Policy debates about long term care (also known as adult social care in the UK context) are framed by twin problems of population ageing and “affordability” – a shorthand for protecting the inheritances of families with moderate and higher wealth. This framing, by drawing attention away from current unmet needs for care and the mechanisms that drive a need for care in the first place, also obscures solutions that would be both more sustainable and more equitable.

This paper offers an alternative framing that centres the social determinants of social care, and illustrates it with empirical data for England from a range of household and user surveys. Just as the social determinants of health framework highlights the pervasive impact that people’s living and working conditions have, cumulatively, on their health, so a social determinants of social care framework enables us to examine the marked socio-economic gradients and ethnic differences in the risks of developing many of the conditions commonly associated with a need for long-term care, among both the working age and older population. Furthermore, because the geographic clustering of socio-economic disadvantage is not adequately reflected in public resource allocation formulae, the resources available relative to need are lower in the most deprived areas and this in turn leads to stark gradients in unmet need, as reflected in both access to, and quality of, care.

The paper concludes by arguing that viewing social care through the lens of social determinants opens up a more productive policy space: connecting the health inequalities agenda with preventative social care; re-examining the distribution of scarce public resources; and recognising that the largest gains are to be made where the need is greatest.

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