Few of us are immune from the anxiety that can quickly set in when we contemplate our own ageing. Who will be there for us when us can no longer physically take care of ourselves? Who will be around to remind us of who we were in our moments of lucidity when our minds have started slipping away?
For those of us who don’t have children, these questions take on a particular significance. I had mixed feelings after watching Still Alice, an Oscar-winning depiction of early-onset dementia. It made for grim viewing. But it was easy to imagine the ways it could have been even grimmer: what if the protagonist, Alice, had no children, a partner long departed or divorced, or friends who had drifted away?
Increasing life expectancy is one of the great markers of human progress. But the flipside of our stretched lifespans is that we are more likely to experience longer periods of significant physical and mental decline at the end of our lives. And there’s a strong, unwritten assumption about how we as a society accommodate this shift: it’s that the generational tables will eventually turn so that you will eventually come to depend on your children, who were once so utterly dependent on you.
But the medical advances of recent decades have been accompanied by profound and positive social shifts as women have moved en masse into the workplace, reducing the capacity for caring within families. This increase in numbers has prompted a debate about how we care for children, and where the role of the state in providing childcare begins and ends.
In contrast, the balance that has been struck between the role of the state and families in caring for older people is uneasy and implicit. State provision of professional care for older people has grown, but remains limited in comparison to healthcare: it is means-tested and basic. The system relies heavily on the informal caring done by family members, estimated at 7.6bn hours in 2010. Without this, it would collapse.
There are signs, though, of a growing disjunction between what we implicitly assume families will do, and what actually happens. Older people without children barely feature in policy discussion or planning for local provision. Yet their numbers are set to grow: the proportion of women not having children has increased from one in nine to one in five in a generation. It’s been estimated that by 2030, there will be more than a million adults aged 65 to 74 without children, almost double the number in 2012. Some groups, such as older LGBT people and adults with learning disabilities, are particularly affected.
But in any case, having adult offspring has never been a guarantee they’ll be around. The scattered nature of modern life may further erode this likelihood. What happens when ageing parents and their adult children live at different ends of the country, or on different continents, and where families have drifted apart over time? Then there are the financial pressures that might make it impossible for many to give up jobs to care full-time for their parents, no matter how much they want to. Informal caring usually falls to women, who are also more likely to be low paid and to have insufficient pension provision. Since women live longer than men, on average, and are more likely than men to have partners older than them, they are also more likely to end up alone.
Despite these trends, the state is retracting further, thanks to spending cuts that have seen funding for social care fall by as much as 30% in some areas since 2010. Little surprise, then, that even as the population ages, the number of people getting state help with the costs of their care has fallen by a quarter in the past five years. Age UK estimates there are now more than a million older people who struggle without the support they need with everyday tasks such as getting out of bed, preparing and eating meals, and going to the toilet.
The NHS is also increasingly stretched. Like so many in his generation, my grandfather spent the last weeks of his life in hospital. He wouldn’t have been assigned a mattress designed to prevent bedsores had my mother and uncle not repeatedly asked for it – not because the staff on the ward didn’t care, but because even a few years ago resources were thinly spread. The more rationing there is, the more older people have to rely on family members pushing on their behalf.
The worrying thing is that this retraction is happening by stealth. It has serious implications for what we expect families to do. But to the extent that ministers have addressed it, it’s been simply to make vague allusions about the importance of personal responsibility and familial duty, without being upfront about the tradeoffs involved, and what they might mean for older people without family in their lives who can pick up the pieces.
We need a more explicit debate about where the responsibilities of the state and families start and stop. The state has a critical but limited role to play. It can’t provide love and companionship. It can’t fight tooth and nail against itself for you to get a limited slice of rationed resources. But it can and should provide a basic standard of professional personal care as a critical safety net. This requires an honest conversation about how much this will cost and how to pay for it.
This is not just important for older people without children. While the state can’t replace loving family relationships, it can profoundly affect them. We tend to fetishise Asian cultures that have a greater tradition of care of older people taking place within extended families, such as the Japanese. But scratch beneath the stereotype, and a more complex picture emerges. The Japanese word kaigo-jigoku translates to “care-giving hell”. One survey in the 1990s suggested one in two family carers in Japan had subjected older relatives to some form of abuse, with one in three acknowledging feelings of “hatred”. Such findings hint at the consequences of expecting families to do too much, especially when the conditions involved include advanced dementia, which requires skilled professional care.
Resolving the question of what the state can and ought to do is relatively easy compared with the much knottier problem of how to create a society that has an abundance of the things – love, companionship, emotional support – that the state can never hope to provide.
Look to civil society, and there are important clues. North London Cares is a charity that matches older people and younger professionals to provide each other with companionship. HomeShare schemes connect people who might benefit from low-cost accommodation with older people who have a spare room and need light-touch support to stay in their own home. The schemes may look different, but the fundamentals are common. They are not about setting up the sorts of transactional relationships more associated with professional care; they explicitly seek to build mutually-beneficial relationships that create bonds of love, care and commitment.
They offer a glimpse of what a kinder society might look like; a kernel of transformative potential. But it’s a long way off being realised. As much as such schemes might be part of the solution, they are a rarity. And this takes us to the fundamental truth that all questions about ageing eventually point towards: if we want to create a better world in which to grow old, it’s down to us.