Laura Greene works at Kingston and Richmond NHS Foundation Trust where amongst multiple roles, she is lead for Unpaid Carers and chairs the Kingston & Richmond Frailty Board Workstream on Frailty & Unpaid Carers.
“Caring is a social infrastructure, as important as housing, transport and paid care — but it is taking too much from the carers themselves.”
Across the UK, more than 5.7 million people provide unpaid care (ONS, 2021; Carers UK, 2023). They are the invisible extension of the NHS and social care system, sustaining people at home, preventing admissions and enabling discharge. For geriatricians, they are ever-present, though rarely formally identified: sitting at the bedside, answering questions, managing medications and quietly holding together increasingly complex care arrangements.
Yet the evidence is unequivocal: unpaid caring is not a neutral act. It is a powerful and under-recognised determinant of health, one that is associated with poorer outcomes not only for the carer, but also for the patient.
As specialists in frailty, complexity and whole-person care, members of the British Geriatrics Society are uniquely positioned to change this.
Caring as a clinical risk factor
Unpaid caring meets every criterion of a social determinant of health. It shapes income, restricts social participation, disrupts sleep and is associated with chronic stress and physical strain. Public Health England recognised this explicitly in 2021.
The consequences are measurable and profound:
- Mental health: 81% of carers report increased stress and anxiety; 77% report worsening mental health (Carers UK, 2022). Loneliness is reported by 36% of carers versus 6% of the general population (ONS, 2022).
- Physical health: High-intensity carers (50+ hours/week) are twice as likely to report poor health (Brimblecombe et al., 2018), with musculoskeletal pain, fatigue, and sleep disturbance common.
- Older carers: 1.5 million people aged 65+ are themselves carers, often managing multimorbidity alongside caring strain (Age UK, 2023).
- Mortality and decline: Evidence from the English Longitudinal Study of Ageing (ELSA) links intensive caring with earlier disability onset and increased mortality risk.
- Poverty and long-term risk: 1.2 million carers live in poverty (Joseph Rowntree Foundation, 2023), compounding health inequalities.
These are not incidental findings. They are predictable, patterned outcomes of sustained caring exposure.
And yet, in contrast to other risk factors routinely identified in geriatric medicine, unpaid caring remains largely peripheral and thus, undiagnosed.
The missed opportunity in frailty pathways
We know that frailty is rarely an individual condition. It is relational.
When a clinician applies the Clinical Frailty Scale (CFS), they are implicitly assessing a system: the patient’s functional status, environment, and dependence on others. Likewise, Comprehensive Geriatric Assessment (CGA) seeks to understand the interplay between medical, functional, psychological and social domains.
Yet, within this gold-standard holistic assessment, the health status of the unpaid carer, the very person enabling the patient’s stability, is often absent.
This is a potential ‘blind spot’ which when omitted, carries risk.
A frail patient supported by an exhausted, unwell, or unsupported carer is not a stable system. It is a system at high risk of:
- failed discharge
- avoidable readmission
- medication mismanagement
- rapid functional decline
- dual crisis: patient and carer deterioration
Conversely, when the carer is identified, supported and sustained, the patient’s outcomes improve.
Evidence from the Carers’ Clinical Liaison Service at Kingston Hospital demonstrates up to 2.5 days in reduced length of stay and 3% reduction in readmissions when carers are actively supported post-discharge. This is not ancillary. It is core clinical effectiveness.
Geriatricians as co-diagnosticians of caring
Geriatricians are uniquely equipped to identify unpaid carers, not as an administrative exercise, but as a clinical intervention.
In practice, this means shifting from seeing carers as “visitors” or “relatives” to recognising them as:
- co-producers of care, and
- patients-in-waiting, with their own identifiable risk profile
The diagnostic moment already exists.
When frailty is identified via the Clinical Frailty Scale, and when CGA is undertaken, there is a natural and powerful opportunity to ask:
- Who is providing care?
- At what intensity?
- At what cost to their own health?
This need not be additional burden to clinical workflow. It is an extension of good geriatric medicine and professional curiosity.
From identification to intervention
Identification must trigger action.
Once an unpaid carer is co-identified, geriatricians can initiate or advocate for pathways that are already known to mitigate risk:
- Primary care linkage: ensuring carers are coded in GP records (SNOMED) and offered health checks, screening and vaccination
- Targeted prevention: musculoskeletal support, sleep interventions, and mental health services
- Social prescribing: connecting carers to community-based support and respite
- Discharge planning: explicitly incorporating carer capacity into decisions about timing and safety
- System navigation: referral to carers’ services, benefits advice and support organisations
This is preventive medicine at its most efficient: a single intervention that improves outcomes for two interdependent individuals.
A rallying point for geriatric medicine
If unpaid caring is a determinant of health, and the evidence confirms that it is, then failing to identify it is a clinical omission.
Geriatricians have long led the way in advancing holistic, person-centred care. The next evolution of that leadership is to extend the unit of care beyond the individual patient to include the unpaid carer alongside them.
In doing so, geriatricians can:
- improve patient stability and prolong independence at home
- reduce avoidable admissions and system pressure
- address a significant and growing health inequality
- and ultimately, influence the mortality and quality of life of both patient and carer
This is not about expanding scope indiscriminately. It is about honing clinical insight: recognising that frailty does not exist in isolation, and neither does resilience.
Conclusion
Unpaid carers are the hidden infrastructure of our health system. But they are also an at-risk population, whose declining health directly impacts the patients we treat.
Caring is not just a social role. It is a clinical signal.
The question is no longer whether we should identify unpaid carers. It is whether we can afford not to.
