Intended for healthcare professionals

Opinion Acute Perspective

David Oliver: We’re further than ever from solving the social care crisis

BMJ 2022; 379 doi: (Published 19 October 2022) Cite this as: BMJ 2022;379:o2474
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}
    Follow David on Twitter @mancunianmedic

Thérèse Coffey, secretary of state for health and social care and deputy prime minister, has been touring the media studios touting her “ABCD” of priorities for health. The “C” stands for care, but the only firm commitment in her plan is £500m for winter social care, funded from existing budgets.1 This proposal aims to speed up hospital discharges but says nothing about longer term solutions or the far wider range of roles social care plays beyond helping people to leave hospital.

Coffey has also discussed relaxing visa requirements for social care staff coming from overseas (requirements that this government created against advice), a recruitment campaign, and detail-free promises about professional development—but not much else. Considering that the new prime minister and cabinet have no electoral mandate, it’s worth remembering that in 2019 the prime minister, Boris Johnson, promised to “fix the crisis in social care, once and for all, with a clear plan that we have prepared.” Yet, by the Queen’s speech in May 2021, the only mention was that “proposals for social care will be brought forward.”

What was then “brought forward” in August 2021 was a plan to raise over £30bn over the next three years for health and social care through a “health and social care levy,” in the form of an increase in national insurance among working adults, with only £5.4bn over three years going to social care and the rest to the NHS.2

Modelling by the Health Foundation showed that many millions more would be required each year just to maintain current access to social care, let alone expand it.3 Since 2010, serial cuts had left fewer people in receipt of social care, so this was no “once and for all” solution. And at least half the money would go to protect the assets of better-off people by use of a payment cap. The new government is now likely to legislate to scrap the national insurance rise, so even the funding for the £1.7bn a year uplift is in doubt.


Three recent reports have highlighted the growing scale of the crisis. Firstly, the Nuffield Trust published Falling Short: How Far Have We Come in Improving Support for Unpaid Carers in England?4 The brief answer is, “We have got worse.” Despite specific entitlements in the 2014 Care Act for assessment of carers’ needs,5 and the ambitions outlined in the 2008 national carers’ strategy and the 2018-20 carers’ action plan,67 what has actually happened on the ground?

From 2015 to 2021 the number of carers in receipt of “direct support” and payments had fallen; access to breaks for carers was reduced too, with funding for this down by 42%; and local authority spending on support for carers was down 11%. Carers were finding it harder to get support, and their satisfaction was falling.

Most care is already provided unpaid by family and friends, often at serious cost to their own health and wellbeing or their ability to work, and often by older carers who are themselves in poor health. And population demographics mean that more people need personal care every year. If we fail to support carers we fail some of the most vulnerable people in society, who are in turn at risk of using health services more often.

Secondly, Skills for Care published The State of the Adult Social Care Workforce in England 2022,8 which found that vacancies in social care had increased by 52% in one year and were at a record high, with 165 000 posts unfilled. Vacancy rates were now 11%, twice the average across all sectors. Yet projections showed the need for an extra 450 000 social care posts by 2035. Where will they come from?

Finally, the Health Foundation has published The Cost of Caring: Deprivation and Poverty among Residential Care Workers in the UK.9 This found that a quarter of the residential care workforce lived in poverty—one in 10 suffering food insecurity and one in eight whose children lived in material insecurity. Low pay is an issue, at a time when other sectors with less demanding roles are also short of workers. But social care and local government funding are not sufficient to allow employers to pay more and yet remain viable.

Three years and four health secretaries on from Johnson’s promise, we’re still no nearer to anything resembling an adequate future-proof plan for social care, or even a present-proof one.