Care work in a neoliberal era

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How is it that vulnerable people can suffer abuse from people paid to look after them? Lee Humber argues that part of the answer lies in the ruthless profiteering infecting the care industry.

It’s four years since the physical and verbal abuse of people with learning disabilities living at the Winterbourne View home in Gloucestershire was exposed. An undercover documentary made by the BBC revealed sickening abuse secretly filmed by a journalist posing as a care worker. Staff at the home were subsequently jailed.

A public outcry led to an inquiry and encouraged politicians of all stripes to denounce the workers involved. They called for changes in the way that services are provided for some of the most vulnerable in our society, as well as for a general end to the types of long-term residential accommodation in which the abuse took place.

Four years on, a new report, Winterbourne View: Transforming Care, has found that little has changed. In fact, the number of people with learning disabilities being sent to residential accommodation has risen. The report calls for a Bill of Rights for people with learning disabilities to protect themselves with. The call has been broadly supported by the Minister of State for Care and Support Norman Lamb.

So what can socialists say about how we provide care for the vulnerable? How can we understand what is happening to the care sector in the neoliberal era? And how can we hope to explain how it is that such dreadful abuse occurs? To answer these questions we need to consider developments in the care industry in the modern era, and particularly how the provision of services for people with learning disabilities has changed.

The social care workforce in the UK is huge, with the total number of adult social care jobs estimated at 1.63 million in 2012. The number of organisations providing care in the same year was estimated at 17,000, continuing the upward trend in numbers of care providers which began its relentless rise in the early 1990s.

Since then there has been a massive shift in resources from public to private provision, supplied by the so-called “independent sector” consisting of both for-profit private companies and not for profit voluntary sector organisations. In 2013 some 89 percent of publicly funded homecare was provided by the independent sector. This is up from just 5 percent in 1993.

Specifically in terms of provision for people with learning disabilities, a report by business analyst Laing & Buisson shows that the total value of the combined market for residential and non-residential social care of people with learning disabilities or long term mental health conditions was £8.2 billion across the UK in 2012-13.

Over 80 percent of services are now provided by the independent sector, with companies and organisations competing to win public money from local authorities in time-honoured, neoliberal economic fashion. This outsourcing represents a huge saving to local authorities. The average cost of independent sector-run residential accommodation is 23 percent lower than the equivalent provided by local authorities. In home-based care the saving is even bigger, with average independent sector costs being £14.70 per hour compared with £35.50 per hour for council-run services.

The lower costs associated with independent sector care result from the low pay and poor working conditions prevalent in a sector characterised by low union membership density and poor legal regulation. This low-pay, high-workload context is true in both for-profit companies and not for profit charities. This has implications for quality of care.

The author of the Laing & Buisson report, William Laing, worries that any extension of the independent payment scheme — through which individuals potentially control how they spend their own care budget while being supported in their own homes — may undermine profitability in the residential sector. Laing writes: “The residential sector cannot be described as a ‘burning platform’, since there [remains] robust demand…though it can be viewed as a platform that is melting around the edges.”

He optimistically consoles investors, however, that “supported living is also a diversification opportunity” with several for-profit groups “also now committed to developing this line of business as an extension of core business and as a defensive strategy in case the market shifts”.

If the language itself, when used in connection with those in need of care and support, is utterly repugnant, the sentiments behind it are obscene. The quality of care is of no concern to the corporate multinationals increasingly involved in care provision. Only the quantity of cash to be squeezed out of the public purse is important, while people with learning disabilities and other groups are reduced to little more than commodities to be bought and sold on a market of the vulnerable.

We need to understand residential care provided for those with learning disabilities and mental ill health in the broader context of residential care for vulnerable sections of the population generally, and, in particular, in connection to homes for older people. The same neoliberal approaches apply across the board. As another financial advisor, Julian Evans, put it recently, the “grey market” is particularly “hot” in the current period.

Potential investors have not been put off by exposés of resident abuse in privately-run homes. “A lot of investors see the scandals as a bit of a positive because the negative publicity has created less competition in an increasingly crowded commercial property market”, says Evans.

The size of the market in care homes for older people is enormous, with around 430,000 elderly and disabled people living in long-term residential care. Only one in ten live in council or NHS-run institutions with voluntary and for-profit companies accounting for 57 percent of the independent sector. This is up from just 5 percent in 1989.

As the collapse of care home operator Southern Cross into administration in 2011 showed, the residential care industry is balanced on a knife edge of financial ruin, based as it is on high levels of debt. This has potentially terrible consequences for residents, families and staff. As business analyst Nick Hood wrote recently: “The thing that worries me the most is the unusually high level of borrowing across the industry… Gearing currently stands at 82 percent. Care homes are essentially property businesses that provide a service, so you expect the figure to be high but not above 60 percent. I’m running a warning flag up the mast for government and the Care Commission. Just imagine what would happen if interest rates rise.”

Hood points to the fact that a third of UK care homes have notched up unsustainable debt. Over 700 companies were described as “zombie” business, with liabilities worth more than assets. In fact the debt levels in the residential care home sector are so high that even shares in market leaders such as Four Seasons, Care UK and NHP are officially rated as junk bonds, or sub-investment grade, and dangerously risky for investors to buy. NHP, for example, had debts of £1.8 billion in 2013. Barchester, another provider, formally made a profit of £16 million in 2011 but in 2013 still had debts totalling over a billion pounds.

The reason for the debts is largely due to the sale and lease-back model favoured by neoliberal economics. The Private Finance Initiative (PFI) scheme, which has seen hospitals burdened with rising levels of debt, causing them to lay off workers and close wards, is a particular sort of sale and lease-back approach. In the residential care industry, global conglomerates have been buying land and homes from care providers, and leasing them back at inflated rates.

Buyouts, bond issues, refinancing and other corporate and ownership concealment strategies put the residential care sector almost completely beyond the control and monitoring of local authorities, who provide much of the sector’s funding. As Laing adds gleefully, “It is virtually impossible for local authorities to monitor the financial health of providers on presently available statutory information.”

Meanwhile, personal links between the industry and government are many and varied. For example, Guy Hands, who runs Four Seasons from tax exile in Guernsey, became close friends with William Hague during their days at Oxford University. Hague was Hands’ best man at his wedding.

The way the market works has put private providers largely beyond even the limited democratic control of local authorities. Market-led provision adds to costs, increases the risk of collapse and increases the determination with which companies seek to keep costs down with the attendant effects on the quality of care provided. Staff pay accounts for some 57 percent of costs in residential homes, so that attacks on workers’ wages and employment conditions are constant.

Long hours, low pay and little training or support are a given in the industry (see box). It is in this context that we need to consider incidents of resident abuse. Given the vast numbers of care workers working in residential homes, reports of abuse are extremely rare.

Of course we unreservedly and without exception condemn and oppose any and all such acts of aggression — verbal, physical or otherwise — in the strongest terms possible. But perhaps socialists can offer an interpretation of why it does happen, using the theory of alienation.

Marx explained that capitalism gives workers no choice but to sell their ability to work — their labour power — in order to survive. To make their profit, capitalists immediately take from workers the products of this labour, which Marx called commodities, alienating workers from part of themselves in regard to the effort, time and skill they have put into the commodity through their labour.

Through this process of exploitation, labour itself becomes an alien thing, potentially an object to be resented by workers and possessed by the capitalists. But what is it that care workers produce? We might say that the commodity they produce is “care” itself, as defined in the dictionary as “the provision of what is necessary for the health, welfare, maintenance, and protection of someone or something”.

The form this care commodity takes is encapsulated in the number of tasks care workers perform — see, for example, a recent job application for a care worker which required applicants to have skills and abilities enough to perform 30 separate administrative and people-focused tasks including such things as:

“To actively talk and listen to service users, allowing for their personal choice in their own home; to ensure all home visits are for the time allowed, as scheduled and request the service user’s signature on supplied timesheets at the end of each visit, showing accurate time of arrival and departure.”

This task-based care commodity can become personified in the objects of care — the people that care workers support — who, in rare and specific circumstances, can become the targets of care workers’ bitterness, frustration and anger. As we have seen above, capital is interested in the quality of the life experiences of the vulnerable only to the extent that it makes their “care product” more attractive to sell.

The free market reveals more clearly the profit motives that drive the entire industry, shaping the experiences of carers and cared for alike, with its incessant need to exploit care workers more thoroughly and maximise profits from their efforts. When workers resist this, they defend not only their own standards of living but also the standards of care they can provide.

The historic 90-day strike of workers at Care UK which ended in November in partial victory was not only in defence of their own wages and conditions, but centrally in defence of the standards of care for the people with learning disabilities. To collectively resist the dehumanising nature of neoliberalism in this way is to fight for our rights to relate to each other more fully as human beings, to reassert the collective and collaborative nature of society.

As mentioned, Winterbourne View: Transforming Care calls for a Bill of Rights with which people with learning disabilities can protect themselves. Socialists would support this call. In fact, among other things we would like the bill to be written in Easy Read format so that everyone can understand it. We want it to contain provision for people to be able to freely choose how they are supported — in residential homes, supported living, or in their own homes — with measurably high-quality services provided by skilled, highly-paid and motivated professional staff funded by uncapped public funds.

We want the bill to contain legal provision for corporate and private owners of care provision to be prosecuted if their standards of care — and the pay and conditions they offer — fall below standards set by democratically elected bodies of representatives of people receiving care and care workers.

But I’m not convinced this is what Norman Lamb has in mind.

Care workers from Guy Hands’ Four Seasons wrote about the conditions they are forced to endure on the on-line whistleblowing site, Glassdoor:
“Staff are taken on to fill staff shortages — many are unskilled. The training is inadequate…poor carers are training new staff — which yields poor standards of care.”
“We always work on the minimum staff but high standards are expected. Four care staff to 40 service users is so wrong.”
“There is a bullying culture… Having your views and concerns disregarded is terrifying especially when they concern service users and care.”
“I get paid minimum wage for a very physically and mentally demanding job. You can sometimes be doing the job of others due to staff shortages.”
“The managers…see us as expandable to be replaced if/when we leave. I’ve never been spoken to as badly by a boss as I have working for Four Seasons health care. Residents are neglected due to the low staffing levels.”

Lee Humber is a lecturer in Health Studies at Oxford Brookes University and a member of the University and College Union