This is a cracker of a book. It is about the greatest social issue of our age: who cares? Who should care, in particular, for the very young, for the disabled and for those who, as they grow older, can no longer care for themselves? What makes the book stand out is the quality and depth of the research and the focus on the central questions that have arisen in the past sixty years: how to manage the consequences of the movement of women into the paid workforce, of families becoming smaller and more fragmented, and of life expectancy rising. 

The book opens with the assertion that ‘women’s autonomy and financial independence have been the biggest steps forward in human freedom in high-income countries since 1945’. Women accounted for around 25 per cent of the UK’s paid workforce in the late 1950s and over 70 per cent by the late 1990s. This surge gave a one-off boost to GDP. Women are now making big inroads into what were once majority-male fields (men, by contrast, are making almost no headway in majority-­female sectors). But all this has been accompanied by other changes.

Among the most dramatic has been the fall in the birth rate in Britain: last year was the fiftieth anniversary of its first fall below the replacement level of 2.1 births per woman. The average family size, around 2.8 children per woman in the late 1960s, is now 1.49, the lowest ever. ‘The decline has accelerated in the past few years,’ notes David Goodhart. As recently as 1981, the average age of a mother when she had her first child was twenty-five. Now it is thirty-one and rising. In 2016 there were more births to women over forty than to women under twenty. 

A majority of children are now born outside marriage. Of the 625,000 births registered in England and Wales in 2021, fewer than half, 304,000, were to married couples. In just under a third of cases, the parents were not living together. There has been, notes Goodhart, ‘a rapid normalisation of cohabitation, divorce, and births outside marriage’. But cohabiting couples are younger, poorer and less stable than married ones. Indeed, one third of unmarried couples with a child break up before the child’s fifth birthday. By their early teens, nearly half of children in the UK no longer live with both of their biological parents.

So families have become less stable. Parental separation is likely to damage a child’s life chances: ‘Even children from comfortable backgrounds have, on average, lower educational attainment and incomes later in life if their parents separate when they are young,’ Goodhart says. Perhaps not surprisingly, young people are more mentally fragile than ever before.

There have also been huge changes in the experiences of women outside the home, and these have brought big changes in the home. In 1971, about half of all women in the UK were employed. By 2023, that figure had risen to 72 per cent. ‘The even bigger social and psychological change’, says Goodhart, ‘was the rise in working mothers with dependent children, including preschool children.’ In 2020, for the first time, families with children and two full-time working parents outnumbered families with a father working full-time and a mother working part-time. There are nearly three million mothers in the UK with children aged four and under. Goodhart believes that some 40 per cent of them would prefer to be stay-at-home mothers, at least for the early years. ‘Children now are costly consumer goods and a lifestyle choice,’ he argues.

Childcare is not the only form of care that has been transformed. The rise in life expectancy has created a growing need for the care of those with chronic illnesses or dementia. More than ever before, however, family members are poorly equipped to provide care. When families lived close together, that was a task taken up by daughters. It still often falls to daughters, but there has been in general a ‘flight from care’, as Goodhart calls it, driven by changes in technology and expectations, along with the emergence of the ‘smaller, less stable and more dispersed family’. In the UK, the adult social care sector now employs 5 per cent of all workers, more than the proportion in the transport and construction sectors. Annual staff turnover is 28 per cent. The low pay in the care sector is ‘a miracle sitting on top of a disgrace’. 

All this is driving up state spending. Increasingly, the care that was once provided by families is provided or subsidised by the state. Some 53 per cent of all UK resident adults in 2022 paid less in taxes than they received in benefits and services. For many local authorities, spending on social care accounts for more than half its budget. When it comes to childcare ‘the UK has opted for a high-regulation/low-qualification’ model, based on paying subsidies to childcare companies. Tougher regulation has helped to cut the number of childminders – a cheaper and more flexible form of childcare than nurseries – by more than half since 2008. The recent expansion of state support is unlikely to help the poorest 30 per cent of parents much – both parents must work at least sixteen hours a week to qualify. 

Among the solutions Goodhart suggests are handing to parents with preschool children the complex state subsidies for formal childcare to spend on themselves, on grandparents or on formal childcare. ‘This would work out at roughly £3,000 per preschool child a year,’ he estimates. Another option is to ‘front-load’ child benefit. If half were paid in the first three years of parenthood, it would give parents more than £3,000 a year. ‘The weekly cost of a one-year-old child is double the cost of the same child aged ten,’ he notes. A third and more expensive possibility would be to introduce an extra tax allowance for couples bringing up children together. At present, he points out, ‘a French person earning around £45,000 who is married with three children pays no income tax at all, while in the UK they would pay about £9,000 in tax and National Insurance’.

The erosion of the family and the fall in the birth rate will have long-term implications for the care of the old and the sick. But can the fall in fertility be stopped? It is, of course, a global phenomenon. A growing number of countries are adopting pro-natalist policies – some with modest success. Georgia has seen fertility rise from 1.5 births per woman in 2003 to 2.2 in 2015 – perhaps because the patriarch of the Georgian Orthodox Church promised personally to baptise every third and subsequent child (try that, Justin Welby). A better incentive might be to increase the availability of free IVF: at present 75 per cent of IVF treatments in the UK are paid for.

When it comes to social care, part of the solution involves reducing demand. ‘I had no idea, until I looked at the numbers,’ says Goodhart, ‘that we collaborate so much in our own physical decline.’ Rates of some cancers and heart disease could be substantially diminished by changes in diet and behaviour. The most significant factor is lack of exercise. ‘Over 40% of UK adults fail to do even 30 minutes of somewhat intensive exercise five times a week,’ Goodhart reports. The health sector should promote exercise more vigorously. One hospital offers free Apple watches to patients with type 2 diabetes, which they can keep if they exercise enough each day.

Using care workers better would also help. Social care employs more people than the NHS, but its funding and governance are split across three government departments and local authorities. Whereas plenty of NHS bigwigs pop up on Question Time, there are few public voices for social care. The care sector could do, suggests Goodhart, with a chief executive. Local authorities, too, need more thoughtful attention. In Torbay, for instance, the local authority is exploring the possibility of assigning tasks that are now confined to medical staff (like wound dressing) to care workers and rationalising the visiting patterns of staff working for different care companies to reduce unnecessary travel. 

Most of the solutions so far tried have involved immigration and the return of new mothers to work. Work by the Danish government suggests that ‘non-Western immigrants and their immediate descendants [make] nowhere close to a positive contribution over their lifespan’. The recent surge in international recruitment for the health and local care services, argues Goodhart, ‘makes no long-term sense’ for the UK.

So what are the answers? None are easy. They involve ‘strengthening family life, promoting higher fertility, upgrading public economy care work and encouraging men to move into female-majority sectors’. It sounds unpromising. But, Goodhart points out, artificial intelligence might start to eat into middle-class jobs ‘in the way that automation and globalisation have already done to working-class jobs’. An increasing proportion of jobs will be in ‘creativity and caring in their many forms’.

This detailed account of the changes in population structure and in the workforce may not immediately alter government policy. But it amply demonstrates the extent of recent shifts and the ways in which they have surreptitiously affected the lives of so many people. This is a book that all politicians need to read.