Rt Hon Chris Heaton-Harris was MP for Daventry from 2010 to 2024 and served in the Cabinets of three Prime Ministers. He has since founded Oak Insight, a public affairs company.
Gaurav Menon is a social care executive with more than two decades of experience in highly regulated sectors. He is Registered Manager of Rosedale Retirement Home, Ross-on-Wye, Herefordshire.
There are moments when politics suddenly becomes personal.
For Andy Burnham, social care had become personal long before he entered Downing Street.
His father, Roy, was living with Alzheimer’s disease and receiving residential care, and when Burnham spoke about social care in July he did so not simply as a politician revisiting a policy area he had known during his time as Health Secretary, but as a son who had now seen the system from the other side of the door.
He spoke about watching care workers look after his father: the skill involved, the professionalism, the ability to care for somebody else’s mum or dad with patience and dignity. Roy Burnham died earlier this month.
There would be something deeply inappropriate about attempting to turn a family’s bereavement into a political argument, but there is nevertheless something important in what the Prime Minister had already said before his father’s death. Like hundreds of thousands of other families, he had experienced care not as an abstraction, a budget line or an item in a manifesto, but as something upon which somebody he loved depended upon.
That experience matters, because perhaps the greatest obstacle to sensible social care reform has always been the distance between the way the system is discussed and the way it is actually lived. People often discover social care suddenly. A parent falls. Dementia progresses. A husband who has managed reasonably well at home stops eating properly. A daughter who has quietly provided increasing amounts of support for three or four years reaches the point at which she simply cannot do any more. Families who had assumed that health and care formed one coherent public system discover that they do not.
They encounter assessments, thresholds, local-authority commissioning, private fees, means testing, Continuing Healthcare, capacity assessments and an industry whose financial architecture is largely invisible until the moment they urgently need it.
By then there is rarely much time to learn.
When we wrote the first Who Cares? series in June, our purpose was to describe some of that world from inside it.
We wrote about workforce pressures, immigration, regulation and the strange relationship between a predominantly independent care sector and a state that commissions enormous quantities of care without owning most of the organisations delivering it. Three months later, social care is receiving political attention at the very highest level. Burnham is making it the centre-piece of his first Party Conference as Prime Minister and has said it is going to be a big part of the Labour manifesto at the next election. He has asked Baroness Louise Casey to accelerate her work on a National Care Service, opened cross-party discussions and has put workforce, prevention and better integration with the NHS at the centre of the Government’s stated approach.
The Government has also explicitly recognised that social care in England is delivered overwhelmingly through private and charitable providers.
That creates an opportunity, but only if we begin in the right place. Social care is frequently described as broken, and in important respects it is. Yet that description can obscure another truth: there is an enormous amount within British social care that works extraordinarily well. Walk into a good residential home and the first thing one notices is not a funding model. It is a relationship based business: A care worker remembers that a woman with dementia was once a teacher and talks to her about her classroom while helping her dress. Somebody in the kitchen notices that a resident who normally enjoys breakfast has eaten almost nothing for two mornings. A senior carer spots a subtle change in somebody’s behaviour and asks for a clinical review before the deterioration becomes obvious. A house keeper becomes the person a frightened resident confides in because hers is the familiar face that appears at the same time each morning. None of these things is particularly dramatic. Most will never appear in a government report. Yet taken together they are the difference between merely keeping a person safe and actually caring for them.
That distinction is important because reform should begin by asking not simply what is wrong with social care, but what good social care actually consists of. Policymakers understandably think in systems: funding streams, commissioning structures, workforce numbers, regulation and integration. Those things matter enormously, but the service itself is intensely personal. A care home is simultaneously somebody’s home, somebody else’s workplace, a regulated service, a small or medium-sized business, a clinical environment and, quite often, the place in which somebody will spend the final months or years of their life. Any reform that understands only one of those identities will misunderstand the sector as a whole.
THE MARKET BEHIND THE PROMISE
The economics sitting underneath this human service are peculiar. Adult social care is not the NHS. Most provision in England comes from independent, private and charitable organisations operating in a market, and those organisations carry the commercial risks associated with any business: wages, utilities, insurance, food, repairs, financing, occupancy and investment. At the same time, a substantial proportion of their income comes from local authorities purchasing care on behalf of people who qualify for public support. Government figures for 2025/26 put the average local-authority fee for residential care without nursing for somebody aged 65 or over at £956 per week, and £1,089 for nursing care before NHS-funded nursing care. More than 90 per cent of authorities reported increasing their average fees that year, which is important and should be acknowledged. But those figures also illustrate why the discussion needs to move beyond the simplistic idea that providers merely need to become more efficient.
Providing good residential care has an irreducible cost. Staff must be present around the clock. They have to be recruited, trained and supervised. Buildings must be heated, insured and maintained. Residents need food, laundry, equipment and activities. Increasingly complex needs require increasingly competent people. Dementia care in particular is labour-intensive because human reassurance cannot simply be automated. None of this means that every provider is efficient, nor that every fee demanded by a provider represents good value. It means only that somewhere underneath every placement is an arithmetic reality. If the cost of the staffing, food, energy, maintenance and regulatory requirements necessary to provide the agreed standard of care exceeds the amount being paid for that care, the gap does not vanish because everybody has good intentions.
Local authorities face precisely the opposite side of this problem. Their budgets are under severe pressure, adult social care is already their largest area of discretionary expenditure, and commissioners have an entirely legitimate responsibility to secure value for public money. Providers need sustainable fees; councils need affordable placements. Both positions are rational. The mistake is to portray one side or the other as the problem. The real difficulty is that the resident sits in the middle of a negotiation in which the true cost of good care is not always the starting point.
This is also why the language used around commissioning matters. There is a perfectly proper place for negotiation, competition and procurement. What becomes dangerous is allowing the price of care to become detached from a clear understanding of what we expect the service purchased at that price to provide. What staffing level are we expecting? What standard of food? What training? What level of management oversight? What condition should the building be maintained in? What should happen when somebody’s dementia progresses and their needs increase considerably after admission? Until those expectations are described honestly, arguing about whether £900, £1,100 or £1,500 is the “right” weekly fee is largely meaningless.
There is a more sensible sequence available to us. Decide what good care should look like. Calculate what delivering it properly costs. Determine which part should reasonably be met by the individual and which part by the state. Then decide how the state raises its share. British politics has repeatedly attempted the process in reverse: beginning with what government believes it can afford and then asking the care system to fit itself inside the resulting number.
That is one reason why the debate has gone round in circles for so long.
The self-funder sits in another part of this complicated equation.
England’s social care system remains means tested, and people with sufficient assets can find themselves paying the full cost of residential care. At the same time, the independent sector has often relied upon stronger private fees to provide financial headroom where publicly commissioned rates are tighter. It is therefore possible for two people with similar needs living in the same building to have very different funding arrangements. Families understandably ask why somebody who worked and saved throughout their life should see a substantial part of those savings consumed by care. Providers ask why the genuine cost of care cannot simply be recognised in the public fee. Councils ask where the additional money is supposed to come from. There is no great mystery as to why social care reform has repeatedly defeated governments: each of those questions is reasonable, while answering all three simultaneously is extremely difficult.
That is why the development of a National Care Service deserves considerably more scrutiny than its name alone. Burnham has not yet presented a detailed final model, and the Casey Commission is now expected to report in 2027. The Government has said that a future service should be sustainably funded, preventative, centred around individuals and better integrated across hospitals, community services and social care. Those are principles around which substantial agreement is possible. The difficult part comes afterwards: deciding who pays, how providers are funded, what happens to the existing independent market, and how the country moves from the present system to whatever replaces it without destabilising the organisations currently caring for hundreds of thousands of people.
The answer cannot simply be to pretend that the existing market does not exist. Thousands of providers have invested in buildings, recruited workforces and developed expertise over decades. Some are excellent, some are mediocre and some should undoubtedly improve. But collectively they constitute the infrastructure through which most formal social care is currently delivered. Reform therefore needs to distinguish between profit and profiteering, between efficient operators and poor operators, and between reasonable commercial return and extracting value at the expense of care. Collapsing all private provision into a single caricature would be as unhelpful as pretending the present market is functioning perfectly.
FAMILIES ARE ALREADY PART OF THE SYSTEM
There is another part of the care economy which receives even less attention because very little money visibly changes hands: the family. Carers UK and the Centre for Care estimate the economic value of unpaid care across the United Kingdom at approximately £184 billion a year. More than a statistic, that figure represents millions of people quietly reorganising their lives around somebody else. Some reduce their working hours. Some abandon careers. Some spend their own savings. Some reach retirement only to discover that instead of slowing down they have become the principal carer for a spouse or a parent. Carers UK’s 2025 research found substantial effects on employment and financial security among people with caring responsibilities.
After the first Who Cares? series, a 75-year-old woman wrote to us about caring for her mother, who was approaching 100 and living with dementia. She was paying for three hours of support each week to assist with personal care while continuing to carry the overwhelming majority of the responsibility herself. Residential care where she lived was approaching £2,000 a week.
Her question was simple: “What does the future hold for the many carers like me?”
It stayed with us because there is no neat answer. Yet her situation illustrates why thinking about social care only in terms of care-home beds misses much of the picture. Family care and formal social care are not separate universes. They are stages of the same journey. A daughter may begin by doing the shopping once a week, then managing medication, then visiting every evening, then sleeping at her mother’s house several nights a week, then organising carers, and finally trying to find residential care after the arrangement becomes impossible to sustain. The state frequently becomes heavily involved only near the end of that journey, despite the fact that earlier support might have prevented or delayed the crisis.
This is where the more positive potential for reform lies. Prevention should not mean a slogan attached to a policy document. It should mean giving people the practical support that enables independence to continue for as long as it reasonably can. It means respite that arrives before a family carer collapses rather than afterwards. It means better links between GPs, community nursing, home care and residential services. It means helping families understand the system before they are trying to navigate it during a hospital discharge. And it means recognising that supporting an unpaid carer is not peripheral to social care policy. It is one of the principal ways in which the formal system is prevented from being overwhelmed.
THE PROFESSION WE STILL CALL ‘LOW-SKILLED’
The same change in perspective is needed with the paid workforce.
Care work has spent far too long being discussed as though its principal characteristic is that almost anybody can do it. Anyone who believes that should spend a day alongside a good care worker supporting people with dementia. The job requires the ability to help somebody who may be frightened or confused with intimate personal care without stripping away their dignity; to recognise subtle deterioration in someone unable to explain what is wrong; to administer medication safely; to deal calmly with distress or behaviour arising from cognitive impairment; to communicate with families and clinicians; and sometimes to help a person and their relatives through the final hours of life.
There are, of course, entry-level roles in care, as there are in almost every industry. But describing the sector itself as low-skilled has consequences. Language influences status; status influences recruitment and pay; and pay and professional development influence whether experienced people stay. Burnham’s decision to focus publicly on the skills of the people who cared for his father was therefore significant. In July he described their professionalism and argued for higher pay, training and greater recognition of the workforce. The Government has also placed workforce development among the areas it wants the accelerated social-care work to address.
There is an opportunity here to think much more ambitiously about what a career in social care can be. A care assistant should be able to develop expertise in dementia, medication, nutrition, safeguarding or end-of-life care; progress into senior roles and management; undertake recognised qualifications; and, where appropriate, move more easily between social care and the NHS. The objective should not be to turn care homes into miniature hospitals – that would destroy something valuable about social care – but to recognise that the complexity of the people now entering residential care requires professional knowledge and judgement.
This becomes particularly important as people move into residential care later in life. Many residents now arrive with several long-term conditions, complex medication regimes, significant frailty and advanced dementia. The distinction between “health” and “social care” may make administrative sense, but it often makes considerably less sense when looking at the needs of an individual resident. The care worker helping somebody eat may simultaneously be preventing malnutrition. The member of staff noticing swelling in somebody’s legs may trigger treatment for a developing clinical problem. The person encouraging a resident to walk to lunch is not merely providing companionship; they may also be helping preserve mobility and reduce falls risk. Good social care is preventive healthcare far more often than our accounting systems acknowledge.
That is also why technology should be seen as an opportunity rather than a replacement for people. Artificial intelligence, better digital records and improved information sharing could remove substantial amounts of repetitive administration from the working day. Sensors and monitoring systems may improve safety. Better data could allow deterioration to be spotted earlier. But the objective should be to give care workers more time with people rather than to engineer people out of care. The scarce resource in social care is not data. It is attentive human time.
THE SETTLEMENT WE ACTUALLY NEED
The ageing of the population is usually described as a burden, but perhaps that is another framing worth reconsidering. Britain already knows with considerable certainty that it will require more care in future. Dementia prevalence will rise, more people will live longer with multiple conditions, and families are likely to be smaller and more geographically dispersed. In almost any other area of national life, predictable long-term demand of that scale would provoke serious planning. We plan energy infrastructure because we know electricity will be needed. We debate housing targets because we know people will need somewhere to live. We invest in transport because the economy depends upon movement. Care infrastructure deserves the same seriousness.
That does not automatically mean a larger state, nor does it automatically mean preserving every part of the existing market. It means deciding what sort of mixed system the country actually wants and then constructing a funding model capable of sustaining it. There is plenty of room for ideological disagreement within that conversation. Some will favour a larger universal entitlement funded collectively through taxation. Others will believe individuals who can afford to contribute should continue to do so. Some will favour greater public provision; others will argue that independent operators provide diversity, innovation and capital that government would struggle to replicate. Those disagreements are legitimate. What is no longer legitimate is pretending that no decision needs to be made.
A durable settlement should also resist the temptation to search for a single villain. Local authorities are not deliberately trying to impoverish providers; they are trying to meet statutory responsibilities with finite budgets. Most independent providers are not trying to exploit vulnerable people; they are attempting to run viable organisations in an intensely regulated and labour-heavy industry. Families delaying admission are not necessarily behaving selfishly; many are trying to reconcile love, guilt, uncertainty and frightening financial consequences. Care workers are not leaving because they lack commitment; many can earn similar or better money doing work carrying substantially less emotional and regulatory responsibility.
Once we recognise those incentives, reform becomes less about blaming one another and more about changing the environment in which decisions are made. A sensible system would make quality financially rational. It would reward organisations capable of retaining experienced staff. It would make long-term investment in buildings and training worthwhile. It would make preventative support available before families reach breaking point. It would give commissioners enough financial room to purchase quality rather than simply manage scarcity. And it would give citizens a clearer understanding, long before they need care, of what the state will provide and what they may reasonably be expected to contribute themselves.
Perhaps most importantly, it would begin with a better question. For decades British politicians have asked: how much social care can we afford? The answer will always be contested because there is no upper limit to what could theoretically be spent. The better starting point is: what standard of care do we believe people should be able to expect in this country? Once that is established, the cost can be calculated and the argument about who pays can at least take place in the open.
There is reason for optimism in the fact that the subject is finally being discussed at this level. The Prime Minister has put his own experience of care into the public conversation. The Government has accelerated the Casey Commission, committed itself to cross-party discussion and accepted that social care cannot be separated from the future of the NHS. None of that guarantees successful reform. Similar moments of apparent consensus have come and gone before. But acknowledging the nature of the problem is a better place to begin than pretending it can be solved through another short-term funding settlement.
We should also remember that Britain is not attempting to create a caring society from scratch. It already has one. Every day, families look after relatives whom the state could never afford to support entirely on its own. Care workers perform extraordinarily difficult jobs with patience and affection. Good providers build organisations in which people can continue to live recognisable lives despite frailty or dementia. Councils, NHS teams, charities and community organisations solve problems every day that never reach a minister’s desk. Much of the system survives not because its architecture is particularly elegant, but because the people inside it continually compensate for its weaknesses.
That should not be an excuse for asking them to compensate forever. It should be the foundation on which reform is built.
When somebody enters a care home, the question should not ultimately be whether they are a self-funder or a local-authority placement, whether the invoice comes from a council or a family, or whether the organisation providing their care is private, charitable or public. Those questions matter greatly to the people financing the system, but they matter very little to the ninety-one-year-old woman sitting down to breakfast.
She wants to be safe. She wants to be comfortable. She wants somebody to know how she takes her tea. She wants to be spoken to rather than spoken over. She wants somebody to notice when she is not herself.
And somewhere, usually close by, there is a son or daughter hoping for exactly the same things.
That is social care.
The task before government is not to invent it. It is to build a settlement capable of allowing the people already providing it well to continue doing so — and to make sure that, when the rest of us eventually need them, they are still there.
Based on continuing research by Gaurav Menon.
Rt Hon Chris Heaton-Harris was MP for Daventry from 2010 to 2024 and served in the Cabinets of three Prime Ministers. He has since founded Oak Insight, a public affairs company.
Gaurav Menon is a social care executive with more than two decades of experience in highly regulated sectors. He is Registered Manager of Rosedale Retirement Home, Ross-on-Wye, Herefordshire.
There are moments when politics suddenly becomes personal.
For Andy Burnham, social care had become personal long before he entered Downing Street.
His father, Roy, was living with Alzheimer’s disease and receiving residential care, and when Burnham spoke about social care in July he did so not simply as a politician revisiting a policy area he had known during his time as Health Secretary, but as a son who had now seen the system from the other side of the door.
He spoke about watching care workers look after his father: the skill involved, the professionalism, the ability to care for somebody else’s mum or dad with patience and dignity. Roy Burnham died earlier this month.
There would be something deeply inappropriate about attempting to turn a family’s bereavement into a political argument, but there is nevertheless something important in what the Prime Minister had already said before his father’s death. Like hundreds of thousands of other families, he had experienced care not as an abstraction, a budget line or an item in a manifesto, but as something upon which somebody he loved depended upon.
That experience matters, because perhaps the greatest obstacle to sensible social care reform has always been the distance between the way the system is discussed and the way it is actually lived. People often discover social care suddenly. A parent falls. Dementia progresses. A husband who has managed reasonably well at home stops eating properly. A daughter who has quietly provided increasing amounts of support for three or four years reaches the point at which she simply cannot do any more. Families who had assumed that health and care formed one coherent public system discover that they do not.
They encounter assessments, thresholds, local-authority commissioning, private fees, means testing, Continuing Healthcare, capacity assessments and an industry whose financial architecture is largely invisible until the moment they urgently need it.
By then there is rarely much time to learn.
When we wrote the first Who Cares? series in June, our purpose was to describe some of that world from inside it.
We wrote about workforce pressures, immigration, regulation and the strange relationship between a predominantly independent care sector and a state that commissions enormous quantities of care without owning most of the organisations delivering it. Three months later, social care is receiving political attention at the very highest level. Burnham is making it the centre-piece of his first Party Conference as Prime Minister and has said it is going to be a big part of the Labour manifesto at the next election. He has asked Baroness Louise Casey to accelerate her work on a National Care Service, opened cross-party discussions and has put workforce, prevention and better integration with the NHS at the centre of the Government’s stated approach.
The Government has also explicitly recognised that social care in England is delivered overwhelmingly through private and charitable providers.
That creates an opportunity, but only if we begin in the right place. Social care is frequently described as broken, and in important respects it is. Yet that description can obscure another truth: there is an enormous amount within British social care that works extraordinarily well. Walk into a good residential home and the first thing one notices is not a funding model. It is a relationship based business: A care worker remembers that a woman with dementia was once a teacher and talks to her about her classroom while helping her dress. Somebody in the kitchen notices that a resident who normally enjoys breakfast has eaten almost nothing for two mornings. A senior carer spots a subtle change in somebody’s behaviour and asks for a clinical review before the deterioration becomes obvious. A house keeper becomes the person a frightened resident confides in because hers is the familiar face that appears at the same time each morning. None of these things is particularly dramatic. Most will never appear in a government report. Yet taken together they are the difference between merely keeping a person safe and actually caring for them.
That distinction is important because reform should begin by asking not simply what is wrong with social care, but what good social care actually consists of. Policymakers understandably think in systems: funding streams, commissioning structures, workforce numbers, regulation and integration. Those things matter enormously, but the service itself is intensely personal. A care home is simultaneously somebody’s home, somebody else’s workplace, a regulated service, a small or medium-sized business, a clinical environment and, quite often, the place in which somebody will spend the final months or years of their life. Any reform that understands only one of those identities will misunderstand the sector as a whole.
THE MARKET BEHIND THE PROMISE
The economics sitting underneath this human service are peculiar. Adult social care is not the NHS. Most provision in England comes from independent, private and charitable organisations operating in a market, and those organisations carry the commercial risks associated with any business: wages, utilities, insurance, food, repairs, financing, occupancy and investment. At the same time, a substantial proportion of their income comes from local authorities purchasing care on behalf of people who qualify for public support. Government figures for 2025/26 put the average local-authority fee for residential care without nursing for somebody aged 65 or over at £956 per week, and £1,089 for nursing care before NHS-funded nursing care. More than 90 per cent of authorities reported increasing their average fees that year, which is important and should be acknowledged. But those figures also illustrate why the discussion needs to move beyond the simplistic idea that providers merely need to become more efficient.
Providing good residential care has an irreducible cost. Staff must be present around the clock. They have to be recruited, trained and supervised. Buildings must be heated, insured and maintained. Residents need food, laundry, equipment and activities. Increasingly complex needs require increasingly competent people. Dementia care in particular is labour-intensive because human reassurance cannot simply be automated. None of this means that every provider is efficient, nor that every fee demanded by a provider represents good value. It means only that somewhere underneath every placement is an arithmetic reality. If the cost of the staffing, food, energy, maintenance and regulatory requirements necessary to provide the agreed standard of care exceeds the amount being paid for that care, the gap does not vanish because everybody has good intentions.
Local authorities face precisely the opposite side of this problem. Their budgets are under severe pressure, adult social care is already their largest area of discretionary expenditure, and commissioners have an entirely legitimate responsibility to secure value for public money. Providers need sustainable fees; councils need affordable placements. Both positions are rational. The mistake is to portray one side or the other as the problem. The real difficulty is that the resident sits in the middle of a negotiation in which the true cost of good care is not always the starting point.
This is also why the language used around commissioning matters. There is a perfectly proper place for negotiation, competition and procurement. What becomes dangerous is allowing the price of care to become detached from a clear understanding of what we expect the service purchased at that price to provide. What staffing level are we expecting? What standard of food? What training? What level of management oversight? What condition should the building be maintained in? What should happen when somebody’s dementia progresses and their needs increase considerably after admission? Until those expectations are described honestly, arguing about whether £900, £1,100 or £1,500 is the “right” weekly fee is largely meaningless.
There is a more sensible sequence available to us. Decide what good care should look like. Calculate what delivering it properly costs. Determine which part should reasonably be met by the individual and which part by the state. Then decide how the state raises its share. British politics has repeatedly attempted the process in reverse: beginning with what government believes it can afford and then asking the care system to fit itself inside the resulting number.
That is one reason why the debate has gone round in circles for so long.
The self-funder sits in another part of this complicated equation.
England’s social care system remains means tested, and people with sufficient assets can find themselves paying the full cost of residential care. At the same time, the independent sector has often relied upon stronger private fees to provide financial headroom where publicly commissioned rates are tighter. It is therefore possible for two people with similar needs living in the same building to have very different funding arrangements. Families understandably ask why somebody who worked and saved throughout their life should see a substantial part of those savings consumed by care. Providers ask why the genuine cost of care cannot simply be recognised in the public fee. Councils ask where the additional money is supposed to come from. There is no great mystery as to why social care reform has repeatedly defeated governments: each of those questions is reasonable, while answering all three simultaneously is extremely difficult.
That is why the development of a National Care Service deserves considerably more scrutiny than its name alone. Burnham has not yet presented a detailed final model, and the Casey Commission is now expected to report in 2027. The Government has said that a future service should be sustainably funded, preventative, centred around individuals and better integrated across hospitals, community services and social care. Those are principles around which substantial agreement is possible. The difficult part comes afterwards: deciding who pays, how providers are funded, what happens to the existing independent market, and how the country moves from the present system to whatever replaces it without destabilising the organisations currently caring for hundreds of thousands of people.
The answer cannot simply be to pretend that the existing market does not exist. Thousands of providers have invested in buildings, recruited workforces and developed expertise over decades. Some are excellent, some are mediocre and some should undoubtedly improve. But collectively they constitute the infrastructure through which most formal social care is currently delivered. Reform therefore needs to distinguish between profit and profiteering, between efficient operators and poor operators, and between reasonable commercial return and extracting value at the expense of care. Collapsing all private provision into a single caricature would be as unhelpful as pretending the present market is functioning perfectly.
FAMILIES ARE ALREADY PART OF THE SYSTEM
There is another part of the care economy which receives even less attention because very little money visibly changes hands: the family. Carers UK and the Centre for Care estimate the economic value of unpaid care across the United Kingdom at approximately £184 billion a year. More than a statistic, that figure represents millions of people quietly reorganising their lives around somebody else. Some reduce their working hours. Some abandon careers. Some spend their own savings. Some reach retirement only to discover that instead of slowing down they have become the principal carer for a spouse or a parent. Carers UK’s 2025 research found substantial effects on employment and financial security among people with caring responsibilities.
After the first Who Cares? series, a 75-year-old woman wrote to us about caring for her mother, who was approaching 100 and living with dementia. She was paying for three hours of support each week to assist with personal care while continuing to carry the overwhelming majority of the responsibility herself. Residential care where she lived was approaching £2,000 a week.
Her question was simple: “What does the future hold for the many carers like me?”
It stayed with us because there is no neat answer. Yet her situation illustrates why thinking about social care only in terms of care-home beds misses much of the picture. Family care and formal social care are not separate universes. They are stages of the same journey. A daughter may begin by doing the shopping once a week, then managing medication, then visiting every evening, then sleeping at her mother’s house several nights a week, then organising carers, and finally trying to find residential care after the arrangement becomes impossible to sustain. The state frequently becomes heavily involved only near the end of that journey, despite the fact that earlier support might have prevented or delayed the crisis.
This is where the more positive potential for reform lies. Prevention should not mean a slogan attached to a policy document. It should mean giving people the practical support that enables independence to continue for as long as it reasonably can. It means respite that arrives before a family carer collapses rather than afterwards. It means better links between GPs, community nursing, home care and residential services. It means helping families understand the system before they are trying to navigate it during a hospital discharge. And it means recognising that supporting an unpaid carer is not peripheral to social care policy. It is one of the principal ways in which the formal system is prevented from being overwhelmed.
THE PROFESSION WE STILL CALL ‘LOW-SKILLED’
The same change in perspective is needed with the paid workforce.
Care work has spent far too long being discussed as though its principal characteristic is that almost anybody can do it. Anyone who believes that should spend a day alongside a good care worker supporting people with dementia. The job requires the ability to help somebody who may be frightened or confused with intimate personal care without stripping away their dignity; to recognise subtle deterioration in someone unable to explain what is wrong; to administer medication safely; to deal calmly with distress or behaviour arising from cognitive impairment; to communicate with families and clinicians; and sometimes to help a person and their relatives through the final hours of life.
There are, of course, entry-level roles in care, as there are in almost every industry. But describing the sector itself as low-skilled has consequences. Language influences status; status influences recruitment and pay; and pay and professional development influence whether experienced people stay. Burnham’s decision to focus publicly on the skills of the people who cared for his father was therefore significant. In July he described their professionalism and argued for higher pay, training and greater recognition of the workforce. The Government has also placed workforce development among the areas it wants the accelerated social-care work to address.
There is an opportunity here to think much more ambitiously about what a career in social care can be. A care assistant should be able to develop expertise in dementia, medication, nutrition, safeguarding or end-of-life care; progress into senior roles and management; undertake recognised qualifications; and, where appropriate, move more easily between social care and the NHS. The objective should not be to turn care homes into miniature hospitals – that would destroy something valuable about social care – but to recognise that the complexity of the people now entering residential care requires professional knowledge and judgement.
This becomes particularly important as people move into residential care later in life. Many residents now arrive with several long-term conditions, complex medication regimes, significant frailty and advanced dementia. The distinction between “health” and “social care” may make administrative sense, but it often makes considerably less sense when looking at the needs of an individual resident. The care worker helping somebody eat may simultaneously be preventing malnutrition. The member of staff noticing swelling in somebody’s legs may trigger treatment for a developing clinical problem. The person encouraging a resident to walk to lunch is not merely providing companionship; they may also be helping preserve mobility and reduce falls risk. Good social care is preventive healthcare far more often than our accounting systems acknowledge.
That is also why technology should be seen as an opportunity rather than a replacement for people. Artificial intelligence, better digital records and improved information sharing could remove substantial amounts of repetitive administration from the working day. Sensors and monitoring systems may improve safety. Better data could allow deterioration to be spotted earlier. But the objective should be to give care workers more time with people rather than to engineer people out of care. The scarce resource in social care is not data. It is attentive human time.
THE SETTLEMENT WE ACTUALLY NEED
The ageing of the population is usually described as a burden, but perhaps that is another framing worth reconsidering. Britain already knows with considerable certainty that it will require more care in future. Dementia prevalence will rise, more people will live longer with multiple conditions, and families are likely to be smaller and more geographically dispersed. In almost any other area of national life, predictable long-term demand of that scale would provoke serious planning. We plan energy infrastructure because we know electricity will be needed. We debate housing targets because we know people will need somewhere to live. We invest in transport because the economy depends upon movement. Care infrastructure deserves the same seriousness.
That does not automatically mean a larger state, nor does it automatically mean preserving every part of the existing market. It means deciding what sort of mixed system the country actually wants and then constructing a funding model capable of sustaining it. There is plenty of room for ideological disagreement within that conversation. Some will favour a larger universal entitlement funded collectively through taxation. Others will believe individuals who can afford to contribute should continue to do so. Some will favour greater public provision; others will argue that independent operators provide diversity, innovation and capital that government would struggle to replicate. Those disagreements are legitimate. What is no longer legitimate is pretending that no decision needs to be made.
A durable settlement should also resist the temptation to search for a single villain. Local authorities are not deliberately trying to impoverish providers; they are trying to meet statutory responsibilities with finite budgets. Most independent providers are not trying to exploit vulnerable people; they are attempting to run viable organisations in an intensely regulated and labour-heavy industry. Families delaying admission are not necessarily behaving selfishly; many are trying to reconcile love, guilt, uncertainty and frightening financial consequences. Care workers are not leaving because they lack commitment; many can earn similar or better money doing work carrying substantially less emotional and regulatory responsibility.
Once we recognise those incentives, reform becomes less about blaming one another and more about changing the environment in which decisions are made. A sensible system would make quality financially rational. It would reward organisations capable of retaining experienced staff. It would make long-term investment in buildings and training worthwhile. It would make preventative support available before families reach breaking point. It would give commissioners enough financial room to purchase quality rather than simply manage scarcity. And it would give citizens a clearer understanding, long before they need care, of what the state will provide and what they may reasonably be expected to contribute themselves.
Perhaps most importantly, it would begin with a better question. For decades British politicians have asked: how much social care can we afford? The answer will always be contested because there is no upper limit to what could theoretically be spent. The better starting point is: what standard of care do we believe people should be able to expect in this country? Once that is established, the cost can be calculated and the argument about who pays can at least take place in the open.
There is reason for optimism in the fact that the subject is finally being discussed at this level. The Prime Minister has put his own experience of care into the public conversation. The Government has accelerated the Casey Commission, committed itself to cross-party discussion and accepted that social care cannot be separated from the future of the NHS. None of that guarantees successful reform. Similar moments of apparent consensus have come and gone before. But acknowledging the nature of the problem is a better place to begin than pretending it can be solved through another short-term funding settlement.
We should also remember that Britain is not attempting to create a caring society from scratch. It already has one. Every day, families look after relatives whom the state could never afford to support entirely on its own. Care workers perform extraordinarily difficult jobs with patience and affection. Good providers build organisations in which people can continue to live recognisable lives despite frailty or dementia. Councils, NHS teams, charities and community organisations solve problems every day that never reach a minister’s desk. Much of the system survives not because its architecture is particularly elegant, but because the people inside it continually compensate for its weaknesses.
That should not be an excuse for asking them to compensate forever. It should be the foundation on which reform is built.
When somebody enters a care home, the question should not ultimately be whether they are a self-funder or a local-authority placement, whether the invoice comes from a council or a family, or whether the organisation providing their care is private, charitable or public. Those questions matter greatly to the people financing the system, but they matter very little to the ninety-one-year-old woman sitting down to breakfast.
She wants to be safe. She wants to be comfortable. She wants somebody to know how she takes her tea. She wants to be spoken to rather than spoken over. She wants somebody to notice when she is not herself.
And somewhere, usually close by, there is a son or daughter hoping for exactly the same things.
That is social care.
The task before government is not to invent it. It is to build a settlement capable of allowing the people already providing it well to continue doing so — and to make sure that, when the rest of us eventually need them, they are still there.
Based on continuing research by Gaurav Menon.