress — in sanitation, diet, medicine — as if more is always better. But the cost of this “progress” is rarely factored in.

£12 billion every year is the latest pledge to fix health and social care, mostly for the elderly. But what are we doing with all these extra years?

It depends, of course. Some will work longer; some will have more time with their grandchildren and great grandchildren. Others will be warehoused in care homes, living out their twilight years amid the background smell of stale urine, bored ridged between monthly visits from their guilty children. Many are not like this, but a great deal of them still are. My mother has made us promise we will take her to Dignitas long before it comes to this — and that when we bring her ashes back from Switzerland it will be in a Harrods bag, not a Tesco one. This, apparently, is dignity in dying.

Social care has come a long way since it was conceived in alms houses provided by the church: through Victorian workhouses, state-funded provision in the twentieth century and, more recently, to profit-making private companies. As our population gets older, so the need for such services grows ever larger. It is commendable that the Government is seeking to address the growing cost of social care, albeit through a tax levy that falls disproportionately on the working poor and the young. But the one thing that we are not talking about — and our silence is becoming ruinously expensive — is what a good life, and indeed a good death, looks like.

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To put it another way, without a sense of what human life is for, and what its basic natural or even theological rhythms might be, we fall back on the idea that more is always better. Without some sort of agreed understanding that human life exists within fundamental limits, society will inevitably find itself unsustainable.

The idea of growth, of always seeking more, is built into the very nature of capitalism, as it is within liberal progressivism. In a secular society, meaning tends to get replaced by the idea of more; or rather, more becomes the meaning.

It is not a coincidence that just as we are pouring billions into end-of-life care, the fantastically wealthy are seeking their own way of outwitting ageing and death. Amazon founder Jeff Bezos is now throwing his fortune at some comically ludicrous “eternal life” start-up that seeks to keep him alive forever. “Man plans, God laughs”, as the old Jewish proverb puts it. It’s not just that Bezos can’t succeed in this ridiculous vanity project, but that we shouldn’t want him too. Death, after all, gives life its purpose.

The philosopher Martha Nussbaum once asked why it was that the immortal Greek gods would often fall in love with mortal human beings; Calypso with Odysseus, for instance. Her insightful response was that those who can die are capable of things that immortals are not. They are, for example, capable of courage, of risking everything for others on the battlefield in a way that immortals cannot. Indeed, the very possibility of love itself is bound up with the ability to sacrifice oneself for another. A life without the possibility of death becomes some sort of meaningless extension of mere existence — the unbearable lightness of being.

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This means that there is no way of solving the social care crisis in purely economic terms. Because one cannot address a metaphysical question through economic policy. Indeed, the very basic question of what human life is for is one that politicians, still less economists, no longer feel they have any use for.

The first stage to recover a basic metaphysical scaffolding would be to reclaim something of that story in which death has some sort of wider significance, rather than being viewed as just some anticlimactic end. Because if having more — going on longer — is the meaning of life in a secular society, then death is inevitably and always some sort of failure. Whereas we would once have said of the dead that they have passed into glory, we now hear the medics apologise that “there was nothing that we could do”. Death was once — potentially, at least — an expression of some ultimate triumph. Now it is the bitter failure of our technology. And whatever we spend on it, no amount of money will overcome this gap.

Death, then, is the political issue we are not talking about. Even after the pandemic, when the daily death figures were broadcast on every news broadcast, we continue to say little about death other than making the uncritical assumption it is always to be avoided.

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And so we are sleepwalking into a state of affairs in which the young will resent the elderly for the burden they place upon them. Of course, we should support the generous funding for social care. What we ought to be challenging is whether the medical technologies that are keeping us alive for ever longer complement our understanding of what human existence is for.

But I see little appetite for that. In a secular society, we have few intellectual or cultural resources to challenge the pervasiveness of more-ism. And to live deeper, more meaningful lives is not the same as living longer ones.

More than two-thirds of the 5,776 deaths in their population of ten million were older people in care settings, the majority in residential homes. There are grim stories of the elderly being given morphine and left to die rather than overload hospital wards, along with more familiar claims of failure to supply protective equipment and underpaid agency staff working across different locations. An official investigation found the deaths concentrated in 40 of Sweden’s 290 municipalities, with 91 homes needing further investigation. “We failed to protect our elderly,” admitted Lena Hallengren, minister for health and social affairs. “That’s really serious and a failure for society as a whole. We have to learn from this.”

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A similar tragedy unfolded in Britain. The big difference was that our leaders chucked 25,000 elderly people out of hospitals, sending them into care homes that were sometimes paid to take them in order to clear space in intensive care units. Incredibly, many of these patients were not tested for coronavirus, despite being sent into places packed with the elderly and disabled people most at risk from this disease. Ludicrous Government advice still claimed, until 10 days before lockdown: “It remains very unlikely that people receiving care in a care home or the community will become infected.

Official data revealed that almost 20,000 care home residents in Britain died with confirmed or suspected coronavirus during the peak 10 weeks of pandemic, although excess death figures suggests the real numbers may be even higher. “Years of inattention, funding cuts and delayed reforms have been compounded by the Government’s slow, inconsistent and, at times, negligent approach to giving the sector the support it needed during the pandemic,” commented the Public Accounts Committee two weeks ago in a devastating indictment of failure.

Britain has the second highest number of deaths as a percentage of its nursing home population in Europe. (There are currently about 400,000 people living in 17,000 nursing and residential care homes across England). The worst was Spain, a country that likes to believe the family is at the heart of its society. Soldiers called in to help tackle the crisis found elderly people in care homes abandoned by staff, with corpses lying in beds; prosecutors are investigating whether to launch criminal cases. In Italy, another supposedly family-orientated nation, police launched probes into what were described as ‘massacres’ in huge care homes. Belgium has the world’s highest Covid-19 death rate, with two-thirds of fatalities occurring in nursing homes during its peak weeks of pandemic as the sector was overlooked in the rush to protect hospitals.

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The same issues emerged in North America. The first major outbreak in the United States was centred around a Seattle care home run by one of the largest private operators, which was linked to 40 deaths. Now the world’s richest nation has the planet’s highest death toll due to its dire pandemic response, with four in 10 fatalities linked to long-term care facilities. Canada reacted better, resulting in a relatively low per-capita death rate. Yet an official study found 81% of its fatalities were in care homes — the worst rate among 16 wealthy nations examined and twice the average level in Organisation for Economic Co-operation and Development (OECD) nations. “This report confirms what we all suspected: Canada is not taking care of our seniors as it should be,” said prime minister Justin Trudeau.

Much about this new virus remains mysterious but we do know it impacts hardest on older people and those with underlying health conditions. So we must ask tough questions about these deadly failures. Those let down also include people with disabilities, who comprise two-thirds of the British deaths, according to the Office for National Statistics. And do not be fooled into thinking there was anything inevitable about these fatalities, even among the most at risk groups. Countries such as Australia, Austria, The Netherlands and Slovenia implemented more successful prevention measures in care homes, leading to fewer infections and lower death rates in long-term facilities.

This pandemic has ruthlessly revealed the failure of some social care systems. Many issues have been depressingly similar, with hospitals given highest priority while care homes and their undervalued, overloaded staff were forgotten in the panic of pandemic. So many aspects of the response — from initial political imperatives through to distribution of advice and protective gear — have highlighted the secondary status of this vital public service, as well as that of the elderly and disabled people who rely on it for their daily needs. It is significant to note that carers are paid on average about one-third less than people who do similar jobs in hospitals across OECD nations; it underscores their societal valuation and fosters the frighteningly high churn rates among staff.

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In this country, the health service gets worshipped by politicians and public alike while confusion surrounds fragmented social care — until people suddenly discover they or their loved ones rely on it for survival. The crisis struck after two decades of White Papers, Green Papers and other consultations calling for reform of the sector. Yet real-term spending on social care has fallen over the past decade, despite surging demand, in stark contrast to the additional billions poured into the sacred National Health Service.

Clearly the system needs a huge injection of cash. It is not impossible to find the necessary sums when there is the political will: the £20bn spent furloughing British workers over the past two months alone could fund the care system for a year. But simply ploughing in money will never be enough — not least when in Britain, as in other badly-afflicted nations such as Spain, a key part of the problem has been expansion of the sector by debt-funded private equity firms that rake off vast sums, often using tax havens and complex corporate structures. Their financial model relies on economies of scale delivered through larger ‘homes’ — yet the inevitable consequence is that, when disease strikes, there are more deaths in bigger units crammed with citizens at most risk of dying. One recent Scottish study concluded that care home size was “strongly associated with outbreaks”.

This dark tsunami of death exposes systemic corrosion, sometimes dating back decades. So if extra cash were to go into the system, how would we ensure it delivers better services and ends up in the right pockets? Politicians have a poor record at controlling increases in state spending while the voices often heard representing the sector are simply lobbyists for big providers. This is the first big challenge in any reform.

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There are, though, more fundamental questions that need to be addressed. Our care system has become essentially custodial: people who need support are warehoused out of sight from the rest of society. Elderly and disabled citizens have been corralled into what the Canadian sociologist Erving Goffman termed ‘total institutions’, designed to reduce risk and facilitate operations for staff at the expense of the freedom and self-respect of the inhabitants.

Goffman, writing some six decades ago, focused on the institutionalisation of mental health patients, something that remains a big problem in Britain with a flawed psychiatric system that relies increasingly on incarceration, restraint and over-medication. More recently, the brilliant physician-writer Atul Gawande has explored the issues concerning treatment of the elderly. He raises concerns over profiteering firms who infantilise their charges while also asking profound questions about the effect of the elevation of our quest for longevity over the quality of life itself.

Today, in the wake of this terrible tragedy, we have a chance to pick up on such threads. We should move beyond the simplistic and rather sterile debate about funding to delve deeper into a floundering system. We need to ask ourselves how we ended up with a system that hides away and often dehumanises the citizens at its core? These are complex concerns. Dementia is a complicated disease to manage, as I saw over several years with my own father who died shortly before lockdown. I am also well aware from my adult daughter of the challenges in providing effective and empowering support for a person with profound disabilities. But as a society, we need to ask ourselves why we so readily commit people to spend years in residential institutions far removed from the warmth and spirit of genuine homes. These issues go to the heart of our shared humanity.

We live in an ageing society in which extraordinary medical advances are keeping people alive longer, but this also leads to more citizens with comorbidities. The Government has responded to the pandemic with crowd-pleasing pledges to build more hospitals and to fix the long-standing problem of families selling homes to fund care. But it is neglecting the more pressing care challenges: sorting provision of decent community services; the drastic need for improved co-ordination between health and social care services; the dwindling support for people in less prosperous parts of the country after the system shifted towards wealthier self-funders. Ultimately, there is a critical need to shift from provision of top-down to bottom-up services that empower users and families rather than bureaucrats, officials and private equity barons. This can only be done by confronting the drift towards warehousing.

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There is a glimmer of hope in the Government’s recruitment of Camilla Cavendish to help shape their oft-promised plans for social care reform. The former journalist turned political adviser is author of a well-informed book on ageing societies that pointed to smart innovations in other nations. She highlighted the benefits of ideas such as Germany’s Mehrgenerationenhäuser (multi-generational houses), which provide support for older people alongside facilities for younger generations such as family advice centres and nurseries, and the superb Dutch Buurtzorg model of community nursing based on small local teams delivering care for people in their own homes. Both countries escaped the worst carnage rates among older citizens — as did Denmark, which focuses spending on alternatives to residential institutions such as retirement communities and supported living in flats.

Another person who understands such issues is Doreen Kelly, who has spent 20 years — first in Scotland and now in the south-west of England — getting people out of institutions and into supported living. She runs Beyond Limits, a small firm focused on people with autism, learning disabilities and mental health struggles, and has been alarmed to see the rise of big providers who view care homes as property plays and vulnerable human beings as commodities. “It has become an industry with bigger and bigger places that warehouse people,” she tells me. “But it is difficult to be person-centred when you run large places. The bigger you become, the more you focus on bureaucracy and red tape and accounts rather than delivering personalised care.”

Our default position, she says, is to shut away the old and disabled with other people who are old and disabled, rather than at the heart of communities. This explains why social care can become so forgotten and so dysfunctional in such rich countries — and with such devastating consequences in a pandemic. “There is more to life than being fed, watered and kept warm,” she says. “You can have aspirations in your seventies and eighties but if left in these care homes there is often little to do. We must always place people at the centre of social care systems.” Yet she sees one upside to the Covid crisis since it has sparked a sharp reminder how much we depend on each other. ”And that,” she says “includes everyone.”

The ultimate question, of course, is simple: how much does society really care? Not much in the past, as revealed in such hideous style by this cruel pandemic. So what about in the future?

The problem isn’t just that loneliness makes people sad; it’s also killing people, according to a 2017 report by the Jo Cox Commission. It claimed that loneliness (or “weak social connection”) is “as harmful to health as smoking 15 cigarettes a day”. It also suggests that it costs UK employers £2.5 billion a year.

But an “epidemic” is a disease that has spread suddenly — which by analogy implies a problem which has rapidly and recently increased in its magnitude. And I’m not at all convinced that is the case, or that the doomy claims about its health effects are well-supported.

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One of my reasons for thinking this is a new study, available in preprint ahead of publication in the journal Psychology and Aging. It asks: has loneliness among older people got worse in recent years?

It found that “newer” old people (baby boomers born 1948-1965) are no more likely to think of themselves as lonely than “older” old people (born 1920-1947), and that older people have not become more likely to think of themselves as lonely in the last decade (2005-2016). There may be more lonely older people now, it says, but that’s because there are more older people in general. The average older person appears to be no more likely to be lonely than they were a decade ago.

I’m always wary of trusting any one study, though. All the more so when that study confirms my own beliefs. Also, it’s about elderly Americans, so its findings may not apply to, for example, younger Britons. But I think it is a good study: it has a large sample size and, most importantly, it has preregistered hypotheses, so that we know it probably can’t have p-hacked its way to exciting but false findings.

And my other reason for tentatively trusting it is that, everywhere else, the fact that loneliness is increasing just seems to be taken for granted. The BBC article I linked to earlier points to ONS data that finds that more older people are living alone, but it doesn’t say whether that’s just because there are more older people — and, of course, “living alone” is not the same as “lonely”.

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The trouble with tackling loneliness

By Giles Fraser

The Jo Cox report says that nine million British adults are lonely, but doesn’t say whether that’s more than there used to be, and in fact says that “over the years, studies on loneliness have reached different conclusions” about whether it’s getting worse. Indeed, the report states that they have “found relatively consistent levels of chronic loneliness among older people — with between five and 15 per cent reporting that they are often or always lonely”. Which sounds to me like it’s not increasing.

Even scientific papers seem to have this problem. A paper in the Journal of Family & Consumer Sciences which calls loneliness “a private problem, a public issue” does the same thing, saying that loneliness is common, but making no effort to actually show that it has got more common. A letter in the Lancet does something similar, and quotes a magazine article in the Harvard Business Review as its evidence that it’s a problem.

I don’t claim that I’ve done a full systematic literature review, but my quick searches for “increasing loneliness” and “loneliness epidemic” on Google Scholar find lots of articles about how loneliness changes over a lifetime or how common it is now or how it correlates with various health outcomes, but I can’t see any that actually say that loneliness is more common now than it was 10 or 20 or 40 years ago.

You see surveys that find that young people are the loneliest age group, but I don’t know why that would be a surprise — surely most of us remember being lonely as teenagers, even those who seemed socially active from the outside. It doesn’t mean that people are getting lonelier, and it doesn’t seem to be a new thing.

The first study I found with a Scholar search of “loneliness and age” was from 1988 and found that high school students were the most likely to be lonely back then, too, long before Instagram or whatever we’re blaming it on these days.

And there’s also a lot of misinformation about it. The Jo Cox Report’s claim that loneliness is as bad as 15 cigarettes a day is, to put it baldly, false, even though it gets trotted out in reputable newspapers. The report references “Holt-Lunstad 2017”, which turns out to be a meta-analysis by Julianne Holt-Lunstad, which as far as I can tell makes no direct comparison to smoking. It does find that loneliness is associated with a 26% higher risk of death per year, but that’s about half as much as the increased risk of smoking between one and four cigarettes a day.

Furthermore, we can be extremely confident that smoking is the actual cause of many of those deaths. That’s not true of loneliness. It may be that, say, unhealthy people are less likely to get out and about, and so are more likely to be lonely. The Holt-Lunstad study tried to account for that sort of thing, but it cannot show causality, and there are loads of complex ways that loneliness and poor health could interact (poverty or substance abuse could lead to both loneliness and illness, for instance) that are not a simple story of “loneliness leads to death”.

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As a nation, we are taking this “epidemic of loneliness” extremely seriously; last year, the Government actually appointed a “minister for loneliness” (I imagine she spends a lot of time in No 10, making sure Theresa’s all right). And we’re not the only ones. There was a plan to set up a fund, and for the ONS to develop a method of measuring loneliness. The US Surgeon General has declared an “epidemic of loneliness”. We’ve also got a Local Government Association guide to “combating loneliness” and a national “strategy for tackling loneliness” (which, again, seems to take it for granted that the problem has got worse, without actually making any effort to show as much).

And it’s part of a general feeling that society is more atomised — that we all spend our time scrolling through Instagram or playing video games, rather than sitting around a fire in the bosom of our family, sharing our jar of mead and wiping our elderly parents’ bottoms, as we did in the Before-Times. Things were always better in the past. But there’s not much evidence that technology is making us sadder, or lonelier.

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By Carl Miller

That is not to say that being lonely is not terrible. And if there are simple, well-evidenced, cost-effective ways of reducing it, then great. But there are a lot of shaky – and in some cases plain false — claims going round about loneliness, and it’s worth addressing them.

First, I’m unconvinced (although I am open to being persuaded) that there is an “epidemic”, in the sense of a problem that has grown and spread. Maybe loneliness is an endemic disease in our society, but there doesn’t appear to be good evidence that it is worse than it was before. It could be that we’re just more willing to talk about it and acknowledge it as a problem — which may be a positive thing in its own right, of course; but it is not the same thing.

Second, the actual health impacts of loneliness are being greatly overstated. It’s not as bad as smoking by a long way — and, in fact, given the nature of the problem, it’s actually incredibly hard to tell whether “loneliness” is a cause of ill health, or a symptom, or a byproduct of the real cause, or what.

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I’m not saying that we shouldn’t do anything about it. It could be that, even if it’s not getting worse, the problem is bad enough to be worth dedicating significant resources to (although, as always, every pound you spend reducing loneliness is a pound you can’t spend on neonatal intensive care units or diabetes drugs, so bear that in mind). But let’s have the conversation honestly, and stop saying “epidemic” and “as bad as smoking”.

The problem isn’t just that loneliness makes people sad; it’s also killing people, according to a 2017 report by the Jo Cox Commission. It claimed that loneliness (or “weak social connection”) is “as harmful to health as smoking 15 cigarettes a day”. It also suggests that it costs UK employers £2.5 billion a year.

But an “epidemic” is a disease that has spread suddenly – which by analogy implies a problem which has rapidly and recently increased in its magnitude. And I’m not at all convinced that is the case, or that the doomy claims about its health effects are well-supported.

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One of my reasons for thinking this is a new study, available in preprint ahead of publication in the journal Psychology and Aging. It asks: has loneliness among older people got worse in recent years?

It found that “newer” old people (baby boomers born 1948-1965) are no more likely to think of themselves as lonely than “older” old people (born 1920-1947), and that older people have not become more likely to think of themselves as lonely in the last decade (2005 – 2016). There may be more lonely older people now, it says, but that’s because there are more older people in general. The average older person appears to be no more likely to be lonely than they were a decade ago.

I’m always wary of trusting any one study, though. All the more so when that study confirms my own beliefs. Also, it’s about elderly Americans, so its findings may not apply to, for example, younger Britons. But I think it is a good study: it has a large sample size and, most importantly, it has preregistered hypotheses, so that we know it probably can’t have p-hacked its way to exciting but false findings.

And my other reason for tentatively trusting it is that, everywhere else, the fact that loneliness is increasing just seems to be taken for granted. The BBC article I linked to earlier points to ONS data that finds that more older people are living alone, but it doesn’t say whether that’s just because there are more older people – and, of course, “living alone” is not the same as “lonely”.

Suggested reading

The trouble with tackling loneliness

By Giles Fraser

The Jo Cox report says that nine million British adults are lonely, but doesn’t say whether that’s more than there used to be, and in fact says that “over the years, studies on loneliness have reached different conclusions” about whether it’s getting worse. Indeed, the report states that they have “found relatively consistent levels of chronic loneliness among older people – with between five and 15 per cent reporting that they are often or always lonely”. Which sounds to me like it’s not increasing.

Even scientific papers seem to have this problem. A paper in the Journal of Family & Consumer Sciences which calls loneliness “a private problem, a public issue” does the same thing, saying that loneliness is common, but making no effort to actually show that it has got more common. A letter in the Lancet does something similar, and quotes a magazine article in the Harvard Business Review as its evidence that it’s a problem.

I don’t claim that I’ve done a full systematic literature review, but my quick searches for “increasing loneliness” and “loneliness epidemic” on Google Scholar find lots of articles about how loneliness changes over a lifetime or how common it is now or how it correlates with various health outcomes, but I can’t see any that actually say that loneliness is more common now than it was 10 or 20 or 40 years ago.

You see surveys that find that young people are the loneliest age group, but I don’t know why that would be a surprise – surely most of us remember being lonely as teenagers, even those who seemed socially active from the outside. It doesn’t mean that people are getting lonelier, and it doesn’t seem to be a new thing.

The first study I found with a Scholar search of “loneliness and age” was from 1988 and found that high school students were the most likely to be lonely back then, too, long before Instagram or whatever we’re blaming it on these days.

And there’s also a lot of misinformation about it. The Jo Cox Report’s claim that loneliness is as bad as 15 cigarettes a day is, to put it baldly, false, even though it gets trotted out in reputable newspapers. The report references “Holt-Lunstad 2017”, which turns out to be a meta-analysis by Julianne Holt-Lunstad, which as far as I can tell makes no direct comparison to smoking. It does find that loneliness is associated with a 26% higher risk of death per year, but that’s about half as much as the increased risk of smoking between one and four cigarettes a day.

Furthermore, we can be extremely confident that smoking is the actual cause of many of those deaths. That’s not true of loneliness. It may be that, say, unhealthy people are less likely to get out and about, and so are more likely to be lonely. The Holt-Lunstad study tried to account for that sort of thing, but it cannot show causality, and there are loads of complex ways that loneliness and poor health could interact (poverty or substance abuse could lead to both loneliness and illness, for instance) that are not a simple story of “loneliness leads to death”.

Suggested reading

Our shameful social care crisis

By James Bloodworth

As a nation, we are taking this “epidemic of loneliness” extremely seriously; last year, the Government actually appointed a “minister for loneliness” (I imagine she spends a lot of time in No 10, making sure Theresa’s all right). And we’re not the only ones. There was a plan to set up a fund, and for the ONS to develop a method of measuring loneliness. The US Surgeon General has declared an “epidemic of loneliness”. We’ve also got a Local Government Association guide to “combating loneliness” and a national “strategy for tackling loneliness” (which, again, seems to take it for granted that the problem has got worse, without actually making any effort to show as much).

And it’s part of a general feeling that society is more atomised – that we all spend our time scrolling through Instagram or playing video games, rather than sitting around a fire in the bosom of our family, sharing our jar of mead and wiping our elderly parents’ bottoms, as we did in the Before-Times. Things were always better in the past. But there’s not much evidence that technology is making us sadder, or lonelier.

Suggested reading

The dangers of a digital life

By Carl Miller

That is not to say that being lonely is not terrible. And if there are simple, well-evidenced, cost-effective ways of reducing it, then great. But there are a lot of shaky – and in some cases plain false – claims going round about loneliness, and it’s worth addressing them.

First, I’m unconvinced (although I am open to being persuaded) that there is an “epidemic”, in the sense of a problem that has grown and spread. Maybe loneliness is an endemic disease in our society, but there doesn’t appear to be good evidence that it is worse than it was before. It could be that we’re just more willing to talk about it and acknowledge it as a problem – which may be a positive thing in its own right, of course; but it is not the same thing.

Second, the actual health impacts of loneliness are being greatly overstated. It’s not as bad as smoking by a long way – and, in fact, given the nature of the problem, it’s actually incredibly hard to tell whether “loneliness” is a cause of ill health, or a symptom, or a byproduct of the real cause, or what.

More from this author

Is cancer screening doing more harm than good?

By Tom Chivers

I’m not saying that we shouldn’t do anything about it. It could be that, even if it’s not getting worse, the problem is bad enough to be worth dedicating significant resources to (although, as always, every pound you spend reducing loneliness is a pound you can’t spend on neonatal intensive care units or diabetes drugs, so bear that in mind). But let’s have the conversation honestly, and stop saying “epidemic” and “as bad as smoking”.