Social care is a class question

Another speech, another set of headlines…and another long wait for something to be done about the crisis in adult social care. In March Baroness Casey told a Nuffield Trust Summit that social care had never had its own “creation moment”. 

“Instead,” she said, “we are left with a system with add-ons and work arounds. Sticking plasters and glue.” All very true. But what to do about it?

It was 2024 when Casey was appointed to her role chairing a commission investigating adult social care. She will deliver her final report in 2028. The can has been kicked down the road for decades. 

Report after report

Since 1997 there have been at least 22 major reviews, commissions and reports – the Royal Commission on Long Term Care for the Elderly in 1999, a White Paper on Building the National Care Service in 2010, the Dilnot report Fairer Care Funding in 2011, and David Cameron’s 2012 Dementia Challenge, and so on.

‘With all the talk about cost, something’s being missed: why is dementia rising at all?’

None has had its recommendations implemented. What are the chances of the government – any capitalist government – accepting the new report in 2028 and, crucially, implementing it immediately? Zero. And the reason for this guaranteed delay and inaction is simple: money.

In the 2022/23 financial year, local authorities spent £23.3 billion on adult social care. The Health Foundation estimated that an additional £8.3 billion would be needed by 2032/33 just to keep place with growing demand.

The major driver for these costs, according to the Alzheimer’s Society, is dementia, accounting for something like £17 billion.

There is a kind of fiscal panic about dementia. In a way that’s unsurprising, given that the cost is set to balloon to £40 billion by 2040. But with all the talk about cost, something’s being missed: why is dementia rising at all?

Not just about ageing

One common assumption is that the rising prevalence of dementia is just down to an ageing population. The idea is that as people live longer, more people will inevitably suffer some form of dementia. It’s seen as a sort of curse of progress.

Yet six or seven years ago, the evidence was that dementia rates had been falling – strongly – across Europe and the United States. Research presented at Alzheimer’s Research UK’s 2019 conference in Harrogate indicated that the incidence of dementia actually fell by 13 per cent per decade between 1985 and 2015.

While this fall in incidence was taking place, life expectancy was rising over that same thirty year period – by 4 years in the US and in Britain by 7.6 years for men and about 6 years for women. The reasons for this are not fully understood, and are likely to include better health provision, reductions in air pollution, and safer workplaces.

Now look what’s happening. The improvement in life expectancy has ground to a virtual halt. Meanwhile, the incidence of dementia is rising.

Class divide

The inescapable conclusion is that dementia cannot be an inevitable by-product of old age. Other factors are at play. And, in fact, research is clear that dementia is more common among people with lower socioeconomic status than among richer people, even though – as is well known, richer people live longer than poorer people.

That research is not just US-based. It was also the conclusion following up over a quarter of a million people registered in the UK Biobank.

Of course, rich people can and do get dementia. But just as it’s a fact that smoking kills even though many individuals who have smoked all their life live well into their 90s, so poverty is a major driver of dementia – and of public care costs too – even though it’s not confined to the poor.

All this is – or should be – well known to politicians. But as the Institute of Health Equity at University College London puts it, “While there is clear evidence to support a focus on social and economic factors in mental health, cognitive impairment and dementia, this is not widely drawn on or developed in most relevant policies or interventions.”

Poverty

So it’s no accident that the resurgence of dementia is going hand in hand with the growth of poverty. The Joseph Rowntree Foundation says it is over 20 years since the last prolonged fall in poverty in Britain. In its report on poverty published in 2025, it says, “Each of the 5 Parliaments since 2005 has recorded lower quarterly income growth than the last 13 Parliaments before 2005, stretching back to the start of available data in 1955.”

The foundation notes that the lack of income growth “started with the economic slowdown even before the global financial crisis and persisted through the crisis itself”. 

‘Dementia is bound up with declining health, declining wages, rising unemployment…’

Put all the research together, and the inescapable conclusion is that in this country dementia and its associated costs are intimately bound up with declining health, declining wages, rising unemployment – in short, with the decline of Britain. Dementia is a class question.

Faced with burgeoning costs and what looks like a guaranteed increase in the number of people needing care, the Casey commission is not going to be able to wave a magic wand. 

In her speech to the Nuffield Summit in March Casey spoke clearly and eloquently about the disorganisation and fragmentation of social care. She spoke, too, about the scandal whereby NHS organisations are paying private providers to find ways of cutting how much they spend on Continuing Health Care budgets for people with long-term health needs. 

And if these companies are successful, they get a cut of the savings. “I am left questioning how on earth we got here?” she said. Here’s an answer: a couple of decades of bringing the market into the NHS.

But these are not just financial questions. They take no account of the misery and havoc that conditions such as dementia wreak among those hit by it and among their families. 

Nor the cost to the army of unpaid carers, estimated (from Census returns) to be 5.8 million in 2024. It could be higher. The results from polling conducted by YouGov for Carers UK came up with a figure of around 7 million unpaid carers.

And all this unpaid caring is storing up problems for the future. In the polling, around half of current and past carers say caring had a negative impact on their health. And it will often affect their ability to work too.

The key messages in the Institute of Health Equity’s report include as elevating the risk of poor mental health and dementia the following: lower educational attainment, poor quality manual employment, unemployment, sporadic employment, poor housing, and cold homes.

The idea that any report, however well intentioned, can address all this is fanciful. If workers want the best chance of a long, happy and healthy life, they must face the facts: dementia is a class question. And doubly so. 

Firstly because it tends to affect workers much more than it does the owners of capital. But also because workers themselves must, as a class, rise to the challenge of the decline of Britain – or suffer the consequences.