Wanying Wang, London School of Economics and Political Science (SSCR Doctoral Student)
What happens to healthcare use when access to social care becomes free? This question matters as social care and healthcare are tightly linked in everyday life, even though they are often discussed as separate systems. When older people cannot get help with daily activities such as washing, dressing, or moving around, health problems may worsen and care is often delayed until hospital treatment becomes unavoidable. Despite the close connection, we still know relatively little about how social care reforms affect healthcare use, and even less about whether these effects differ between women and men.
In our recent study, we address the question by examining what happened after Scotland removed means-testing for personal care in 2002, and by asking whether the effects differed for older women and men.
In July 2002, Scotland introduced Free Personal Care (FPC) for older adults. The reform removed means-testing for personal care delivered at home or in residential settings. England and Wales did not do the same and continued to rely on means-tested support. The policy difference created a useful setting to study what happens when financial barriers to personal care are removed. We used data from the British Household Panel Survey, which follows the same people over time. Our analysis focused on adults aged 65 and over and compared changes in Scotland with changes in the rest of the UK before and after the reform.
Who used more social care?
We first examined whether free personal care actually changed take-up of services. We found a clear increase in the use of home help among older women, but less change among men. This gender difference is not surprising. Older women are more likely to live alone, to be widowed, and to have fewer informal care options from partners or family members. Removing means-testing appears to have made formal care more accessible for women who previously faced barriers.
What happened to healthcare use?
We then looked at three types of healthcare use: visits to a general practitioner, outpatient appointments, and inpatient hospital admissions. The effects again differed by gender.
Among older women, access to free personal care led to a sustained increase in hospital admissions. The increase was larger for women who lived alone, those with higher care needs, and those from more disadvantaged backgrounds. For men, we found small reductions in some types of healthcare use, which is consistent with social care acting as a substitute for healthcare rather than a trigger for additional use.
At first glance, an increase in hospital admissions among women may appear concerning. However, our findings suggest a more complex story.
Why might hospital use increase for women?
One explanation is that regular contact with care workers increases engagement with the wider health and care system. Home help can help identify health problems that might otherwise go unnoticed, leading to earlier referrals and treatment. From this perspective, higher hospital use may reflect previously unmet needs being identified rather than a decline in health.
Another factor is informal care. Men are more likely to receive care from spouses, which may reduce the need for both formal care and healthcare. Women, who are less likely to have this support, may turn to formal systems once the barriers are removed.
What does this mean for policy?
Our findings highlight that expanding access to social care does not have uniform effects. The same policy can reduce healthcare use for some groups while increasing it for others. These differences matter for how we assess the costs and benefits of social care reforms.
Importantly, higher healthcare use among older women should not automatically be seen as a policy failure. If free personal care helps identify unmet needs and supports timely treatment, it may improve well-being and long-term outcomes, even if short-term hospital use rises. Our findings raise further questions about how social care reforms affect quality of life, health outcomes, and longer-term costs, not just service use. It also underlines the need for gender-aware and needs-sensitive approaches when designing and evaluating social care policy.
As debates about social care funding continue, evidence from Scotland reminds us that removing financial barriers can change who gets support, how people engage with services, and whose needs are finally recognised.
For the full research article on which this blog post was based, see:
Wang, W. and Costa-Font, J. (2026). Unequal Care, Unequal Health Care? Gender Differences in Health Care Use after Adult Care Access. Social Science & Medicine, 389:118833. https://doi.org/10.1016/j.socscimed.2025.118833
