Rt Hon Chris Heaton-Harris was MP for Daventry 2010 -2024 and was in the Cabinets of three Prime Ministers he has since founded a public affairs company called Oak Insight
Gaurav Menon is a social care executive with more than two decades of experience operating in highly regulated sectors, including adult social care and environmental services.
This is part 1 of a mini-series Who Cares? with part 2 tomorrow and part 3 on Friday Based on ‘The Future of Adult Social Care in England: A Predictive Analysis’ by Gaurav Menon
England’s adult social care sector is not approaching a crisis. It is already inside one. The forces driving it are structural, compounding, and largely irreversible within any planning horizon that current political discourse is willing to contemplate. Understanding what has gone wrong, and what could yet be done, demands looking honestly at a number of different but related pressure points.
The Problem
A New Generation of Residents – Far More Complex Than Before
The people entering residential care today are categorically different from any previous generation, and the difference has a traceable cause. Born in the 1950s, 1960s, and 1970s, this cohort grew up as ultra-processed food became a dietary staple. The public health consequences of that transition are now presenting in concentrated form in care home admission data.
Residents today typically arrive simultaneously with type 2 diabetes, chronic heart failure, chronic kidney disease, and vascular dementia. The King’s Fund has documented that over 70 per cent of new care home admissions present with three or more comorbidities. More complex residents require more skilled staff, higher ratios, more clinical input, and more sophisticated medication management – each of which costs more than the fee rates currently paid by local authorities.
The COVID-19 Legacy
The pandemic permanently altered the sector. Care home residents accounted for approximately 42 per cent of all COVID-19 deaths in England and Wales during the first wave, and the psychological trauma across the workforce has driven sustained staff departure and burnout in the years since. The longer-term consequence is Long COVID: the ONS estimated 1.9 million people in the UK were experiencing self-reported symptoms as of early 2023, many of them care workers who have simply left, quietly, without appearing in vacancy statistics.
The NHS Overflows Into Social Care
The NHS has been operating at or beyond safe bed occupancy thresholds, clinically defined at 85 per cent, routinely exceeded at 94 per cent or above, for the better part of a decade. When a bed is needed and an existing patient is medically stable, that patient must leave. The destination, for someone who cannot return safely to independent living, is a social care placement.
A care worker asked to manage a complex wound without adequate training is not failing in their duty. They are operating in a system that has placed them in an impossible position.
Residents arriving from hospital discharge today present with wound management requirements, catheter care needs, and antimicrobial-resistant infections are now clinical presentations being managed in social care settings by staff whose training and pay is premised on a social rather than clinical model of care.
Funding That Does Not Add Up
LaingBuisson estimated the average weekly cost of residential care delivery at approximately £1,200–£1,400 per person in 2024. Local authority fee rates in many parts of England remain materially below this figure. The gap is covered, in practice, by higher charges to self-funding residents – a hidden private tax on older people levied to compensate for public underfunding. The employer National Insurance Contributions increase effective from April 2025 added approximately £40,000–£60,000 per year to the cost base of a home employing thirty staff, with no equivalent fee uplift in most areas. The Dilnot Commission’s recommendations for a lifetime care cost cap have been subject to partial and delayed implementation across fifteen years.
A Workforce Past Its Limits
Skills for Care estimated approximately 152,000 vacant posts in 2023/24, representing a vacancy rate of 9.9 per cent, with annual turnover above 28 per cent. The National Living Wage has compressed pay differentials in ways that make care work structurally uncompetitive with sectors offering comparable physical demands without the emotional intensity, regulatory burden, or unsociable hours. A care worker and a logistics operative may earn within pennies of each other per hour. In a rational labour market, the differential in demand would command a wage premium. In the care sector, it does not, because fee rates cannot sustain one.
The Loss of the Independent Sector
CQC data from 2023 and 2024 shows a net reduction in registered care home bed capacity for the second consecutive year, driven primarily by closures among independent operators. When an independent care home closes, residents are displaced at a point of high vulnerability into placements that may be distant from their established social networks. The beds lost through provider exit do not return. No new independent operator is entering the market at current fee rates.
What Could Yet Change
The Generation That Watched
The most consequential shift in the politics of care is happening not in Westminster but in the homes and hospital corridors of people in their fifties and sixties who are navigating the care system on behalf of someone they love. They are reading fee increase letters. They are watching understaffed teams do extraordinary things with inadequate resource. There is a well-evidenced principle in behavioural economics that people are significantly more willing to contribute to something they understand and have personal proximity to. The political conditions for a genuine funding settlement may be created not by advocacy from within the sector but by lived experience from without.
Community That Chooses to Understand
In Ross-on-Wye, a market town on the Welsh border, something is being built that deserves recognition in national policy. The town is working to become a genuinely dementia-friendly community where care home residents and local people share the same spaces as a matter of course, where the Memory Café launched in August 2023 provides warm, human monthly connection, and where Rosedale Retirement Home has built a genuine partnership with the local Meeting Centre. Communities that know care from the inside will, over time, produce a different public conversation about funding and contribution. Community engagement is not a soft add-on to care delivery. It is the infrastructure on which public consent for adequate funding must eventually be built.
The Workforce That Stayed
Against everything this sector has faced: the pay, the pressure, the pandemic, the weight of end-of-life care at staffing ratios that were never adequate – a substantial number of people chose to stay. They stayed because the work means something that wages do not capture. Care workers who remain do so because they cannot easily walk away from a resident who knows their name, from a family who trusts them, from a death they helped to make peaceful. That quality – the orientation toward the particular needs of a particular person, in a particular room, on a particular night – is irreducible. It is what the sector retains even when everything else is under strain. It is the foundation, fragile and under-recognised, on which any better future must be built.
Based on research by Gaurav Menon, Registered Manager, Rosedale Retirement Home, Ross-on-Wye, Herefordshire. March 2026.
Rt Hon Chris Heaton-Harris was MP for Daventry 2010 -2024 and was in the Cabinets of three Prime Ministers he has since founded a public affairs company called Oak Insight
Gaurav Menon is a social care executive with more than two decades of experience operating in highly regulated sectors, including adult social care and environmental services.
This is part 1 of a mini-series Who Cares? with part 2 tomorrow and part 3 on Friday Based on ‘The Future of Adult Social Care in England: A Predictive Analysis’ by Gaurav Menon
England’s adult social care sector is not approaching a crisis. It is already inside one. The forces driving it are structural, compounding, and largely irreversible within any planning horizon that current political discourse is willing to contemplate. Understanding what has gone wrong, and what could yet be done, demands looking honestly at a number of different but related pressure points.
The Problem
A New Generation of Residents – Far More Complex Than Before
The people entering residential care today are categorically different from any previous generation, and the difference has a traceable cause. Born in the 1950s, 1960s, and 1970s, this cohort grew up as ultra-processed food became a dietary staple. The public health consequences of that transition are now presenting in concentrated form in care home admission data.
Residents today typically arrive simultaneously with type 2 diabetes, chronic heart failure, chronic kidney disease, and vascular dementia. The King’s Fund has documented that over 70 per cent of new care home admissions present with three or more comorbidities. More complex residents require more skilled staff, higher ratios, more clinical input, and more sophisticated medication management – each of which costs more than the fee rates currently paid by local authorities.
The COVID-19 Legacy
The pandemic permanently altered the sector. Care home residents accounted for approximately 42 per cent of all COVID-19 deaths in England and Wales during the first wave, and the psychological trauma across the workforce has driven sustained staff departure and burnout in the years since. The longer-term consequence is Long COVID: the ONS estimated 1.9 million people in the UK were experiencing self-reported symptoms as of early 2023, many of them care workers who have simply left, quietly, without appearing in vacancy statistics.
The NHS Overflows Into Social Care
The NHS has been operating at or beyond safe bed occupancy thresholds, clinically defined at 85 per cent, routinely exceeded at 94 per cent or above, for the better part of a decade. When a bed is needed and an existing patient is medically stable, that patient must leave. The destination, for someone who cannot return safely to independent living, is a social care placement.
A care worker asked to manage a complex wound without adequate training is not failing in their duty. They are operating in a system that has placed them in an impossible position.
Residents arriving from hospital discharge today present with wound management requirements, catheter care needs, and antimicrobial-resistant infections are now clinical presentations being managed in social care settings by staff whose training and pay is premised on a social rather than clinical model of care.
Funding That Does Not Add Up
LaingBuisson estimated the average weekly cost of residential care delivery at approximately £1,200–£1,400 per person in 2024. Local authority fee rates in many parts of England remain materially below this figure. The gap is covered, in practice, by higher charges to self-funding residents – a hidden private tax on older people levied to compensate for public underfunding. The employer National Insurance Contributions increase effective from April 2025 added approximately £40,000–£60,000 per year to the cost base of a home employing thirty staff, with no equivalent fee uplift in most areas. The Dilnot Commission’s recommendations for a lifetime care cost cap have been subject to partial and delayed implementation across fifteen years.
A Workforce Past Its Limits
Skills for Care estimated approximately 152,000 vacant posts in 2023/24, representing a vacancy rate of 9.9 per cent, with annual turnover above 28 per cent. The National Living Wage has compressed pay differentials in ways that make care work structurally uncompetitive with sectors offering comparable physical demands without the emotional intensity, regulatory burden, or unsociable hours. A care worker and a logistics operative may earn within pennies of each other per hour. In a rational labour market, the differential in demand would command a wage premium. In the care sector, it does not, because fee rates cannot sustain one.
The Loss of the Independent Sector
CQC data from 2023 and 2024 shows a net reduction in registered care home bed capacity for the second consecutive year, driven primarily by closures among independent operators. When an independent care home closes, residents are displaced at a point of high vulnerability into placements that may be distant from their established social networks. The beds lost through provider exit do not return. No new independent operator is entering the market at current fee rates.
What Could Yet Change
The Generation That Watched
The most consequential shift in the politics of care is happening not in Westminster but in the homes and hospital corridors of people in their fifties and sixties who are navigating the care system on behalf of someone they love. They are reading fee increase letters. They are watching understaffed teams do extraordinary things with inadequate resource. There is a well-evidenced principle in behavioural economics that people are significantly more willing to contribute to something they understand and have personal proximity to. The political conditions for a genuine funding settlement may be created not by advocacy from within the sector but by lived experience from without.
Community That Chooses to Understand
In Ross-on-Wye, a market town on the Welsh border, something is being built that deserves recognition in national policy. The town is working to become a genuinely dementia-friendly community where care home residents and local people share the same spaces as a matter of course, where the Memory Café launched in August 2023 provides warm, human monthly connection, and where Rosedale Retirement Home has built a genuine partnership with the local Meeting Centre. Communities that know care from the inside will, over time, produce a different public conversation about funding and contribution. Community engagement is not a soft add-on to care delivery. It is the infrastructure on which public consent for adequate funding must eventually be built.
The Workforce That Stayed
Against everything this sector has faced: the pay, the pressure, the pandemic, the weight of end-of-life care at staffing ratios that were never adequate – a substantial number of people chose to stay. They stayed because the work means something that wages do not capture. Care workers who remain do so because they cannot easily walk away from a resident who knows their name, from a family who trusts them, from a death they helped to make peaceful. That quality – the orientation toward the particular needs of a particular person, in a particular room, on a particular night – is irreducible. It is what the sector retains even when everything else is under strain. It is the foundation, fragile and under-recognised, on which any better future must be built.
Based on research by Gaurav Menon, Registered Manager, Rosedale Retirement Home, Ross-on-Wye, Herefordshire. March 2026.