Constructions of childlessness and ageing: legitimising dependency on unpaid care?

Abstract

Purpose

A narrative has developed in recent years to link ageing without children to support needs in later life. Social care has long been viewed as a private, familial responsibility, whilst health care is a societal, public good. Childlessness is framed negatively in terms of increased demands on care services and wider family networks. As governments tackle the issue of how to fund and deliver an equitable and sustainable long-term care sector, this paper aims to argue that it is more critical than ever to evaluate views of childlessness in the context of ageing.

Design/methodology/approach

Policy-oriented commentary paper.

Findings

If the focus on childlessness and ageing is through a lens of a potential care deficit, this continues to frame ageing without children as a risk and does little to challenge increasing reliance on unpaid care. Research and policy need to explore how to make access to social care more equitable and reduce expectations of unpaid care. They also need to increasingly emphasise exploration of aspects of later life beyond the issue of care, for example, by more of a focus on communities, what matters to people to age well and lives that extend beyond traditional views of nuclear families.

Originality/value

This paper uses the UK as a contextual example to argue that the research and policy communities have a role to play in evaluating their constructions of childlessness and ageing and questioning whether they do little more than legitimise government’s unwillingness to take responsibility for social care.

Citation

Hall, A., Spiers, G. and Hanratty, B. (2022), "Constructions of childlessness and ageing: legitimising dependency on unpaid care?", Quality in Ageing and Older Adults, Vol. 23 No. 4, pp. 165-173. https://doi.org/10.1108/QAOA-10-2021-0078

Introduction

A narrative has developed in recent years to link ageing without children to support needs in later life. Childlessness is framed negatively in terms of increased demands on care services and wider family networks, arising from the assumed ways in which the disadvantages of childlessness are manifest in older age. In this context, older people without children have unmet needs for support to maintain independence, advocacy, care coordination or day-to-day social interactions that are essential for well-being (Abdi et al., 2019). In contrast to this unidimensional portrayal of childlessness as a burden on families and the state, the absence of children represents a range of experiences and family structures. Choice, infertility, bereavement or single status may all leave older people without adult offspring. In an increasingly mobile world, children by birth or marriage may live too far away to be frequent visitors. Yet, underpinning much of the narrative of childlessness are assumptions about where responsibilities lie for care provision. Social care has long been viewed as a private, familial responsibility, whereas health care is a societal, public good. Many constructions of childlessness and ageing implicitly endorse this view and point to a need for a ready supply of unpaid family carers when formal care is unavailable or unaffordable. Challenging a narrow construction of ageing without children first requires a critique of the received wisdom that dissociates social care from collective responsibilities. Exploration of the positive implications of childlessness across the lifecourse will also act to counter negative views of ageing. Using the UK as a contextual example, we argue that the research and policy communities have a role to play in evaluating their constructions of childlessness and ageing and questioning whether they do little more than legitimise government’s unwillingness to take responsibility for social care.

Caring for an ageing population: whose responsibility is it?

Loss of independence with age leaves some older people needing help with day-to-day activities in their home and community (Abdi et al., 2019). This can range from assistance with washing and shopping, for example, to people with the highest levels of dependency who require 24-h care within a residential setting. These diverse inputs are all labelled “social care” and provide the support that plays a critical role in older people’s lives. This may encompass practical and emotional support and is provided as unpaid care by family and friends or as paid-for care by professionals (The King’s Fund, 2017). In the UK, adult social care is devolved across the four nations of the UK, but unlike healthcare, it is neither universal nor centrally funded. In England, Scotland and Wales, local authorities are responsible for providing adult social care, but such care is limited to people who meet eligibility and financial criteria, the latter of which is becoming more difficult to meet, particularly in England (Bottery and Ward, 2021; Oung et al., 2020; Social Care Institute for Excellence, 2015). Many are expected to contribute to the costs of their care. The private care sector that exists alongside that provided by the state is available to people who are able and willing to pay for support. It is estimated that England has a much higher proportion of self-funders than the other UK nations (Oung et al., 2020).

Between 2015/16 and 2019/20, the number of people in England aged 65 years and over who requested care from their local authority grew by 5% (Bottery and Ward, 2021). Forecasts also suggest that demand for social care shows no sign of slowing. For people aged 85 years and over, growth in populations with a high and low dependency of 91% and 148% is expected by 2035 (Kingston et al., 2018). Yet current levels of provision do not match this growing need for care. Since 2015, the number of people in England aged 65 years and over who were granted long-term support has fallen by 7% (Bottery and Ward, 2021). English local authority spending on adult social care has taken a decade to return to levels seen in 2010, which reflects a real-term reduction in overall local authority spending power of 29% (Bottery and Ward, 2021). In short, the demand for care exceeds the public supply and available funds, and many older people cannot access the support they need.

In the absence of available state care, people who need support rely on help from unpaid carers. UK data prior to the onset of the Covid-19 pandemic show that the largest group (34%) are adult children supporting parents outside their own household, and a further 6% are providing care for parents with whom they live (Department for Work and Pensions, 2020). A third of people aged 55 have living parents/in-laws and grandchildren, with half of these people simultaneously providing unpaid support to both, and this is expected to increase as more of this cohort become grandparents (Vlachantoni et al., 2020). A third of carers provide over 35 h of care per week, with 14% providing in excess of 50 h (Department for Work and Pensions, 2020). These data do not capture the impact of the Covid-19 pandemic, which has seen the estimated number of unpaid carers in the UK rise by around 50%, from 9 million to 13.5 million (Carers UK, 2020). The number of people with dementia requiring care is also expected to rise by 124% between 2015 and 2040 (Wittenberg et al., 2020).

Unpaid care (particularly the practical, hands-on aspect) is highly gendered, reflecting stereotypical expectations that women will fulfil caring roles (Wenger, 1987). More recently, European data from the generations and gender survey (GGS) has suggested that this gender division is greater still when considering emotional care (Patterson and Margolis, 2019). The Covid-19 pandemic saw substantial gender differences in unpaid care during lockdown periods (Xue and McMunn, 2021). Unpaid care may also be performed more by those without children. At a European level, data from the GGS show that in middle age, childless people are 20%–40% more likely to provide practical, financial and emotional support to their parents than individuals with children (Pesando, 2019).

Despite the clear need for social care to support healthy ageing, this sector has been persistently neglected within policy. Efforts to reform the adult social care sector are challenged by diverse public views about the extent to which costs should be shared between the state and the individual and the role of taxation in funding care (Gregory, 2014; Ipsos MORI, 2018; Read et al., 2021; The Health Foundation, 2017). For example, Ipsos MORI polling in 2017 revealed that most (88%) of those polled favoured a protected budget for healthcare, but only 40% favoured a protected budget for older people’s care (Ipsos MORI, 2018). Poor understanding among the general public about how social care is funded, alongside assumptions that social care is free at the point of use, may have further undermined any motivation to reform the sector.

The change from the “Department of Health” to the “Department of Health and Social Care” in 2018, with the appointment of a minister for care, suggested the sector would take a greater policy priority (National Audit Office, 2019). Covid-19 has glaringly exposed the crisis in social care, and long-promised reform to make social care in England “fit for the 21^st century” has been keenly awaited (Charlesworth et al., 2021). Scotland has proposed more advanced reform plans, but all four UK nations grapple with questions about funding (Oung et al., 2020). In September 2021, the UK government announced a new Health and Social Care Levy to increase funding to the National Health Service (NHS) and adult social care (HM Government, 2021). The core “cap and floor” plans for social care echoed the proposals outlined by the Dilnot Commission some ten years earlier (Commission on Funding of Care and Support, 2011), including capping the costs borne by individuals in England on personal care (at £86,000) and raising the upper capital limit to means-tested support. Although reform to health and social care funding is very welcome, the proposal has been met with a lukewarm response. The Institute for Fiscal Studies described it as “better than doing nothing”, but expressed concerns that funding is to come from taxes that will disproportionately be borne by younger people and those on lower incomes, that the reforms protect assets held in property but penalise financial assets (the rhetoric is around people not having to sell their homes to pay for care), that the additional funding will be insufficient to address the deep cuts to spending over the past decade, and may end up being swallowed by the NHS with little left for social care (Johnson et al., 2021; Zaranko, 2021).

Despite the recent government announcement, the consequence of decades of lack of political impetus is that responsibility for older people’s care is neither fully assumed nor wholly rejected by the state. Rather, an unpaid care workforce – often adult children – is left to address the gaps, ensuring responsibility for care remains what Victor (2010) calls a private and familial matter.

Constructions of childlessness in the context of ageing

Like many countries, the UK is seeing growing numbers of people without children. The latest Office for National Statistics (ONS) figures for England and Wales illustrates a developing trend in delayed parenthood and childlessness among women since the 1960s (Office for National Statistics, 2019). Of women born in 1934, 21% had not had children by age 30, and 11% had not had children by age 45. Thirty years later, these figures suggest an evolving picture. Of women born in 1964, 38% were without children at age 30, and 20% were by age 45 (Office for National Statistics, 2019). In 1989, the proportion of women who had not yet had children rose to 49%. Families are changing with more generations consisting of fewer members (termed “verticalisation”) and rising patterns of cohabitation, divorce and remarriage (Government Office for Science, 2016). The implication of these trends is that many people are now expected to age without children. By 2045, there will be a threefold increase in the number of women in England and Wales who reach the age of 80 without children (Office for National Statistics, 2020a). The proportion of older people living alone is also set to rise over the next two decades (Office for National Statistics, 2020a). Because birth registration data do not contain information about the number of children a man has had, it is not possible to use these data to provide robust estimates for men. However, survey data suggest similar patterns may be seen in men reaching old age without children (Office for National Statistics, 2020b).

Increasing levels of childlessness reflect a range of circumstances and drivers, including choice, infertility and changing economic contexts. Evolving social norms and more opportunities for education and workforce participation have enabled women to exercise greater reproductive choice. Macro-economic changes and the costs of living may also drive decisions to have children (Johnson, 2020). Increased social acceptance of diverse sexual orientations means we are seeing more same-sex families. Changes to adoption and fertility legislation have enabled same-sex partners to adopt or have their own biological children. Robust data regarding parenthood among lesbian, gay, bisexual, transgender and queer or questioning (LGBTQ) people are patchy, but evidence suggests around half of older LGB women and three-quarters of older LGB men do not have children (Guasp, 2011) and a sizeable minority of LGBTQ people interested in adoption are concerned about discrimination (Costa and Tasker, 2018). A broader view of childlessness may also account for people whose children by birth or marriage are estranged or live too far away to be frequent visitors.

Constructions of childlessness within society are predominantly negative. There is a long-standing societal perspective that people without children have deviated from the social norm. Viewed as an homogeneous “other”, childless adults are often rendered to ageist and gendered stereotypes (Dykstra and Hagestad, 2007; Hadley, 2019; McCutcheon, 2020). Within the context of research and policy, the view of ageing without children adopts a pessimistic narrative, in which childless adults are framed as deficient in a source of care and will therefore have unmet needs for support to live independently. Data from the Survey of Health, Ageing and Retirement in Europe across 12 European countries show that low-level support needs among childless older adults may be met by unpaid care. When support needs become more intense, professional care is needed sooner than for those who have children (Deindle and Brandt, 2017). Childless older adults, therefore, may experience higher unmet care needs, particularly in countries with lower levels of formal support, such as those in Southern Europe (Deindle and Brandt, 2017). Underpinning this narrative is the assumption that this sort of care and support is a private, familial responsibility rather than a responsibility that lies with the state.

We see examples of this narrative and assumption in two recent UK reports: “Living longer: implications of childlessness for tomorrow’s older population” (Office for National Statistics, 2020a) and “Future of an Ageing Population” (Government Office for Science, 2016). The ONS report discusses the implications of growing numbers of older people who will not have children to provide care, whilst the Foresight report considers the consequences of changing family dynamics. A spotlight on the future care needs of older people is welcome and an important part of the discussion about the readiness and sustainability of the social care sector. However, the prevailing discourse that underpins these reports (and others) reinforces the largely unquestioned assumption that where family members exist, they are expected to be willing and able to provide unpaid care.

A similar assumption underpins UK strategies for unpaid carers. For example, the Carers Action Plan 2018–2020 (Department of Health and Social Care, 2018) recommends improving the identification and involvement of carers within health services, addressing the substantial challenges faced by carers in balancing their caring role with employment, and recognition of carers’ roles by wider community stakeholders. This support for carers is critical; however, the dependency on unpaid care goes unchallenged. Indeed, the Plan explicitly acknowledges without critique that every year, more people become carers and that unpaid care is an integral part of the health and social care system.

The question missing in much of the discourse around childlessness and ageing is not so much the extent to which adult children are available to provide unpaid care but the extent to which they should be relied upon to do so in the first place. A failure to pose this question within a policy context legitimises the dependency on unpaid care. The link between ageing without children and the implications for addressing later life care needs is clearly a symptom of a poorly funded adult social care sector; given that the sector is likely to require “tens of billions” of pounds to ensure adequate funding (Foster et al., 2020; House of Commons Health and Social Care Select Committee, 2020), it is not surprising that the dependency upon unpaid care goes relatively unquestioned, when the benefits to the state outweigh the costs (Chapman and Wilson-Morris, 2019). Similar narratives are seen in the context of China, where falling birth rates and ageing populations have led to similar concerns around access to care (Yu, 2020). In contrast, childlessness is no longer seen as a lack of an insurance policy in old age in Nordic countries, where the provision of later life welfare, health and social care is stronger (Hansen et al., 2009).

Changing the discourse about childlessness, ageing and care in research and policy

Understanding childlessness in the context of ageing is important. It should be considered alongside an evidence-informed debate about equitable access to social care and reducing unmet needs among people who require support to live well as they age. Conflating these issues risks perpetuating a narrative that legitimises the dependency on unpaid care. In response to the growing interest in ageing and childlessness and the necessity of addressing deficits in adult social care, research and policy communities should be encouraged to give careful consideration to how these issues are framed.

Discussions about older people and unmet social care needs should challenge the assumption that adult children are an available and willing substitute for formal care. This is critical given the long-term adverse outcomes of caring. Carers are a vulnerable group in their own right, and unpaid care is a social determinant of health (Spiers et al., 2021). A substantial body of international evidence shows that carers experience poor health and well-being, often neglecting their own needs to prioritise those of the person for whom they support (Brimblecombe et al., 2018). Loss of employment and long-term financial insecurity arising from loss of earnings and costs of care are common. There is a social gradient to unpaid care, as higher levels of unmet need among older adults (and thus a higher need for care) are generally found among those of lower socioeconomic status (Vlachantoni, 2019). The use of language is important, and we must avoid a discourse that places responsibility for care entirely with families. That is, in the research and policy communities, we must start talking about ageing without an adequate supply of formal adult social care rather than ageing without children (or without other family members or friends) as a synonym for ageing without unpaid care. Potential solutions to problems perceived by people ageing without children include identification by care services of people ageing without family support or improved training for service providers about specific issues relating to this group (Beth Johnson Foundation and Ageing Without Children, 2016). These may be sensible suggestions to address such concerns. Many of these points could be applied to everyone to avoid the interpretation that if someone has family, their care needs will be met without professional support.

Other issues that should be considered in relation to childlessness and ageing include the implications for socioeconomic capital and inequalities. For example, does the accumulation of wealth over the lifecourse differ for people without children, and if so, what does this mean for later-life socioeconomic inequalities? Related to this is the consequence of intergenerational transfers of wealth. Will rising levels of childlessness result in fewer transfers, and how might this shape long-term socioeconomic inequalities, both within and between generations? In the absence of intergenerational transfers, older people are more likely than those with children to give to non-family networks such as charities (Kohli and Albertini, 2009). These represent important economic contributions to society and should be part of a wider discussion around ageing and childlessness.

A broader debate could also explore the positive implications of childlessness across the lifecourse, which may counteract the ageist narrative that (childless) older people are a burden to society and families.

Conclusion

As governments tackle the issue of how to fund and deliver an equitable and sustainable long-term care sector, it is more critical than ever that we evaluate how we view childlessness in the context of ageing. Research and policy communities should look beyond the implications for the provision of support and care; conflating the two risks legitimising the view that care is a private, rather than public, responsibility. This is not to dismiss the importance of research into experiences and outcomes of ageing without children. It is important to understand how people in middle age without children may be planning for later life. However, if the focus on childlessness and ageing is almost exclusively through a lens of a potential care deficit, this continues to frame ageing without children as a risk and does little to challenge the reliance on unpaid care. Research and policy need to explore how to make access to social care more equitable and reduce expectations of and burden upon unpaid care. They also need to increasingly emphasise exploration of aspects of later life beyond the issue of care. Examples may include more focus on communities, what matters to people to age well, and lives that extend beyond traditional views of nuclear families.

Acknowledgement

The authors thank both our academic and professional support colleagues from National Institute for Health and Care Research Policy Research Unit in Older People and Frailty, with whom we discussed the ideas presented in this paper during unit meetings.

Ethics approval: This paper is a critical comment article drawing on published literature; therefore, ethics approval was not required.

Statement of funding: This report presents independent research funded by the National Institute for Health and Care Research Policy Research Unit in Older People and Frailty. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. Policy Research Unit Programme Reference Number PR-PRU-1217–21502.

Author contributions: AH proposed the topic of the article, and all authors discussed the conceptualisation and format of the article. AH and GS jointly led the drafting of the manuscript with critical comment and revision from BH. All authors have approved the submitted version.