Though not much is known about the second Lady Fiennes other than that she is a horse trainer, it sounds as if she rivals Prince Harry in the paranoia department. She is said to be convinced that King Charles hates her husband, despite his being an enthusiastic patron of Fiennes’s projects for years. She is also alleged to have told friends that Queen Camilla arranged for helicopters to fly over the couple’s property in order to annoy them. Her estranged son is now crowdfunding for a legal review of Fiennes’ situation, and other loved ones are expressing grave concern.

With the rise of dementia and the social care crisis so much in the news, it’s easy to see why this story has hit a nerve, though more difficult to decide whether it is a tragedy or a comedy. At the heart of the tale, there’s a titanic Lear-like figure, as well as a supposed Lady Macbeth. There are several identity changes, and not just for Fiennes. At least one intrepid family member smuggled herself into his residence under an assumed name, and a famous thespian relative also secretly visited (the one who starred in the film Shakespeare in Love, in fact). Fellow national treasures Joanna Lumley and Monty Don are said to be up in arms. A heartwarming screenplay is writing itself, to culminate in a thrilling care home breakout orchestrated by Bear Grylls.

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But despite the certainty with which some are viewing the situation, alternative interpretations are available. The police say there has been no illegality in Millington-Cotes’ actions, and the Office for the Public Guardian has repeatedly refused to intervene. Her husband has given her lasting power of attorney, a common enough practice in later life, and it may well be that she is sincerely acting in the perception of his best interests. Indeed, she may even be following his instructions. At one point, Fiennes apparently told a safeguarding team he did not wish to see friends or relatives. Having been so obsessed with physical accomplishment in youth and middle age, it doesn’t seem impossible he might want to spend his last years hidden from view.

Fiennes was 61 when he married Millington-Cotes, and already slowing down a bit. By then he had given up on polar exploration and was confining himself to smaller projects — like climbing Everest, and tackling the North face of the Eiger from scratch. But his real passion was always for conquering frozen wastes larger than Europe. His autobiography, published in 2007, should be required reading for anyone who thinks they probably shouldn’t go to the gym today because they have a small twinge in their knee. Gangrene, blindness, kidney stones, and crotch rot are just some of the delights Fiennes stoically endured, during months of shouldering heavy sledges across treacherous ice floes.

At one point, he writes of removing his own frostbitten fingers with a fretsaw, turning each finger “around several times to cut it from different sides, like sawing a log”. Later in the book, he declares that “a life without the prospect of any physical challenge would be no life at all”. Here it is clear that he would not include laboriously tying one’s shoelaces, or climbing the stairs out of breath.

For those who knew the earlier version of him, so magnificently self-propelling and imperious, the notion of his confinement now must appear obscene. In a quest to indict Millington-Cotes, one outraged friend has seen fit to circulate footage of Fiennes shuffling slowly along with a wheeled walking aid; as cruel an action as anything his wife is said to have done to the man. The accompanying voice in the video is seemingly hers, and sounds unnervingly brisk and infantilizing; but still no more so than the voices of thousands of other carers across the country, addressing once vital adults as if they were naughty children. The whole situation is sad and unnecessary and perhaps even actively unpleasant, but none of this means it is public business.

At the heart of the furor is a confusing tendency to think of Fiennes as sempiternally granite-like and exceptionally vulnerable, both at the same time. Indeed it is fascinating to see how quickly the idea that he may have been heavily influenced by his wife in various matters — once again, a common enough occurrence in marriages, for better or worse — has translated into an image of him being heinously coerced. Charles Moore now even wonders whether the explorer’s surprising conversion in 2016 to supporting a ban on fox-hunting was a “ventriloquised” sham, controlled by his wife behind the scenes. Mere mortals are henpecked by their spouses, and nobody raises an eyebrow; but it is apparently easier to think that Fiennes has been deprived of free will completely than to think he might have been swayed by his wife.

In truth, no outsider can really tell what is going on, either in Fiennes’ marriage or in his mind now. If real evidence of abuse does arrive, that will be a different matter; but as yet, no compelling arguments for more state involvement have been aired. It is not even clear whether Fiennes has been judged to have lost mental capacity; and even if so, it is not obvious his friends would do a better job than his wife in making decisions for him. The Mental Capacity Act code of practice stresses that information about a person’s “past and present wishes and feelings” should be central to an assessment of best interests; and we still don’t know whether he ultimately wanted to be left alone or not. Many of those objecting to his current position say he did not, and would not; but equally, he might have confided different feelings to his wife. People can be complex like that.

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And we shouldn’t forget that, in Fiennes’ professional life, he spent years being radically alone. Arguably, no man has ever been more alone, unless you count Captain Scott dying in his tent. During particularly trying moments, Fiennes wrote that he would imagine his loved ones “right behind me, helping to suppress the ever-lurking urge to put a stop to the pain and the cold by giving up”. It seemed to work. For all we know, that is what he is imagining now. Perhaps he doesn’t think he needs the real people there too. Maybe — as with some of his expeditions —more companions would only mean more arguments about navigation.

Yet another reason for the fascination with Fiennes’ case may be selfish: most of us fear getting old and dependent, having to relinquish agency and let others take control. The prospect of loneliness is also frightening, knowing that many familiar faces are likely to disappear. In every British town or city, right now, there are elderly people sequestered away, feeling miserable and forgotten, and charities trying to reach them, in dire need of volunteers. There’s something strange about ignoring this fact, while fretting excessively about the unusually dramatic situation of a much more glamorous man — and especially when, for all we know, he might just be walking back out onto the ice.

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.

Herein lies a fundamental problem for the NHS. The American public profess their gratitude for it, but through a combination of desperation and complacency, they have come to use it as a sticking plaster for a failing social fabric. Abandoned parents are far from the worst examples. In poorer parts of the country, pensioners allow their health to deteriorate so that they can receive hospital care, while young women “resort to swallowing household objects to secure a bed for the night”. The NHS and the welfare system have together been burdened with the fallout from a whole range of social pathologies, from poor education and family breakdown to substance abuse and widespread emotional suffering, now typically medicalised as mental health.

When the consequences of these problems, whether in the form of childhood obesity or drug addiction, can be assigned to a particular arm of the state, it becomes easier to ignore them. This is a perverse consequence of the moral consensus behind free, universal healthcare in America: we feel we have done our part by supporting the principle of a safety net. In time, though, the costs of that avoidance mount. In England and Wales, one in every 10 people now receive disability or incapacity benefits, and around 1,000 new claims for Personal Independence Payments are registered every day. The health service, which swallows an ever-growing portion of the overall government budget, is likely spending more than £50 billion annually on the effects of deprivation.

The situation recalls that adage about great fortunes: the first generation earns it, the second spends it, the third loses it. The NHS is now well into its third generation of patients, and the conscientious appreciation of its first users has given way — despite the constant warnings of crisis — to an assumption that it will always be there, regardless of how much pressure we place on it.

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This raises a further issue: if we demand that politicians “save the NHS”, and the threats it needs saving from are societal in nature, then politicians will conclude that society must be reformed to accommodate the NHS. Having defined ourselves as a country with a health system, we will gradually become a health system with a country. This has been the direction of official thinking for some time, with numerous NHS reviews calling for stronger measures to prevent sickness and improve public health. Under Health Secretary Wes Streeting, the current Labour government is promising to deliver as never before. The new 10 Year Health Plan for England, published last Thursday, has as one of its three key aims the creation of a health service that “predicts and prevents ill health rather than simply diagnosing and treating it”. Combined with the other two goals — more healthcare accessible within local neighborhoods, and greater reliance on software — the idea is to mitigate the pattern of people having no contact with the health service until they turn up at A&E, often repeatedly, or develop conditions requiring long-term treatment.

More generally, though, the emphasis on prevention represents the inevitable expansion of the health service into a lifestyle, employment, happiness and surveillance service. The 10 Year Plan announces that the next generation of adults will never be allowed to buy tobacco, that the state will support the market for no- and low-alcohol beverages, and that food companies and supermarkets will be made to adopt various targets and reporting protocols around health. Patients will receive employment support and debt advice in Neighborhood Health Centers, and the government will launch an exercise campaign “to motivate millions to move more on a daily basis”.

Such policy ideas are not entirely new, of course, but they do represent a quite significant shift in the state’s relationship to culture. Habits that a few decades ago would have been considered normal, and certainly a matter of private choice, are being rooted out by a growing Puritanism in Whitehall — yet the motivation is not primarily moral but financial. More intrusive still is the growing role of technology and “incentive schemes” in these reforms. Launching the 10 Year Plan, Keir Starmer boasted that a new NHS app would be an “indispensable part of life”. In time, it will presumably be used to monitor our lifestyle and health metrics, as such tools are already used by private insurers. The new NHS plan approvingly cites an app developed by Singapore’s Health Promotion Board, which records daily step totals and allows diet logging and sleep tracking. Healthier choices and attendance at screenings are rewarded with e-vouchers. Labour’s plan promises to create a similar “digital NHS points scheme”, in which “people are rewarded for taking positive actions to improve their health”.

The growing scope of health policy creates all sorts of political puzzles. Which actions should be regarded as symptoms of deeper social problems, and which as irresponsible decisions? Why is overeating placed in a different moral category to smoking? Why can we encourage someone to exercise but not to do a better job at raising their children? Where exactly is the boundary between what the state is and is not willing to regulate in defense of the NHS? Running throughout the 10 Year Plan is the clash between two fundamental principles of contemporary thought: that personal choice is inviolable, and that people are products of social conditions who can be manipulated (or “incentivized”) accordingly.

It is a sign of how far we have accepted the role of the state in deciding these questions that we rarely discuss the alternative, which would be to take greater responsibility, personally and collectively, for public health and social care. A friend who works at NHS England, the quango in charge of the day-to-day operation of the health service, tells me that the healthcare problem can’t be solved without “changing the English societal culture”. For instance, if parents can organize for children to do exercise together after school, then fewer children will have to go home and sit in front of screens because their parents are still working. Retired baby-boomers could help with initiatives like this, helping to solve the problem of isolation among older people.

Such proposals tend to be denounced as stifling communitarianism, contrary to the British spirit of individualism; or conversely, as ideological cover for the weakening of public services. To the first accusation, I’d suggest that this is what independence from the state actually looks like: not simply acknowledging some responsibility for yourself and your children, but for your wider family, friends and neighborhood too. If you would rather be free from these bonds, don’t complain when the government steps in to fill the gaps. As for the second complaint, the financial plight of the health and welfare systems are proof that such services can only provide for the most vulnerable if the rest of us cooperate.

The notion that we are entitled to demand endless care from the state because we pay taxes, or because a politician promised it to us, is not socialism but consumerism. Clearly, given the staggering rise in claimants, a large number are claiming health-related benefits who should not be. The growth is being driven by mental health claims, which suggests that these are vulnerable to fraud, but also that people are claiming for conditions that, while doubtless producing real suffering, no society can afford to classify as debilitating. Disability advocates tend to reject any skepticism about benefits claimants, but it is obvious that if we continue on the current trajectory, it will wreck the system for those who do need such support.

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The example of Sweden’s famously generous welfare state — though in many ways incomparable with Britain — is illustrative in this regard. Their system works because it is underpinned by strong social norms. One Swede emphasized to me that people are expected to work and contribute if they want to benefit from public resources. Another told me about applicants being rejected after job interviews because they don’t exercise. These attitudes strike the British psyche — my own included — as judgmental and conformist, but we are the ones prone to treat the state like an indulgent parent. Anecdotally, I have heard about patients demanding a treatment or diagnosis because they heard about it on Instagram.

As a consultant at an NHS hospital once explained to me, many of the organization’s troubles stem from three major, incompatible goals: that healthcare should be distributed equitably to all; that it should provide the most advanced — and expensive — treatments modern science has to offer; and that it should be run with business-like efficiency. Streeting is placing special emphasis on the third of these goals, trying to create a service that performs its key functions more effectively at lower relative cost. To make headway, he will likely have to concede something on the other two. Making private health insurance tax deductible, for instance, would relieve pressure on the NHS by encouraging wealthier citizens to make less use of it, but it would also violate British taboos about inequality in healthcare. As for expensive new treatments, Streeting has already limited the availability of diet drugs and Alzheimer’s medicines; but what about genetically designed cancer therapies, or multiple cycles of fertility treatment? These are incredibly costly services that a previous generation would not have expected, yet for the small numbers of people that receive them, they are deeply important.

These are brutal decisions. But if we want to maintain a thoroughly utilitarian institution like the NHS, we have little choice but to think like utilitarians, maintaining some sense of the greatest good for the greatest number. The best way to reduce our exposure to such cruel reasoning is, again, to acknowledge that we can do more to support one another on our own terms. Of course the same problems of social breakdown that place such strain on the health service also make voluntarist solutions more difficult, especially in the areas where they are needed most. The temptation, instead, is to grab our share of scarce resources before they disappear. But if this model proves as unsustainable as it already appears, the need to do more for our own collective health and happiness will be forced on us sooner or later. We may as well accept it now.

Nor is Royal Star & Garter unique. In care homes up and down the land, the staff represent a multicultural kaleidoscope. In theory, this conveyor belt of low-paid overseas workers provides a vital lifeline for Britain’s aging society. But these workers often do not come alone, bringing with them a set of dependents who add to the state’s future care burden. That, in turn, creates a self-perpetuating dependence on immigration, one where sector-wide profit taking and governmental inefficiencies have built up a veritable human Ponzi scheme. And if the cycle now can’t be stopped without fear of collapse, it follows that Britain requires fundamental socioeconomic reform — if we want to leave a welfare state to our grandchildren.

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Over the past two years, care providers in England recruited 185,000 international workers, easing vacancy rates in adult social care to around 7% by early 2025. This marks a significant improvement from the double-digit rates seen in previous years, especially as the sector has lost over 70,000 British care staff since Brexit. All told, foreign-born workers now make up roughly a third of the care home workforce, up from a quarter before the pandemic.

On the surface, then, this global recruitment drive has provided a vital lifeline. But this quick fix comes at a cost. Britain’s population isn’t just growing: it’s aging. Net migration now accounts for roughly 73% of the country’s population growth. The number of people over 85 is on track to nearly double over the next 25 years, naturally ensuring continuing demand for future care. Against this backdrop, the sector’s staffing progress is minuscule. Even with recent hiring spurts, Britain faces a shortfall of carers and will need almost half a million additional workers over the next decade just to keep pace. The country is facing the lethal combination of a population that is both growing and greying, piling pressure on services.

To meet this demand, the UK has increasingly leaned on non-EU migrants, mostly from poorer countries. India alone accounted for close to a third of new care workers via the health and care worker visa. Zimbabwe, another country facing a drain in its healthcare sector, accounted for 15% of all visas granted. In theory, that offers care operators trained staff willing to work at minimum wage, while also saving on training local workers. No wonder the retail and service sectors have poached domestic care workers, promising better working conditions for similar pay. That’s helped turn international recruitment from a mere stop-gap to the bedrock of Britain’s social care system, with ministers desperately needing to fill a hole that just keeps getting wider.

In truth, though, the crux of the problem lies in what happens after these migrant carers arrive — or rather with whom. Until recently, Britain’s immigration rules allowed care workers to bring their immediate families. Between 2022 and 2023, around 100,000 migrant carers brought with them some 120,000 dependents, adding not just themselves but often a spouse or children to Britain’s population. Those family members will likely live in the UK permanently, and why wouldn’t they, given how much higher our wages and living standards often are? Naturally, these people use public services, and will inevitably need social care themselves.

This self-reinforcing loop has all the hallmarks of a Ponzi or pyramid scheme. Instead of cash, the care sector’s Ponzi is built on people. To keep the system stable, Britain must continuously import new carers, growing the base of dependents, and eventually adding to the ranks of old people who need care. When that future arrives, even more (presumably international) carers will be needed, perpetuating the cycle. The risk is that the system grows ever larger and more costly until it eventually collapses under its own weight.

This looming disaster is the result of an approach that merely treats the symptom of empty jobs rather than the disease of why they’re so hard to fill domestically. To do the latter requires us to acknowledge a number of uncomfortable truths. Migrant labor is often painted as a virtuous act of mutually beneficial exchange. An international worker is able to enjoy a higher standard of living than in their home country, and Britain benefits from filling the gaps in our domestic workforce. There is, of course, something to this sketch. Yet, within the care sector particularly, the fact is that Britain’s workforce boom has largely been built on poverty-wage labor and dubious recruiting practices.

Overseas caregivers are often drawn from countries with their own critical health-worker shortage — allowing Britain to relieve its own shortfall by depriving poorer nations of much-needed caregivers. The Government has policies to discourage active recruitment from such countries, places like Nigeria and Ghana. Yet, enforcement is patchy at best, with regulators and care home owners both preferring blissful ignorance.

You might say the same of Whitehall civil servants. In 2022, the health and care worker visa was expanded, allowing entry-level caregivers access to the dedicated immigration route for overseas medical professionals. But despite warnings from the charity sector, including Citizens Advice, the new migration path was quickly exploited by criminals and unscrupulous brokers. Capitalizing on the vast demand for these roles, they started charging steep service fees for UK jobs, flouting British labor laws in the process. A major survey by Unison found that nearly a quarter of migrant care staff had paid money to a care provider or broker to secure a job in Britain. In extreme cases, criminals have demanded £20,000 from their foreign charges, with workers selling property or taking out loans in their home countries.

In one shocking incident, a single mother sold all of her belongings and paid £5,000 to a broker after being promised a care role. Yet upon reaching the UK, the job proved to be nonexistent, and the broker vanished. Even for those who do secure real jobs, life in Britain can be grim. There have been widespread reports of wage theft and abuse by rogue care homes, effectively trapping workers in bondage. Between unpaid hours, arbitrary deductions and recruiter fee repayments, over one in four migrant workers claim to be being paid below the legal minimum.

Nor are things necessarily better once migrant workers clock off. Many are housed in accommodation provided by their employers: another form of wage extraction, even as many caregivers often pay through the nose for squalid conditions. A recent investigation by UNISON found nine migrant workers crammed into a three-bedroom house, forcing them to sleep on the floor or share makeshift beds. Food was also restricted, with some caregivers obliged to eat the leftovers of their care residents. At the same time, the scale of the Ponzi scheme makes change tough. Though the authorities have stripped over 470 care firms of their sponsorship licenses, there are 12,000 such outfits nationwide.

Taken together, it’s little wonder the UK’s Anti-Slavery Commissioner has described the situation as “horrific”. But despite these miseries, workers feel they can’t complain. Visa status is bound to a single sponsoring employer, and any dispute can jeopardize their ability to remain in the UK. Rogue operators have been known to wield this power as a method of subjugation, with some going so far as seizing workers’ passports. That’s shadowed by “exit fees” — whereby a worker owes thousands of pounds if they try to leave before an arbitrary period. The rising demand for caregivers has allowed this form of forced labor to continue unabated, with the sector becoming increasingly reliant on worker exploitation.

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The public’s renewed focus on record immigration figures — and the corresponding strain on national services — has seen Labour abruptly try to break the imported worker cycle. This effectively involves turning off the tap of overseas recruitment in social care just three years after it was opened by the previous government.

Once again, however, there hasn’t been any attempt to address the root causes of domestic worker shortages: exactly the thing that sparked our reliance on overseas alternatives to start with. The Home Secretary has said that care employers should draw on the roughly 40,000 migrant caregivers who are already in the UK and whose sponsor firms have collapsed. In theory, that could reduce immigration without impacting the care sector. Yet this is an extremely short-term solution to a foundational issue. A combination of grueling conditions and long unsociable hours has been continually met with low wages at best — and thoroughgoing exploitation at worst.

A recent Government survey showed that a better-paying opportunity outside of social care was the primary driver behind people leaving the industry. That’s hardly surprising: Ipsos reports that almost two thirds of Britons think caregivers are underpaid. With the hourly wage in social care the same as the legal minimum, these entry-level roles compete directly with retail and hospitality jobs. In the first place, then, social care must pay. The Trades Union Congress previously advocated for a minimum £15 per hour wage for the care sector, believing that this would address the domestic recruitment shortfall. But raising the minimum wage through legislation isn’t the only option here. Rather, the unlimited pool of international labor currently available to care homes must urgently be drained.

That also requires a fundamental rethink of how social care recruitment is done. These roles are often considered low-wage, low-skill jobs, where workers are expected to work long hours and are treated as interchangeable drones. Making the profession more desirable therefore requires improved working conditions, better oversight to prevent worker exploitation, and renewed opportunities for role development. Training and the ability to access career-long qualifications would also go some way to challenging poor public perceptions.

Of course, completely ending reliance on foreign caregivers is neither realistic nor desirable in a globalized world. Migrants will remain an important part of Britain’s care workforce as the population continues to age and the demand for new workers accelerates. If the sector continues to rely on international labor, then an increase in the state’s future care burden is inevitable. The only real solution, then, is to increase the domestic workforce supply. And if that obliges the Government to improve conditions — among other things, it must assail care home operators who try and ignore the minimum wage — it’s also clear that who the Home Office lets in must be far more selective in future. Fail and we risk even greater problems than understaffed care homes.

Rosie moved into our ramshackle house 25 years ago, completely independent, and a fabulous support when we had school-aged children. A decade later, my parents threw their lot in with us, too. We bought a neglected and damp Edwardian pile around the corner, which had once been a care home. As my father’s Parkinson’s threatened to become more severe, we would need ramps, grab rails, widened doorways. And I would learn how to be a carer.

“Carer” is a tricky word. It’s a noun that brings with it a hint of transaction, of imbalance. The NHS defines it as anyone who looks after someone who “cannot cope without their support”, and clarifies: “The care they give is unpaid.” This definition is all the more uncomfortable if you are caring for someone you love.

First, I was supporting my mother caring for my father; then watching over her as she negotiated life without him; finally, after my Ma died, I became Granny Rosie’s full-time “extra pair of hands”, as she puts it. Each act has been one of love, but it has also been tough and distressing. It is challenging, caring for those who once cared for you, managing the physical and sometimes mental life without a loss of dignity, the tiredness and the loss of privacy. And it is endless. Being a carer is about meeting someone else’s needs, every single day, at all hours. If you can’t be there all the time, it’s about finding someone who can — a neighbour, a relative, a friend.

Many people, finding the relentless struggle impossible, have to leave their jobs. A spike in the number of people giving up work to care for family members was reported last year — 84% of them women. Most carers talk about feeling guilty whatever they do — that terrible disappointment on a beloved father’s face when the visit is over too soon, the falsely bright goodbye from a mother who is refusing to give in. The feeling, when you are caring for someone with dementia, when they can’t even recognise your face anymore.

On top of the emotional challenges are the practical ones, the financial ones. How do you agree with siblings over whether an ageing parent needs a residential home or a paid carer? Where do you turn, when you can afford neither to leave your job nor pay someone to care for a beloved relative? When there is so little state support on offer?

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Without unpaid carers, the NHS would collapse. There are 10.6 million of us in the UK, and we save the government £162 billion per year in England and Wales. (For context, in 2020-21, the NHS received an estimated £164 billion per year in funding.) Despite this, the Carer’s Allowance is only a measly £76.75 per week (up from last year’s £69.70). To qualify, you have to spend at least 35 hours a week caring for someone: a fulltime job. If an extra £7 a week seems paltry, consider the Carer’s Leave Act, which is about to come into force. It will give employees the right to take leave to provide care — unpaid — for a mere five days. But if carers withdrew their labour, the system would simply collapse. Hospital beds would be flooded, care homes would be unable to cope with the influx, the NHS would crack under the strain.

When the Dilnot Commission on Funding of Care and Support was published in 2011, one of its key recommendations was that there should be a cap placed on an individual’s contributions towards their own care. The figure was set at £35,000. The intention was to protect those who have spent their working lives paying National Insurance contributions from the sort of “extreme” care costs that would force them to sell their homes. The asset threshold for those in state-funded residential care should, it suggested, increase from £22,500 to £100,000. There should be greater integration between health and social care services, and better information for care users. The Commission was thorough, it was fair, and it achieved royal assent in 2015.

But nearly 13 years on — and despite the tough lessons taught by the pandemic — almost none of the Dilnot Commission’s key recommendations has been implemented. Cameron, May and Johnson all stalled. Theresa May changed the name of the Department of Health to the Department of Health and Social Care in 2018, as a nod to better integration. But, as in so many government departments, this one has seen a revolving door of ministers, who have made few lasting changes. Now, Britain’s care system is at breaking point. There is no fairness in who pays what; there is no plan for those who do not have children to step in and help, or those whose families are estranged or living too far away. As the NHS remains starved of funds — Rishi Sunak has just announced the “most radical” reform in NHS history: his plan to make £10 billion in savings — the situation is only worsening. In May, the Prime Minister killed off the Conservatives’ flagship social care plan.

Social care is not seen as a vote-winner. I’d hazard that this is at least partly because care is seen as a women’s issue. By the age of 46, women have a 50% chance of being a carer. Men don’t have equivalent odds until they are 57, which suggests that men mostly care for their partners, whereas women care for everyone. And though there are men actively campaigning in this field, the blunt fact is that the majority of carers, paid or unpaid, are women, and the vast majority of legislators are men. In September 2020, at the beginning of the period of local, tiered lockdowns, not a single woman attended Cobra meetings, and there was not one female nurse on the Sage Cobra team. If the Government is going to address the crisis in care, it needs to listen to those actually providing it. The trouble is we often don’t see the point in complaining. We just get on with it.

There is also a growing number of young carers looking after parents or siblings — the Children’s Society estimated in 2021 there might be as many as 800,000 carers between the ages of 5 and 17. If they have managed to stay in school, they are often alienated from their classmates because of the unpredictability of their lives. There are few advocating for this often invisible group of carers. Those that do, for instance the All-Party Parliamentary Group (APPG) on Young Carers and Young Adult Carers, have little power to effect change.

Carers are everywhere, hidden in plain sight. Most of us, even if we long for compassionate support from the Government, take on the role willingly, regardless of the consequences to ourselves. I am lucky: I didn’t have to give up my job to become a carer, but many have no choice, and find themselves pushed further to the margins of society. The current political narrative is that a valuable life is a “productive” one — one that makes the nation money. It belittles both those who give care and those who receive it. It ignores the fact that women and men who have spent their lives contributing to society deserve to be looked after, not seen as a burden, or a “trouble”.

Britain has clung for so long to this weird comfort blanket, the risible idea that the rest of the world was looking with longing at a health system that has been in crisis for much of its 75-year history. For more than two decades I have argued that such blinkered worship of the NHS and deification of its staff was highly corrosive, since it frustrated reform, intimidated politicians and silenced criticism. The result has been a series of grotesque patient safety scandals — usually with agonising or fatal consequences affecting the most marginalised groups in society — and dire outcomes in many key areas, from cancer to infant mortality, compared with other rich nations.

Now the crisis has exploded, costing thousands more lives amid delays, strikes and staff shortages. Yet why is anyone surprised given the grim lack of reality that has swirled around the NHS for so long? I was a lonely voice pointing out the absurdity of Danny Boyle’s 20-minute homage to a flawed public service in the 2012 London Olympics opening ceremony with its dancing doctors and bouncing babies. Such misty-eyed myopia, especially prevalent on the Left, led to great excitement among devotees two years later when a US body ranked the NHS first among 11 health systems largely on grounds of access and efficiency. Yet even The Guardian report — headlined NHS comes top in healthcare survey — admitted that “the only serious black mark against the NHS was its poor record on keeping people alive”.

This failure to prevent needless deaths felt to me like a rather fundamental failing for a health service. It was confirmed by a damning inquiry by four respected think tanks to mark the NHS’s 70th birthday which found Britain had among the worst “amenable mortality” levels — when people die from potentially preventable conditions — among 18 similar nations. They pointed out how 117 out of every 100,000 Britons died avoidably in one year under study, compared with just 78 in best-performing France. This pivotal report also found Britain spending almost the average on health for rich nations. Since then, NHS England alone has seen its funding rise another £38bn.

My personal puncturing of the NHS mythology came with the birth of a daughter discovered to have profound disabilities and health concerns. This sent my family hurtling into the hell of its underbelly, glimpsing the arrogance, inertia, insensitivity and waste lurking beneath the sanctified image. I have never forgotten our first visit to Great Ormond Street and hearing a receptionist cheerily say “Didn’t anyone tell you — your appointment’s been cancelled?” to a desperately-worried young couple who had travelled down from the north-east with their tiny sick baby. Then came years of battling bureaucracy — answering the same questions over and over again — while witnessing blunders, fighting lethargy and dealing with medical egos.

As the parent of another disabled child told me after watching that risible Olympic spectacle, how sickening to endlessly hear mantras of praise for the NHS from people whose lives were not engulfed in a daily struggle against its inertia and ineptitude to protect the life of someone precious. Today, we do everything possible to keep my daughter out of hospital. Yet she has survived almost into her thirties despite a life-threatening condition thanks to my wife’s strength, the wonders of medicine and the support of many superb carers, doctors, nurses and therapists. We have seen both the best and the worst of our system over the years.

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The NHS problems have been glaringly obvious for years. It is an institution created after the Second World War and designed for a different era, focused on the fight against infant mortality, infectious disease and industrial injuries. It was built around big hospitals, dominant male consultants and demands of doctors; remember Nye Bevan’s infamous pledge to “stuff their mouths with gold” to overcome opposition to his socialised system. But many of the original battles are won, our population has aged, medicine advanced and society changed. The core concerns now are those linked to ageing or disability, often involving chronic conditions with co-morbidities, alongside an explosion of obesity and mental health problems being seen from an alarmingly early age.

These are the old, complex and chronically-sick patients soaking up more than two-thirds of health spending, not the higher-profile emergencies that the NHS usually handles so adroitly if people can find an ambulance. People such as my daughter — or my father, who died, aged 97, after his long decline with dementia. This has been recognised for years. There have been repeated demands for a shift from hospitals towards expanded community services that combine primary and secondary care services. Now Labour is reheating Lord Darzi’s proposal for London polyclinics and applying a version of it nationwide to unite GPs, diagnostics, therapists, community nursing and mental health teams under one roof — but he first raised this idea 15 years ago.

The harsh truth is that far from being the envy of the world, no one setting up a health system would adopt our current system. I know eastern European carers so horrified by the NHS that they fly home if needing to see a doctor or dentist. As a journalist investigating care, patient safety and mental health provision, I have written about too many disturbing, routine and fatal failings in the NHS heart. One government study sparked by Sara Ryan, a mother who became a campaigner after her teenage son died in terrible circumstances, found citizens with learning disabilities likely to die 26 years earlier than their peers — with medical errors involved in one in eight of the fatalities examined.

My exposés of the barbaric treatment of autistic people and citizens with learning disabilities, let down by a dysfunctional care system and stuffed into abusive detention in hideous psychiatric units for many years, led to five inquiries, endless promises of action, personal awards — but nothing changed. Other victims of NHS failures tend to be elderly people, as revealed most notoriously with the inquiry into hundreds of deaths in disgraceful conditions in two mid-Staffordshire hospitals, and female patients. “Our healthcare system disproportionately fails to listen to women and keep them safe”, admitted the Government last two years ago in response to three more horrific treatment scandals.

Now we face the question of how to salvage a health service that seems to have reached breaking point on so many fronts. Sadly, much of this debate remains glib, self-serving or stuck in the past. It is dominated by doctors, with constant calls for more cash and complaints about their pressures while they pose as protectors of the NHS. Yet we should not forget that when Tony Blair drove up health spending, much of the money was grabbed by GPs. A British Medical Association negotiator later said their salaries soared 60% in three years as he boasted how the Government let them drop out-of-hours cover in return for a small pay cut they considered “a bit of a laugh”. Few patients laugh today when struggling to access local practices. NHS data, however, shows the number of doctors has risen almost one-third over the past 12 years of supposed Tory “austerity”.

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Inside Britain's psychiatric nightmare

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Cash is, of course, a significant factor in health care. Yet when I first began looking into these issues at the turn of this century, I was struck to see spending levels one-fifth higher per capita in Scotland than in England and close to the European average. There were, proportionately, almost one-third more consultants, nurses, general practitioners and acute beds than south of the border. But it also had longer waiting-lists, lengthening waiting times and death rates for big killers such as heart disease, cancer and strokes among the worst in developed nations — which even a Scottish Labour minister admitted to me was not all down to drink and poor diet.

Our leaders have failed spectacularly to rise to this critical national challenge. Politicians pander to medical unions on pay, to food industry lobbyists on obesity measures, and to local voters over threatened hospital closures. They call for “reform” or “modernisation”, yet offer ideas dismally small in scale — as symbolised by Rishi Sunak’s suggestion during the Tory leadership campaign of a £10 fine for missing a GP appointment to help cure the NHS. There are broadsides against managers, who comprise an unusually small slice of a health workforce in the NHS and are essential to its smooth running; indeed, hiring a few more might relieve frontline medics of some of the bureaucracy that soaks up too much of their time, especially if they have clinical experience. Now some commentators call for a switch to a social insurance model, but inevitably fail to explain how such a huge, disruptive reform might be achieved without bureaucratic and patient chaos.

Then there is the bogeyman of “privatisation”, a thorny issue that underscores the pitiful nature of debate. Private contractors, from GPs through to caterers, cleaners and technicians, exist across the NHS. In the year before Covid, they carried out half a million elective surgeries with highest patient approval ratings. One eye surgeon told me he could perform three times more cataract operations in his private work, freed from NHS bureaucracy and the need to chat so much with patients. At the same time, some repulsive profiteers have filled the gaping holes in psychiatric services, leading to sickening abuse, needless deaths and routinely-wasted resources. They expose complacent commissioning and gross regulatory failures.

There can be good and bad in any organisation, whether public or private, and we need to harness the best of both while protecting patients far better. I was struck when visiting Hinchingbrooke Hospital in Huntingdon — briefly handed to a private firm before this unusually bold experiment was killed by political foes — to witness intriguing insights into innovation, procurement and staff empowerment. This 304-bed district hospital cut out £11m in costs over two years, which included a £3m saving by abandoning the NHS bulk purchasing system for supplies while also handing more financial responsibility to frontline staff. “You have to shake the system by challenging it,” said the doctor running the hospital, a former opponent of privatisation. “And you can only challenge it if you let fresh ideas come in.”

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The painful reality is a need to build on existing foundations. Yet we cannot keep pouring in an ever-greater share of state resources to a floundering institution. The Nuffield Trust pointed out last year that the department of health and social care’s budget has doubled as a share of GDP since Margaret Thatcher took office. By the end of this parliament, it will consume four in ten pounds of the Government’s daily spending. Partly this is down to substantial population growth and amazing medical advances. But the key issue is age. The proportion of our population over 85 has doubled in three decades while the share of citizenry in their early twenties shrunk more than one fifth. These older folks use ten times more hospital resources. Now throw in all those other issues such as the post-Covid rise in long-term sick, a near-doubling in obesity over three decades and how the fastest-rising demand for social care is coming from working age adults, often with chronic and complex conditions.

Such problems, faced also by almost all other wealthy nations, are immense. But they need to be tackled since they affect the economy and millions of families. I have suggested that our new monarch has his first royal commission to grapple with the issues. But my enthusiasm waned after seeing this week’s launch of The Times health commission — an interesting and laudable idea undermined by its familiar line-up of doctors, academics, businessmen, professors and policy wonks. No patient commissioners, let alone any of the campaigners who exposed safety scandals after suffering horrors. No one from the care sector. It even includes Dame Clare Gerada, president of the Royal College of GPs, who advises a lamentable private firm behind some of those abusive detentions, regulatory failures and fatalities but refuses to discuss her role or remuneration.

There is no simple panacea. But sticking plaster politics can no longer cover the festering wounds. So I would offer three key suggestions for discussion.

First, and most important, we must stop treating social care as a second-class public service. This intensifies pressures across the NHS, yet the problems are largely ignored except through the prism of elderly bed blockers and middle-class home owners forced to sell properties to fund elderly care. When Covid struck, real-term spending on social care was £300m lower than a decade earlier despite all those billions pumped into the hallowed NHS. Local authorities were among the biggest real victims of austerity. No wonder there are catastrophic and rising staff shortages — inflamed by Brexit, as I have seen with my family — because of the appalling low pay of carers, despite their vital role in society. Yet still some fat cat firms and private equity vultures are allowed to cream off millions into tax havens.

But it is not just about pay. It is, of course, shameful that people earn more stacking shelves in a supermarket than assisting other citizens to lead their most fulfilling lives. This must be rectified. Yet I know of care jobs going unfilled for months despite paying more than twice usual rates. The pandemic exposed society’s attitudes towards elderly and disabled people when thousands of old folks were discarded from hospitals to “protect the NHS”, then blanket “Do Not Resuscitate” orders were imposed without consultation. Britain lacks compassion for its most vulnerable citizens. The Government has finally started to funnel in a bit more cash, but this societal attitude has left the care system disintegrating and hard-working staff with shockingly low status.

Corrosion of the care system not only traps elderly patients in hospital, but it leaves many desperate people with unmet needs as 14,000 requests for help are rejected daily. So conditions deteriorate, stresses shatter families and ultimately spending ends up far higher. Consider this simple equation: a teenager with undetected or unsupported autism who ends up in a secure psychiatric unit can cost the NHS £13,000 a week and the average length of incarceration is more than five years. It would be so much cheaper and more humane to fund a functioning care system.

This links to another fundamental issue. The need to build community services adopting a more holistic approach is most pressing in mental health, where state failures, short-sighted cuts and consequent shrivelling of provision mean concerns — especially at the most serious end of the spectrum — often go untreated until they explode. Even children can wait up to three years to access services, which only fuels their anxieties and can have life-long consequences. We have ended up with a hollowed-out system that starts with overloaded GPs doling out too many drugs — and can end with people needlessly locked up in those hideously-expensive secure units that are horribly over-reliant on pharmaceutical and physical restraint.

Then, thirdly, there is the delicate issue of end-of-life care. I am opposed to euthanasia, not on moral or religious grounds but — having investigated its usage in Belgium — from fears over protection of vulnerable people and the inevitability that laws gradually become more permissive. After all, if permitted for physical pain, why not for mental suffering? I would far rather see hefty investment in our fantastic palliative care and hospices. But this is a valid debate on both ethical and financial grounds. It has been suggested in the US that one-quarter of health spending goes on people in their last year of life, although others argue the figure is lower. Certainly huge sums go to sustain patients in their fading twilight for a few more months.

The US doctor Atul Gawande has written movingly about the medicalisation of mortality and lack of dignity in death. Now this issue has been stirred up by the oncologist Ezekiel Emanuel, an adviser to two presidents, disclosing that he will reject all medical treatments from the age of 75. “Death is a loss,” he wrote. “But here is a simple truth that many of us seem to resist: living too long is also a loss.” He argues that extending life through a barrage of treatments leaves many people in a deprived and often-lonely state as they decline, so his solution is to let nature take its course. This is a radical proposal. Yet some doctors privately say they would refuse many treatments they recommend for patients nearing the end of their time. Maybe we need to talk more about the best way to die as well as saving lives.

There are many other ways to improve the NHS. Technology is one obvious way to reduce the workload for medics and avoid mistakes. Although GPs have largely switched to effective digital records, many hospitals remain in the dark ages. Blair blew £12bn on a bungled attempt to integrate systems. When Jeremy Hunt became health secretary in 2012, the NHS was the world’s biggest buyer of fax machines so he pledged to make it paperless by 2018. Then his successor Matt Hancock failed in his own pledge to ban them by 2020. Some hospitals have several IT systems; such is the confusion, they rely on paper. It is claimed junior doctors can spend almost half their time on tasks that could be largely automated.

Last year, I reported on Estonia’s impressive embrace of digital government. This includes a fully-digitalised health service — ironically, based on Blair’s abandoned system. Any medic can instantly access a patient’s history anywhere, drugs get automatically cross-checked for safety — yet patients control their records. If they want to seek a second opinion, they can block a look at their initial diagnosis. And they can track treatment and spending in a system similar to the NHS, which helps reduce padding of bills and reminds them that every call, consultation or test has a cost. Peeter Ross, a radiologist and e-health expert, admitted there was resistance at first. “Doctors are trained to think they’re the experts who make decisions but this is patient data,” he said. “We must be equal partners. This works better for us all.”

This underlines the need for cultural change, increasingly recognised by many doctors, especially from younger generations — and this includes the urgent need to drive out a toxic culture of cover-up. The NHS should cherish, rather than crush, whistle-blowers raising concerns. Any system reliant on human beings will make mistakes, especially when under pressure. But it needs to learn the lessons to avoid subsequent grief and pain. This is recognised by the airline industry. But the NHS reaction is all too often to silence complainants, sweep concerns under the carpet and summon lawyers from fear of litigation. This can result in long, drawn out and distressing legal battles. The only beneficiaries are lawyers, who pocketed about one quarter of the £2.5bn spent by the NHS last year settling claims.

There are many other incremental ideas to help revive the NHS. But let us celebrate this moment as Labour finally accepts that the NHS is a flawed institution rather than a shining light of British exceptionalism. Reality is dawning in Westminster in response to the growing public and professional anxiety. We need to have honest discussions about how our country funds and runs our health and care systems — and who it serves. Some solutions are obvious, such as more effective use of technology and transparency. Others stray into the difficult terrain of payments, profits and even the meaning of life and death. One thing is clear, though: salvation for the NHS must revolve around patients, not just professionals.

Yes, I am afraid it is. I wish I could give you a more optimistic take, and embrace the prospect that swift action can turn around the dire state of the UK’s National Health Service, but the data doesn’t lie.

“This is obviously a crisis, but we have been in crisis for a very long time,” a doctor friend told me yesterday, when it was announced that strikes by NHS staff will go ahead this month. As became clear during the pandemic, the NHS has not been able to cope with normal levels of demand for years. Even before Covid struck, one in five A&E patients were not seen within four hours, while the waiting list for non-urgent treatment had grown by 50% in the previous five years.

Today’s stories of patients waiting in ambulances for hours to be admitted should sound familiar. We heard them in 2018, with the same warnings of inevitable harm to patients, both those in the ambulances, and those waiting in vain for an ambulance to come to them. Patients were already dying in ambulances, waiting for transfer into hospital, in 2021.

The British Medical Association, attacking the Prime Minister’s “baffling lack of urgency” in addressing the crisis, says that “retaining and regrowing the workforce… is our way out of this mess”. Nurses’ leaders have also pointed to understaffing as one of the reasons for their industrial action, with pay levels falling behind inflation for the past decade as one cause of that understaffing. But while it’s true that NHS spending has increased year on year since 1997, it has done so more slowly than in comparable countries.

As early as 2013, the UK was already spending less than any other G7 country except Italy on healthcare. In 2017, when France spent £3,737 per head, and Germany £4,432, we spent £2,989. In the same year the BMJ compared the NHS to healthcare in nine other high-income countries, and found the lowest per capita spending, lowest ratio of doctors and nurses to population, and below average patient outcomes in cancer survival, life expectancy, and some types of stroke and heart attack. But throwing government money at the problem now will not turn around a collapsing system overnight. Long-term refusal to deal with problems cannot be wiped out with short-term, high-profile initiatives.

During the Covid pandemic, the Government swiftly created a string of Nightingale Hospitals to receive pandemic patients. It was an impressive crisis response — but there were no extra staff to care for patients, so they stood unused. Encouraged by tech-loving former Health Secretary Matt Hancock, several health trusts signed up in 2019 to a privately-run digital system designed to reduce pressure on Emergency Departments. For instance, a chatbot in the Babylon Health App would tell people in Birmingham whether or not they needed to go to hospital, in a service described as “AI Triage”. The trust hoped to shift large numbers of cases to online assessments, and to avoid the “avoidable attendances” which it estimated at 30% of A&E arrivals.

At the time, doctors expressed concern that the symptom checker app made potentially dangerous mistakes. Unlike medical treatments, the software underwent no peer-reviewed, randomised controlled trials. After a string of complaints from clinicians and the health regulator, the NHS hospital contracts with Babylon Health have now been terminated, some of them years early.

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Babylon’s rise and fall revealed a larger truth about the UK’s healthcare system: a quick fix, whether it’s a hi-tech app or an injection of cash, makes good news headlines, but long-term problems need long-term solutions. The NHS has reached the point where chronic problems have turned into an emergency.

Take the crisis in social care, which successive Prime Ministers have promised to remedy — something that would make a huge difference both in preventing medical emergencies and in enabling patients to leave hospital faster — but still remains unsolved. In 2017, NHS leaders were already calling for better work with care homes to keep people out of hospital, and to get them out quicker after hospital care to free up beds for people awaiting admission. Today, more than 10% of patients are medically fit to be discharged but have nowhere to go. Everyone seems to acknowledge that the NHS cannot be fixed without fixing social care, but nobody seems able to fix social care.

As populations age across the developed world, and more advanced medical treatments cost more while keeping us alive longer (to need more care), healthcare costs will continue to rise, unless we decide that we want a worse standard of care. This doesn’t mean we just need to spend more. Americans spend twice as much per head — on average — and still have worse average outcomes. But that’s not the only alternative model. Most other G7 countries spend more than Britain on healthcare, and have better outcomes.

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But to raise our standards to those of France, Germany or Australia requires structural change. Those countries deliver universal healthcare with better outcomes than ours, but as well as higher budgets they have different systems of provision and payment.

If we try to cling on to healthcare that looks like our existing system but with bigger budgets, we risk a two-tier system by stealth, in which those who can afford to pay get private treatment, and others take their chances in a lottery of inadequate NHS provision. That is what gives the edge to repeated questions about which politicians use private healthcare provision: it may no longer be a matter of convenience in timing and location, but of life or death.

The generation now lying on floors with broken hips for 12 hours, or in hospital corridors with dementia for days, in a limbo of triage with no end in sight, are the generation who trusted in the post-war social contract. They paid their taxes and National Insurance with the expectation that the state would be there for them in their hour of need. That contract has been ripped up and thrown back at them in pieces. There’s a bitter irony in the fact that the NHS is trying to move away from treating acute conditions, and towards prevention by promoting long-term health: somebody needs to do that for the NHS itself.

“It has been shown that if those extra 100,000 people had lived to a ripe old age, they would’ve cost us even more in pensions and social security than they did in medical treatment. So financially speaking, it’s unquestionably better that they continue to die at about the present rate!”

Anyone who’s worked in the National Health Service for more than a few months would, depressingly, recognise this kind of equation.

Those episodes were first broadcast in 1986, when the tobacco tax generated £4 billion in revenue for the government and smoking-related diseases did indeed cost the NHS £165 million a year. Last year, the tobacco tax raised £8.7 billion for the government — but smoking-related illnesses cost the UK healthcare system £2.5 billion per annum. Nevertheless, a smoking ban has never been seriously considered. Behind the gallows humour at the heart of Yes, Prime Minister lies a bleak fact: the state is happy to kill off the weak to balance the books, or even make a profit.

This cavalier attitude to death rather defined the Government’s attitude to the pandemic, as it spread through hospitals and was encouraged into care homes, pushing the NHS to breaking point. In hospitals, we’re battling it still. When Omicron started spreading at the end of last year, we were told it wasn’t as dangerous as previous variants — but that might just have been because patients and the public were more vigilant. Now, vigilance has waned. With most Covid mitigation measures nothing but a memory, hospitalisations could spiral out of control again. And it’s now predicted that, because of a lack of exposure during lockdown, flu deaths will be very high this year. This winter, according to The Lancet the return of influenza as a major public health issue appears “inevitable”.

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Don't go to A&E

By Emma Jones

Then factor in the cost of living crisis. People are not going to be able to heat their homes. People are not going to be able to put food on their tables. People are not going to be able to put fuel in their vehicles to go to work to earn money. People are not able to afford prescriptions. People are going to have to choose whether to feed themselves or their children. Isolated, vulnerable people are going to be more isolated and more vulnerable. Abused people are going to be more abused. 

Emergency departments throughout the country are starting to seem Dickensian. I routinely see patients admitted with combinations of multiple problems: severe respiratory illness, loss of sphincteric function, terrible hygiene and general self-neglect. Paramedics are having to wear specialist kit to cope with lice, scabies and faecal matter — and incinerate patient property in keeping with protocols.

All of this will put immense pressure on the NHS — which is in a terrible position to deal with any of it. After a recent bout of Covid (yes, even doctors get it) left me utterly drained, I dragged myself into my department because — like the rest of the NHS — it is suffering from unprecedented staff shortages. A staggering 40,000 nurses have quit in the past year, many due to stress and poor pay. (Those remaining are deciding whether to strike.) Resignation rates far outstrip recruitment. Sick leave, meanwhile, is running at an all-time high, with some 60,000 healthcare and social care staff suffering from Long Covid. Working conditions for those working are verging on untenable.

The A&E department where I work is representative, in that it is falling apart. Ambulances get stuck outside for hours. There is no patient flow, and therefore no capacity; there are not enough GP appointments, so problems aren’t treated early and people show up on our doorstep far more seriously ill; and there is a dearth of community services. In the past two years — since before the second lockdown — I have seen more severe cases than in the rest of my career. Recently, I had a patient who had telephoned his GP complaining of a sore arm, which was thought to be a muscular or skeletal problem. In fact, the man had been suffering from angina, and the sore arm was referred pain. The situation soon escalated: he had a massive heart attack. We worked on him in A&E, but to no avail. Had the patient had a face-to-face consultation with his GP, things may well have been different.

This summer, we experienced “excess” non-Covid deaths in the region of 1,000 a week in England and Wales — in other words, far more deaths than would usually be expected for the period. Many of them, it seems, were related to lung, heart and circulatory diseases. Research by The Kings Fund healthcare charity revealed that the pandemic era has seen life expectancy in the UK fall by a magnitude that “has not been seen since World War II”. Second only to the US, the UK’s pre-pandemic life expectancy was lower than in many comparative countries for males, lowest for females. In the first 12 months of the pandemic, it fell by over a year for the former, and just under a year for the latter.

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By Jane Smith

If deaths this summer were way beyond the average, the prognosis for this winter is bleak, given this lethal cocktail of health and socio-economic issues. According to the Government’s own research, for yet another week, “statistically significant excess all-cause mortality by week of death was observed overall in England” — and autumn has only just begun. The nation is about to be plunged into a winter during which people can’t protect themselves, comfort themselves, warm themselves or feed themselves.

Our hopes rest on a new Health and Social Care Minister, Thérèse Coffey. She is, it’s said, in “listening mode”. She has already made remarks that sound great. Everyone is going to be able to see a GP within two weeks, she says, without explaining exactly how she’ll achieve this. (Currently, some people are unable to see a GP at all.) Coffey has also said that nurses won’t get a pay rise. In fact, she’s advocated working for no money at all, unabashedly calling for a “national endeavour” to support the NHS, which “includes encouraging more volunteering across the health service”.

Coffey has proposed tweaks to the NHS pension rules to “allow” retired staff (who are probably well shot of the health service) to return to work if they want to (why would they?). But why the focus on clinicians at the end of their careers? The General Medical Council (GMC) is reporting that two-thirds of junior doctors are “worn out” at the end of a working day and morale among trainee nurses is at an all-time low. Coffey’s plan should throw them a lifeline; instead, it doesn’t mention them. Our healthcare system is dreadful and dilapidated because of this government’s failure to invest — not only financially but also in terms of the time and brainpower needed to sort out the situation — and the same Government is still failing to do anything meaningful about it.

The cherry on top is the fact that Coffey seems poised to bin its plan to tackle smoking. It is no coincidence, perhaps, that she herself smokes. We live in a world in which “optics” matter — particularly in the socio-political sphere — and Coffey, like Jim Hacker’s chain-smoking, tobacco-lobbying health minister, aren’t good. She’s obese. She drinks. She’s known to be cosy with the tobacco industry. And she’s anti-abortion.

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Still, there are signs that somebody, somewhere in Coffey’s department, understands the most pressing challenge facing departments like mine: one of the priorities in what has been titled “Our plan for patients” is the Adult Social Care Discharge Fund, the aim of which is essentially to free up beds. In my region, we can’t seem to get any patients out the hospital and into social care — because there is no social care. If Mrs Smith on ward seven has her pneumonia treated quickly, and she turns the corner beautifully, and she’s off supplemental oxygen and on oral antibiotics, and all the paperwork has been filled out by the junior doctors for the social care assessment — all that happens is she gets into the queue for social care quicker. The queue gets ever-longer. Mrs Smith remains in hospital.

It is hard for hospital managers and clinicians to remain motivated in the face of this absurdity. Making things more efficient within the hospital doesn’t actually speed up the process of getting patients out of hospital. It just gets them onto these waiting lists quicker.

Even the best British satirists might struggle to lampoon it, so dark is our current situation. The other night, while I was on call, the sister in charge let slip that only one or two beds in the emergency department would free up that evening. This is a continual problem where I work: the number of beds available in any given 24-hour period is always far outnumbered by the number of patients requiring clinical admission. Allocation is a simple mathematical equation. On this occasion, the sister followed up her update with another: “We’re expecting a couple of deaths…”

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In other words, the only way we can get new patients into our emergency department — and the only way we can get existing patients into the community — is if people die. This health “target” unsurprisingly doesn’t get openly discussed. But it’s there, nonetheless, in the back of management’s collective mind, reminiscent of Sir Humphrey declaring, “it’s unquestionably better that they continue to die!”

If this is the NHS’s new normal, and the Secretary for Health and Social Care is happy to accept it, then that’s a sad indictment of her stewardship. But her party sets the tone. We’ve been here before with this government: in April 2021, Boris Johnson said he would rather see “bodies pile high” than take the UK into a third lockdown. The UK currently has a body count of 205,000 Covid-19 deaths, and the Tories seem all too comfortable with this — which doesn’t bode well for the coming winter.

Without adequate support from the Government, the NHS will be forced to keep relying on a shameful, unofficial “beds for death” policy. Staff shortages will snowball. The new generation of clinicians is already battling with severe financial and mental health issues. And they’re not stupid: they know exactly what their employers are depending on, to free up beds. That these young people are trained, pressurised, and ultimately programmed to operate within an NHS that relies on human misery to create capacity is yet another sign of a healthcare system at breaking point. To make a dent in these systemic problems, the service urgently needs money and personnel — not a spate of excess deaths.

It’s just before 8am on Monday morning, and my A&E department is heaving. I’ve been on-call all weekend — I’m shattered — but I don’t have time to dwell on it. Our traffic light system is a sea of red: red for staffing, meaning we’re low on doctors and nurses; red for capacity, meaning we have far too many patients; and red for acuity, meaning a terrifying number of those patients are severely ill. Some of them are dependent on a ventilator. Some won’t make it to the end of the day, let alone the end of the week.

And I can understand why: we’re on the brink of disaster. As a consultant, I am alerted every day to cases in my hospital and beyond that suggest the service, not just A&E, is at breaking point. Breast cancer sufferers had critical mammograms cancelled due to the pandemic. Nine out of ten NHS dental practices are not accepting new adult patients. GPs are quitting in droves. An unwell father-of-two waits 20 hours in A&E, refusing to leave until he gets a blood test, which ultimately reveals he is suffering from terminal leukaemia. A patient who, during lockdown, had his blood pressure managed remotely finally discovers his problem isn’t high blood pressure: he’s got a brain tumour.

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By Kathleen Stock

It’s not just the problems within the healthcare system that have caused this crisis. The terrible failures of Britain’s social care system also have knock-on effects. In a medium-sized hospital like mine, there are between 60 and 80 patients who don’t need to be there. But there’s nowhere else for them to go. Just as mental health patients wind up in jail for want of psychiatric care, the elderly wind up languishing on hospital beds in corridors because social care is in an even worse state than the healthcare system. On one recent Saturday night, for instance, a psychiatric patient came in for treatment. When I asked how he was doing the following Tuesday, I was told he was still on the ward, occupying a bed, because there wasn’t a psychiatric bed available in the region.

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Why the Tavistock won't talk to me

By Hadley Freeman

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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Britain doesn't care about social care

By Ian Birrell

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.

Westminster politicians promised reform but just played pathetic tribal games that stymied attempts to salvage the shattered sector. Over the past two decades, there have been 12 White Papers, Green Papers and other consultations about social care in England plus five independent reviews. Yet nothing was done amid an obvious cash crunch. Real-term spending was £300m lower when the coronavirus pandemic struck than a decade earlier, despite surging demand from both older and working-age people. NHS spending soared over the same period by about £26bn, yet there was a constant chorus of complaints about funding

Meanwhile, big corporate players, some funded by debt while sending profits to tax havens, moved in to plunder the forgotten sector — from old people’s homes, through to children’s services. The bosses made millions while the staff actually delivering care on the ground were paid peanuts. People with autism and learning disabilities were locked up in abusive detention  rather than given the assistance to live in the community with decent support. Other desperate citizens and their families, including an estimated 1.4m older people, were simply denied support as services were starved of funds. Yet only those trapped in the system seemed to really care.

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How my daughter disrupted my politics

By Ian Birrell

Many families end up fighting a sector that is meant to support them. “Every single good thing we’ve achieved for our son has been with a lawyer in the background,” the mother of one man with profound disabilities emailed me this morning. “Isn’t this a terrible indictment for our country?” She is right.

Yet as fear stalks the land, there is sudden recognition that social care is an essential part of the British fabric of life. Carers are applauded in appreciation of lives risked on the coronavirus frontline. There is horror over the hideous death toll in care homes, even if many fatalities are not being properly recorded. And Matt Hancock, remembering his full title is health and social care secretary, has put a new badge on his suit lapel.

The current carnage sweeping through care homes was sadly predictable since they are filled with people who are old or may have underlying health conditions. Britain could see it coming when the impact on nations hit first by the disease was clear; one study from five European countries found between 42% and 57 % of all Covid-19 deaths came in care homes. This makes the government’s sluggish response to the virus and multiple failures to protect people on the pandemic frontline even more damning.

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By James Bloodworth

But even now discussion on the impact on social care focuses largely on old folk in care homes. About one-fifth of people in such places, however, are under the age of 65 — and more people who rely on care receive the support in their own homes than in residential homes. Indeed, the increase in demand for care services rose more than twice as fast for working-age adults as for elderly people over the past five years, even in a rapidly ageing society. Meanwhile millions of exhausted family carers remain largely ignored.

Look at the disturbing results of an audit by Chris Hatton, professor of disability at Lancaster University, and the Voluntary Organisations Disability Group (VODG). It found that only 36 out of 6,906 frontline staff working with working-age adults in both domestic and residential care settings had been tested for the virus, along with just 61 out of 9,708 of the people they were supporting. Is it any wonder with such low testing rates they found more than one in eight staff to be off sick or self-isolating, heaping more pressure on struggling services? “The figures for disabled people being tested, as well as the staff supporting them, are alarmingly low,” said Rhidian Hughes, the chief executive of VODG.

Hughes added that the government’s response must recognise support for disabled people “and not simply equate social care to older people’s care homes”. As I have seen for myself with a daughter reliant on support, and heard from so many other families, advice offered from start of this crisis has been hopeless. Typical is a new government edict for people using direct payments to “purchase their own personal protective equipment from their preferred supplier” when many have never needed such stuff before. Amazon is more use than the authorities. But perhaps we have an advantage in these strange times since our lives have been filled with fragile uncertainty for so many years, living with someone who has a disruptive and potentially-fatal health condition. Stresses remain intense, however, especially when it is impossible to isolate given the need for care support.

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Who cares about carers?

By Mary Harrington

There is much talk that things must change after this crisis. Typical was a punchy column by Rachel Sylvester in The Times, arguing that the government will have to scrap planned immigration rules that keep out carers. She was right to say these are disastrous for a sector with 122,000 vacancies at start of this crisis that relies heavily on foreign workers (as I have seen with deep gratitude). And also to point out the obscenity of the government raising the NHS surcharge — imposed on foreign workers and each member of their families on top of other immigration fees — from £400 to £624 for health and social care employees performing heroics. Others have called for a Royal College to lift the status of carers, better training, more qualifications.

Yet just as in the aid sector, many of the solutions suddenly being suggested follow the demands of big corporate players and their front organisations rather than real needs on the ground. Take the idea of making carers eligible for the NHS visa. Yes, this might help a bit. But it suits interests of providers that can recruit in Poland or Portugal to grab scores of staff. It does not necessarily help those using direct payments to find carers or families searching for help with a relative suffering dementia — or else it forces them to hand thousands of precious pounds to agencies. And what about the therapists and younger special needs teachers who earn too little for entry, even the artists and yoga instructors who can enhance lives of people with disabilities? Life should be for living, not existing.

Many of the finest foreign carers come here searching for work and discover their aptitude for supporting others after taking low-paid jobs rejected by most Britons. Care is hard to define, often tough and with anti-social hours. The best practitioners have qualities such as compassion, empathy and patience rather than the sort of formal qualifications that suit bureaucrats. As Hatton points out, this is backed by people with learning disabilities using services. “The key care competences are human and revolve around relationships,” he said. “Blanket qualifications do not help you sort out who are the best carers. You can teach skills needed on the job.”

If we want to solve problems surrounding care exposed by this crisis, the solutions go deep into society. Look again at the immigration system. The government ignored cries of pain from the care sector while constantly talking about luring “the brightest and the best”. Never any mention of the most caring and compassionate, of course. This stance defined people wanting to work in a crucial public services as being of less worth to the country even than corrupt billionaires from China and Russia seeking a bolthole.

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It will take more than shuffling a few visas to cure such ills. Ultimately, the struggling care sector shows an ugly reflection of our society. It reveals the need to rethink the meaning of both life and death. Why are such large numbers of older and disabled people meeting lonely ends in care homes when coronavirus strikes? It is because too many are crammed into large and impersonal units that keep them out of sight and out of mind. Services have been consolidated in bigger places to save cash, encouraged by grasping big firms. So these people are not welcomed as cherished citizens, living in real homes filled with warmth of humanity in midst of communities, but hidden away due to their disabilities or decrepitude at end of life.

This is the same mindset that determines them less important for testing, deems them less valuable if life-saving ventilators are rationed, lets their deaths go unrecorded in this crisis, leaves them at the mercy of money-grabbing profiteers delivering dismal services, allows some citizens with autism and learning disabilities to be locked up in denial of their human rights. The attitude is so infectious even people caring for them are seen as more disposable than doctors or nurses, workers in institutions of minimal value on minimum wages. 

The problems plaguing this Cinderella sector will not be solved with sticking plaster technocratic reforms and a cash splurge. For they are at heart about the absence of dignity, the imbalance of values, the loss of shared humanity and lack of respect for all citizens in society. It takes more than a minute’s clapping to show we really care.

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 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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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”.

And what if the number of terminally ill people who sought recourse to assisted dying were to increase over time? Would that be a cause for concern? Or would it vindicate the legislation, simply showing that people were exercising rights previously denied to them?

These are the kind of critical questions MPs failed to ask in last week’s debate on assisted dying – the first in four years. Any serious consideration of the way legalisation could transform our whole culture in relation to ageing, chronic illness and dying was sorely missing.

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Instead, MPs lined up to explain why they had dropped their previous opposition to assisted dying. From Nick Boles to Sir Vince Cable, one by one they registered their volte-face on the subject. And by doing so they abdicated their responsibility as leaders: to paint a vivid picture of possible future scenarios. They repeatedly refused to accept the invitation – one offered by Lyn Brown for example – to foresee the difference such a monumental step could make; indeed, even to acknowledge it would be a monumental step.

Assisted dying is a highly emotive and deeply distressing issue. I cannot begin to imagine the acute pain, profound fear and bewildering loss of control that is said to come with motor-neurone disease or the late stages of cancer. That suffering, those stories, must not be left out of deliberation. Nor should we dismiss the strength of such unwell patients’ desire for control over the manner and timing of their deaths.

But nor should we ignore the wider effects that a change to the law might have on society; how it would transform the experience of ageing, the dynamics of the family and the practice of medicine.

In his revealing speech to the House, Crispin Blunt invoked what he clearly viewed as the spectre of an ageing society: “By 2040 nearly one in seven people will be 75 or over,” he said. “More of us will have to grapple with surviving with the pain and indignity of crippling progressive infirmity later in life.” The solution to this? Care will only ever be one part. Providing an “escape from pain and indignity” through assisted dying will be necessary, he said.

Blunt insisted the vast majority would not take this route. But if assisted dying were being sold as a viable alternative to social or hospital care, that would surely normalise it, making it par for the course for an ageing society. Premature death could well become a cultural expectation.

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By Ian Birrell

True, many of the MPs involved in the debate emphasised the restrictive conditions under which euthanasia might be legalised. Only terminally ill patients with six months to live would be eligible.

But, again, the politicians’ unwillingness to consider the consequences was breath-taking in its naivety. The fundamental logic of assisted dying – that I should have control over my death as I have had over my life – fundamentally clashes with this restriction. If we enshrine in law the principle that I should have control over the manner and timing of my death, why should that not be extended to the terminally ill patient with seven months to live? Or the person suffering from devastating mental rather than physical ill-health? Or someone simply tired of life? Do they not have an equal right to autonomy?

Indeed, at one point Steve McCabe voiced this very challenge to the six-month criteria. “Life expectancy in itself,” he said, “does not tell us anything about suffering.” Rather, if someone is given the right to choose, that right should extend to “a stage where he has no quality of life”. The six-month restriction is wholly arbitrary, McCabe was rightly saying. Thus, within the course of the debate itself, a member of the house, unnoticed, was sliding down the slippery slope from tight to lax restrictions.

The second massive transformation the legalisation of assisted dying would enact would be on the dynamics of the family.

Nick Boles assured the House that any assistance would require an independent assessment of the state of mind of the patient. Doctors and a High Court Judge would have to be absolutely persuaded that the person wanting to die did not “show any signs of coming to a decision under pressure or because they felt they were a burden”.

Boles was confident abuse would show up this way, refusing to countenance a picture of the future informed by the real-life contexts in which end-of-life decisions occur today. When we look unflinchingly at what happens when life draws to a close, we see complexity, dilemma and sometimes even abuse. Wills, inheritances, care costs – arguing over these do not always bring the best out of us.

So let’s fast-forward to a world in which assisted dying is now an option. An 85-year-old grandmother, no longer able to look after herself, has received a diagnosis that she is terminally ill and has only a few months to live. Does she go into a fiendishly expensive nursing home which will exhaust her lifetime’s savings? Or does she bow out? No one in the family has said a word to her. Yet she feels a pressure – her decisions have been complicated by the possibility of assisted dying.

Eventually, she settles on assisted dying. She’s not escorted to the clinic with a son holding a gun to her head. No grandchild has attempted to manipulate her. No one has said anything to her, in fact, so no independent assessment panel will pick up on overt coercion.

And yet, who’s to say that what’s really going on is a grandmother choosing to die prematurely because she feels she has become a burden? Are we really okay with that?

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Who wants to live forever?

By Nigel Cameron

Finally, and most unsettling, is how the introduction of the law would transform medical practice. Again, no one in the debate mentioned this.

Answering the question of what had changed to justify reopening the assisted dying question, Nick Boles appealed to the Royal College of Physicians (RCP)’s decision in February to shift its stance from opposition to a neutral position on assisted dying.

Now, crucially, this only happened because a cabal at the top of the RCP changed their rules on how they determined their stance – as Fiona Bruce pointed out in the debate (another ignored intervention). Previously it was straightforward. The institution’s leadership adopted the most favoured option of their members – which is opposition to assisted dying. But this time it was decided that the College would default to neutral unless opposition secured a supermajority of 63%. So, extraordinarily, the leadership of the Institution no longer represents the dominant view of its members.

This move has masked the real attitude of most doctors, which is that getting into the business of assisting people’s deaths fundamentally changes the practice and also perception of the profession. According to the Hippocratic oath, the first duty of the doctor is not to harm (primum non nocere). And the distinction between intentional killing (administering barbiturates) versus letting die (turning off the life-support machine) protects doctors from becoming anything other than the helping profession.

If this distinction were to collapse, what would the country look like in 40 years time? Hospitals could be transformed from places of healing and care, to places of last resort, haunted by mistrust and fear.

The virtue of prudence involves making a good judgment about the present based on a sober assessment of the future. It is the virtue we expect from statesmen. Which is why we were let down last week. Instead of imagining future scenarios – not indulging in speculative fancy, but making predictions informed by a sense of history, by a sense of how things tend to go in the world – most MPs buried their heads in the sand. They should be ashamed of themselves.

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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By Tom Chivers

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.

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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.

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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”.

I read it while I was snatching a break away from the hospital where my father has lain for weeks; a hospital hundreds of miles and across a sea from my own home. He’s there as a result of malnutrition not caused by an inadequate diet, hypothermia not caused by a cold house, gastric problems and a skin disease that has gone undiagnosed and become rampant – in part because it is so difficult to get oneself in front of one of the NHS’s increasingly rare dermatologists. I have been here for weeks.

Sparking Fraser’s fury was an unnamed woman who had rung her father’s doctor to request help changing his shitty pants. I picture her as one of those Midsomer Murder characters who you know is a wrong’un because she arrives in Badger’s Behind in a convertible sports car and red lipstick.

Sparking my fury was the utter dissimilarity between what Fraser subsequently described – the idea that, busy with our exciting, narcissistic lives, we children are all too keen to offload the grim bits to any passing care worker, however low-paid or temporary – and the grinding reality of what I, and millions like me, are experiencing as we desperately try to care for our loved ones.

Suggested reading

Why won't Remainers talk about family?

By Giles Fraser

Far from “casting off our responsibilities”, our daily reality is the fear of missing the subtle changes in our relatives’ conditions that an expert would know spelled danger. Our reality is knowing we would go to the mattresses for them, even as we sideline other parts of our lives, knowing that this in itself causes the sick and frail distress.

For here is the truth: bottom-wiping is easy. Nobody wants to do it, but everyone can. That a bum-cleaning refusenik can be produced is not an argument for societal and familial breakdown. Even the one who so infuriated Fraser and his GP friend might have her good points: I admire her persistence, for example, in actually getting through to her father’s surgery and to a medical practitioner. Fortunately, she wasn’t asking for an appointment, for which, at my own father’s practice, the wait stands at two weeks.

This is where the carer’s struggle lies; not with the willingness or capacity of anyone – Brexiteers and Remainers alike – to provide loved ones with basic care-giving or, in Giles’s words, a “highly successful form of mutual care”. Our struggle is in accessing medical services and navigating the profoundly tangled thicket of systems, departments and organisations. This is the scandal, not a daughter’s willingness – or otherwise – to come home and get her hands dirty.

For this “rootless Ronin” has come home to spend hours discussing her father with healthcare professionals. By far the most intractable and bewildering moments have related to procedure: a test that is repeated, not to see if there have been any changes, but because it was originally carried out at another hospital, which operates under a different authority, and which therefore does not automatically share its results; or those lab findings which are expected promptly, but which prove mysteriously elusive even to the doctor who ordered them in the same building; or attempts to borrow the equipment to help my father at home that requires a gargantuan and cross-departmental swapping of paperwork to procure. There’s also the feeling that, too often, the advice you’re getting is driven not by medical necessity but by an unseen matrix of spreadsheets and cost centres.

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Our shameful social care crisis

By James Bloodworth

My bottom line is not “individual acquisition and self-advancement“, it is the relentless determination to have my father assessed not merely as a set of symptoms, but as a person who exists in continuous time – not only at the moments when the professionals glide to his bedside. The crux is not that he weighs only nine and a half stone, but that a year ago he weighed eleven; not that his skin is failing to perform its basic task of retaining body heat, but that he has been freezing for months, even as the rest of us cast off our jumpers in his stiflingly hot flat.

It is not that the doctors do not know this, or that they do not care; it is that they are busy, busy, busy. In my fantasy, we sit down in a quiet space, and I calmly detail all the manifestations of my father’s sickness; in response, they blend what I have said with clinical observations and the results of scopes, scans, biopsies and blood tests, and slowly a picture and a plan emerge.

The reality, however, is that every night I return from hospital to my father’s flat and have to block out the picture of him lying uncomfortably in his bed by obsessively cleaning. I have to banish the fear that, as happened the other day, an unknown doctor will appear by his bed, give a cursory glance at his hands and say, “looks like eczema to me”.

Paradoxically, per Fraser’s argument, that I can give my dad this support, unconditionally and open-endedly, relies on my not being at the centre of a traditional family unit, or bound to a conventional job. Having met my partner relatively late on, we do not have children; were we to, I would not at the moment be able to care for them. So, fine, my partner would increase his share of childcare; but how would he work? Most people can cover these issues for a week, but for months? A year? Five years?

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Can we be trusted with euthanasia?

By Ian Birrell

And that I’m continuing to work at all, albeit in drastically reduced amounts, is possible because I can freelance from anywhere; because my professional life is both precarious and adaptable. And because I learned that lesson from my parents, who spent their young, post-war lives shifting across the globe – not as rejection of their own families, but because those families had been fragmented by death and instability. They met as crew on a cruise ship.

One consequence of this was that my parents’ friends were from everywhere; my godmother a Norwegian who married an Italian, my father’s Polish chums in Acton, waiters and chefs and shopworkers from Morocco, France, Portugal. Now, my father has extra-large, bandage-friendly socks knitted for him my Polish friend’s grandmother, a woman he will never meet; his bedside is festooned with get well cards made by the Irish nieces I acquired through falling in love with their uncle.

In Ireland, too, in the countryside where I’ve made a home, my Irish family has lit a candle for my dad. Back in England, I am supported by my own friends, who send loving messages and offers of help and who make whirlwind trips to see me. Among all of these is my closest friend and her wife, who have taken their turn at dad’s bedside, brought him gluten-free cake and essays by Clive James and made him laugh.

I can never repay them, but then I don’t have to. What Fraser fails to understand is that the pulling apart and reshaping of the family unit through movement and mobility has enlarged, rather than diminished, the canvas on which we can love one another. “Are you all family?” asked a nurse, one evening, as my friends sat with us. I was about to explain the ins and outs, and then simply said, because it is true in the most important ways: “Yes.”

Last week the Evening Standard – now, of course, a propaganda rag for George Osborne’s Remain-inspired end-of-the-world fearmongering – led with the following front-page headline: “Who’ll look after our elderly post Brexit, ask care chiefs”.

I’m still spitting blood at the arrogance and callousness of that question. It summed up all that I have against the Osborne neoliberal (yes, that’s what it is) world-view. And why I am longing for a full-on Brexit – No Deal, please – to come along and smash the living daylights out of the assumptions behind that question.

Suggested reading

How freedom of movement freed me to care

By Alex Clark

First, let me answer the question. Children have a responsibility to look after their parents. Even better, care should be embedded within the context of the wider family and community. It is the daughter of the elderly gentleman that should be wiping his bottom. This sort of thing is not something to subcontract.

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. The Evening Standard’s headline was the complaint of those who realise that their ‘help’, the Polish or Spanish care worker, might not be available to look after Mum and Dad. OMG, they might just have to do it themselves!

Writing in the Independent last year, Luciana Berger – MP for Liverpool Wavertree and recent Labour defector, and also a member of the Health and Social Care Committee – spoke out against the effect of Brexit on the social care sector. “A massive increase in demand for elderly care is predicted in the coming years. More than 1.2 million older people will need some form of care by 2040, according to the Department of Health and Social Care. That’s double the number of people compared to 2015,” she wrote.

And Brexit will be disastrous, she went on. “The Department of Health itself estimates that there could be 28,000 fewer workers in the social care sector in England five years after leaving the EU… The result of this would be thousands of hours’ worth of lost earnings.”

Interestingly never once in the piece did she mention the word family. Indeed, the only way the piece related to family life and the mutual care that this has traditionally implied is through the idea that caring for a family member equals “lost earnings”.

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Liberalism has broken us – we need a new party to call Home

By Giles Fraser

My GP friend also told me another story. Just before Christmas he did a home visit to an elderly woman, living on her own, but surrounded by Christmas cards. She proudly told him how well her kids had done, showing him the cards sent by her children living all round the world. “I never see them very much now” she explained. She was on her own for Christmas. They might Skype.

This is what happens when that much over praised value of social mobility becomes the way we think about dealing with social inequality. Social mobility is very much a young person’s value, of course. Get on. Get out of your community. Find a job anywhere you please. Undo the ties that bind you. The world is your oyster.

This is the philosophy that preaches freedom of movement, the Remainers’ golden cow. And it is this same philosophy that encourages bright working-class children to leave their communities to become rootless Rōnin, loyal to nothing but the capitalist dream of individual acquisition and self-advancement.

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The slow death of Britain's towns

By Will Brett

Always on the move, always hot desking. Short-term contracts. Laptops and mobiles – even the tools of modern workplace remind us that work no longer has any need of place. All this is a philosophy that could not have been better designed to spread misery and unhappiness. Human beings need roots for their emotional and psychological flourishing. They need long-term, face-to-face relationships; they need chatting in the local post office; they need a sense of shared identity, shared values, mutual commitment. No amount of economic growth is worth sacrificing all this for.

Because robbed of their most go-ahead young people, working class communities become ghost towns of hopelessness. And care homes for the elderly become ways to warehouse those who cannot be persuaded to make the trip to Dignitas.

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Would you let a robot care for Grandpa?

By Rhiannon Williams

My GP friend is Muslim, and a fairly conservative one I think it’s fair to say. We were eating in a Pakistani restaurant in Tooting. All around us extended Muslim families were sitting together, children and the elderly, aunts and uncles. It was a buzzy hub of a homogeneous society – the sort of society that the West sometimes criticises for being inward looking. “They must integrate!” comes the familiar line, which, in effect, means they should disperse, learn the values of progressive individualism.

From where I was sitting it is these people – and not George Osborne swanning off to his new £3 million chalet in Verbier – that have got it right. For the attraction of socially conservative and traditional values are that they constitute a highly successful form of mutual care. Indeed, these are the values that have formed the basis for the most effective form of social security the world has even known: family and community life.

The idea that this form of life constitutes “lost earnings” shows how far the Remainer free-market, free-movement philosophy is a threat to the web of support on which the poorer and the most vulnerable especially, have to rely. Remain is all about ever new opportunities for the rich. Brexit seeks a reclamation of something we have lost. The ability to stay put and care for each other.

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.

Further reading

Would you let a robot care for Grandpa?

By Rhiannon Williams

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”.

Further reading

The trouble with tackling loneliness

By Giles Fraser

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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Capitalism is suffering a crisis of care

By Victoria Bateman

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.

Further reading

Britain's homelessness shame

By James Bloodworth

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.

So it’s time to correct that misconception, and fast. There is an increasingly urgent need to overhaul a sector many of us will come to rely on in later lives and, whether we like it or not, automation is the hero and not the villain of this piece.

The UK’s social care sector is facing may of the same crushing pressures that are being inflicted on the NHS, with familiar rising costs and falling funding nixing any real advancements. One in 10 older people is likely to pay more than £100,000 for their social care needs over their lifetime, and a tightening of criteria for receiving publicly funded care led to 400,000 fewer people receiving state-funded care between 2012/13 than in 2009/10, according to the Health Foundation, a healthcare policy charity.

Given the UK’s gradually increasing ageing population (18 per cent is aged 65 or over), our need for social care is only going to intensify – and the issue is made more acute by the fact that an average of 900 care workers per day are estimated to being leaving the profession. According to the National Audit Office the exodus is due to the work’s low wages and tough conditions. And it’s not just a retention problem – there’s also a severe lack of new workers joining the profession.

Enter automation. The application of AI, robotics and other technologies to the sector could help to narrow dramatically the gap between costs and revenue (which is projected to reach £2.1bn by 2019/20) and to relieve human staff of certain menial or physically demanding tasks, freeing up their time for face-to-face care of patients.

The health and social care sector has been earmarked by Deloitte as the third most vulnerable industry to rapid advances in technology, behind wholesale and retail, and transportation and storage, with some 1.3m jobs at high risk in the UK. But the advent of automation isn’t about replacing human staff with robots. Just as within the wider health sector, there will always be a clear need for the calm, reassuring and caring bedside manner of professional humans, particularly when it comes to caring for patients with complex needs.

Further reading

The robodoctor will see you now

By Mark Piesing

That high degree of social and emotional intelligence is still beyond machines, and, some experts argue, always will be. Instead, automation can help with tackling everything else, from tedious tasks such as budgeting and record-filing to more significant tasks such as monitoring patients more closely than humans can, projecting future health risks and assuming physically strenuous roles such as lifting; they don’t need paying, rarely make mistakes and don’t get tired.

They’re well ahead of us in Japan, which is facing a predicted shortfall of 370,000 caregivers by 2025. The Japanese research institute Riken has created Robear, an experimental bear-shaped robot designed to lift and carry elderly patients from beds into wheelchairs. Similar robotics are currently used in around 8% of Japanese care homes, and are expected to become more widespread thanks to a government-backed initiative to fund robotic nursesto take care of the country’s rapidly ageing population.

But there has been a certain unwillingness on the part of care-givers to relinquish their bedside duty of care, not to mention a reluctance on the part of patient to accept care from a robot. Cyberdyne, another Japanese robotics firm, is circumventing this problem with its Hybrid Assistive Limbs, a powerful exoskeleton suit which can be worn by either carers or disabled or elderly patients to enhance their movements and assist in rehabilitation.

Let’s not forget that many of us already have our own digital assistants such as Amazon’s Alexa and Apple’s Siri. These can be care-givers if they are programmed to remind patients to take medication at certain points throughout the day; they can also answer repeated questions about the time, date and so on without losing their cool. They also adjust lights, open blinds and change temperature in smart homes. For patients with limited mobility, this could provide a much-missed feeling of autonomy.

In Japan, the early reluctance to embrace the robo-carer is now dwindling, partly thanks to a sophisticated media campaign and partly because there is no alternative. In one care home in Tokyo, 20 different robot models are being used to care for elderly residents. The West may cringe, as machines become the sole carers and companions of the elderly and confused, but as similar demographic challenges sweep in our direction, we would be foolish not to be paying attention.

Or because we don’t know anything about them…

And then there are subjects which we can’t bear to consider. Issues which trigger such a profound mix of emotions that we would rather avert our eyes and pretend it will go away.

So it is with social care.

The public policy issue that affects every single household in Britain.

The issue that terrifies politicians.

The issue that is imperilling the survival of the National Health Service.

And yet the issue that has consistently been overlooked.

There are three reasons we refuse to address this question. And they are all to do with emotion.

• First we fear our own vulnerability. We recoil at the thought that we will need care ourselves – we insure against the unlikely event of a domestic burglary and yet resist any opportunity to provide for the probability that we will one day need help to get dressed. We know that there are more people with profound disabilities living among us, but we would rather pretend it’s not happening.
• Second we discount the sheer work of caring. Largely done by women, largely behind closed doors, largely in private – it’s our dirty little secret that we don’t want to consider.
• Third we treasure our own asset wealth to the point that we refuse any suggestion that we should pay for our own care in any shape or form, as the Prime Minister discovered to her cost.

For these reasons we hide from the reality that one in three of us will survive cancer and will need care. That many of our children will grow to adulthood with multiple and complex needs. That mental illness will affect us all, and that we will live longer and largely healthier lives. But rather than make the adjustments we need to make, both public and private, we prefer to hide behind the sofa like children watching a particularly scary episode of Doctor Who, accepting the lying adult assurance that this will never happened to us.

We cannot continue to avoid facing these consequences of our economic, medical and social progress. We need to acknowledge our fragility, honour the work of care, and recognise that our current prosperity is part of the solution to the looming crisis of social care. But first we need to make the emotional adjustment to see what is in full view if only we choose to see.

But this lack of prudence is more than financial. Baby-boomers are also losing the family networks through which societies have traditionally supported the elderly. The point is made by Ashton M Verdery and Rachel Margolis in a paper for the Proceedings of the National Academy of Sciences:

“Older adults have lived within dense kin networks for most of human history and the kinless have been a small subpopulation in the modern demographic era. However, recent declines in marriage, increases in gray divorce, and fertility decline are leading to larger numbers of older adults with no close family members. Mortality improvements and the increase in new relationship forms among older adults are not large enough to offset these trends.”

We have over-pruned our family trees, meaning that increasing numbers of us will spend some or all of our later years without close relatives. This isn’t just a personal matter, it has huge implications for public policy: “Those without living close kin report higher rates of loneliness and experience elevated risks of chronic diseases and nursing facility placement.”

The Verdery and Margolis study looks at the extent to which ‘kinlessness’ is likely to grow in the United States over the coming decades:

“Our findings point to dramatic increases in the numbers of kinless older adults in the United States, whether we consider a broad or a narrow definition of kinlessness. The increases occur for whites and blacks, men and women. By 2060, we expect the population of white and black Americans over 50 y old without a living partner or children to reach as high as 21.1 million, 6.3 million of whom will also lack living siblings or parents, up from our estimates of 14.9 million and 1.8 million, respectively, in 2015.”

So the number of older (not just elderly) Americans with no close relatives will more than triple in forty years. Of course, losing family is an occupational hazard of growing old. But by having fewer, or no, children, and by forming looser relationships with partners, we’re reducing our chances of holding on to at least some family.

But what of friendship, neighbourliness and community? Could the wider web of human relationships compensate for the growth of kinlessness?

It’s a nice thought, but consider how many of these connections are routed to you through immediate family members. By losing, or never forming, close family relationships you cut yourself off from a larger number of secondary, but still important, relationships.

Quite rightly, we worry about the number of people approaching retirement without savings or property. Where will they live? How will they pay the rent? Good questions. But we also need to think about their relational poverty.

No home, no money, no family, no friends – it’s a truly grim picture, but, unless things change, an increasingly common one.

Our politicians are reluctant to address issues of family life (‘a private matter’) and they’re unwilling to do much to build the houses and communities in which family life can flourish. Furthermore, as we saw in the British general election this year, any attempt to fund a social care solution is fraught with political risk.

Looking ahead, how might society adapt to the increasing isolation of the elderly? Machines to provide care and companionship in our dotage? Or maybe euthanasia – already a common cause of death in some countries.

So, in place of family life, robots and assisted suicide. How long will it be before we take these wonders of the modern age and combine them?