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At Millvina House in Anfield, Liverpool, residents living with advanced dementia occupied the day room, many exhibiting vacant stares or sleeping with mouths open, embodying a fearsome human vacancy often dreaded in one’s final days. During a recent visit accompanied by Louise Casey, who leads the commission on social care in England, a vivid scene unfolded: an agitated man suddenly sprang to life, aggressively demanding, “Out! Get out! Get out!” A young care worker quickly attempted to soothe him by stroking his back—an example of the difficult work involved in managing dementia’s challenging symptoms, such as unpredictable aggression. Casey remarked, “People don’t want to know, but if you are born, you will die. Chances are you will need care, and dementia is the biggest killer.”
Casey’s immersion in the realities of social care has left her deeply disturbed by the insufficient help many people receive. The night prior to visiting Millvina House, she accompanied home care workers and described her experience as “profoundly, deeply shocked.” Among those she encountered was an elderly man suffering from diabetes, swollen legs, and partial paralysis following a stroke; he struggled even to open a bottle of water and had no family nearby. Limited by financial constraints, he had his care visits halved. Casey also encountered a woman with early-stage dementia suffering from an untreated, infected stoma bag, which she described as looking “so sore.” Despite the grim circumstances, Casey expressed admiration for care workers, who are often young women earning just £6.50 for a half-hour visit, navigating unknown environments with immense patience. She highlighted the pay disparity between these workers and NHS healthcare assistants, noting a difference of about £4,000 annually. Casey believes that with improved support, many more people could remain in their own homes, which most prefer, and that home visits—even four per day—would ultimately cost less than residential care facilities such as Millvina House.
Millvina House itself symbolizes the complex challenges Casey faces. Currently rated “requires improvement,” the nursing home is attempting to recover from a previous “inadequate” assessment. The Care Quality Commission (CQC) had identified serious failings under private management, including staff shortages, lack of medicines, unlawful restraint, neglect of residents with diabetes, incorrect antibiotic dosing, and questionable feeding and hydration practices. After Liverpool city council temporarily took charge in July 2024, it formally assumed control in September 2025, aiming to prevent the loss of 60 vital beds at a time when 187 beds had already been lost across Liverpool within two years. Another home, Brushwood, was also brought back under council management following damning CQC findings of unclean facilities, demeaning staff behavior, unfamiliar agency workers, and multiple safeguarding issues. Casey advocates for the return of social care services to council or voluntary sector control, emphasizing, “If it’s public money, it should mainly be publicly run.” She opposes the profit-driven involvement of private equity in care homes but acknowledges that without wealthier residents subsidizing those with limited state funding, many services would struggle to survive.
The cost implications of council ownership have become apparent. Local authority-run homes like Millvina require more funding to maintain higher standards, with better pay for staff compared to private providers who are contracted to minimize expenses. Paradoxically, although privatisation was promoted under Margaret Thatcher to reduce public spending, it ended up increasing costs considerably. Central government funding favored private residential care placements over home or council-owned care, leading to a surge in private residential admissions. Consequently, public expenditure on nursing homes and residential care skyrocketed from £20 million in 1979 to £459 million in 1986. Casey plans to analyze this history in her forthcoming report, which is expected to offer a harsh critique of the current state of social care. Her initial report on finance will focus on where wealth lies, noting that older people generally control the majority of wealth—a critical factor in shaping proposals for a national care system.
Addressing the political tensions surrounding social care financing,
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