Emma Dowling – Rethinking Care: From Privatisation to Solidarity

With the population set to age further in the decades to come, the ever-expanding marketisation of care must be replaced by a system based on solidarity.

Emma Dowling is a sociologist at the University of Vienna and author of the book The Care Crisis – What Caused It and How Can We End It.

Cross-posted from Green European Journal

Picture by Susan Jane Golding

The UK is experiencing an ongoing care crisis – one in which different sections of the population are played off against one another. This is a point at which the politics of austerity and the neoliberal imperative of competition come together to produce a particularly harmful way of governing society, in which different groups of people are forced to fight over access to scarce resources. Rather than fight each other, we should figure out how to resist the further entrenchment of divides, while building sustainable care infrastructures based on cross-generational solidarity. However, to do so, we need to drill down through the symptoms of this crisis to what their structural causes are: from the lack of access to adequate care, to the appalling conditions and low or no pay under which care is expected to be provided. 

When it comes to care, often the needs of people who give care are placed in opposition to those who receive it. This is especially prevalent in concerns over the cost of care, where the urgent necessity for improving pay and working conditions in the care sector collides with people’s fears of not being able to afford care in old age, should they require it. The growing care crisis also threatens to play out across generations, as the economic situation of younger people is impacted by years of austerity and privatisation, while the generation that is now retiring is seen to have benefitted from the post-war commitment to public services and social mobility. When younger adults experience less economic security and fewer improvements to their standards of living than those people who are currently of retirement age, younger generations are put in conflict with older generations. 

While those at the very top of society have managed to immunise themselves from austerity and economic difficulties that have become more acute since the global financial crisis of 2008, those at the lower end have been exposed to increased precarity and insecurity. Terms such as the “squeezed middle” or the “just-about-managing” mark a new dividing line that also reaches into the middle class, affecting parts of the population who once considered themselves relatively secure. The so-called “sandwich generation” of middle-aged people who have children and older relatives to care (or pay) for struggles to deal with the multiple demands of having to go out to work to earn an income and manage large amounts of unpaid care work in the face of cuts to public services. 

In the UK, a country where childcare for preschool children is among the most expensive in the world, more than half of parents with young children regularly rely on grandparents to look after their grandchildren so that they can go out to work. At the same time, these grandparents’ own care bills are rising, because funding cuts and more stringent eligibility criteria for social care have caused a surge in people having to pay for their own care. The systematic underfunding of social care is long-standing and entrenched, exacerbated by years of austerity. Means testing is so restrictive that many people who might have previously been able to access care and support are unable to do so today. 

Since 2010, the threshold at which people pay for their own social care has been frozen, meaning it has fallen in real terms, pushing more people into paying for social care privately, or going without. Today, an estimated 1.6 million older people don’t get the support that they need, while the support structures for people with disabilities have also been made much worse. While the number of adults receiving care remained approximately the same between 2005 and 2014, the total number of hours of unpaid caring rose by almost 25 percentage points in this period. This reflects a significant rise in the amount of continuous care being provided at home, more often than not by female members of households or families. 

Double privatisation 

Current demographic changes mean that we are steering towards a situation in which more of us will be living much longer, with complex care needs that will require support and assistance. Over the next 25 years, the population above the age of 85 will almost double. And yet, the trajectory we are on in terms of the financing and organisation of health and social care in older age is one that promises to merely deepen divides, both within generations and also across them. This is privatisation in two senses: in the foregrounding of care as a personal responsibility and in the marketisation of care. 

The relationship between care and capitalism has always been crisis prone. This is because the care of the population – whether to maintain the health of an existing workforce, nurture and educate a future one, or ensure the wellbeing of those who cannot work – is a cost to capital that, systemically speaking, must be kept as low as possible. This insight has been the starting point for feminist analysis that begins with the unpaid work of cooking, cleaning and caring in the home, historically undertaken by women, in order to uncover the huge swathes of invisible work that the capitalist economy has long implicitly relied on. Moreover, when we look to key areas of care – healthcare, social care, education, childcare, domestic work and so forth – we can see how cost reduction, either in the pursuit of profit or in the context of austerity measures, is the driving force. 

Since the 1970s, a crisis of care has been growing. While there has been a jump in the proportion of women working in paid employment outside of the home, there has been very little change to the sexual division of labour, and with that the expectation of whose role in society it is to care. At the same time, there has been significant wage stagnation, meaning that households now require two incomes to make ends meet. This means that more waged work must be done outside of the home, which takes away time from our ability to care or do housework. Added to this is austerity, a shrinking welfare state, and the rise of privatisation and the marketisation of care as an investment opportunity for capital.  

The consequence is a situation in which those who can afford to pay for commercial services do so, and those who cannot have to fit the work in themselves or go without. These developments have relied on the low-paid work of women of colour and migrant women in households and in the care sector to plug the gaps arising from greater female labour market participation, especially among the middle classes. All of this is underscored by a politics of personal responsibility for care as reflected in neoliberal social security practices seen, for example, in private pensions. Moreover, the crisis is exacerbated by the need for more care due to demographic changes, in particular an ageing population. In sum, societal resources for care are exhausted, while care needs are growing. 

Currently, the personal and household services sector is the second-fastest growing sector in Europe, with demand expected to increase due to a combination of ageing and greater female labour market participation. A combination of public service retrenchment and time pressures are pushing people towards digital platform services that promise households a private and privatised form of crisis management when they lack time for care. In recent years there has been a proliferation of such digital platforms for domestic and care services. These platforms usually charge private households a subscription fee to connect with care workers offering childcare or eldercare services on an hourly basis. Hired as independent contractors, care workers sign up to offer their services as part of a growing low-paid and precarious workforce in the gig economy. 

Another example is the roll-out of digital health services in the NHS provided by private contracts. The service GP at Hand, first trialled in London, has been offering patients the option of registering with a digital service that gives them quick access to online GP consultations and ongoing use of an automated AI-driven symptom self-check app. Babylon Health, the private company providing the service, promised patients that they could avoid long waiting times for GP services and promised the NHS that it could save money, by increasing the occasions when users can self-manage their health without needing to see a doctor.  

A final example is the contracting out of social care services to the private sector by local authorities. The creation of a market for social care created investment opportunities for financial capital seeking high returns, including private equity. Much needed financial resources can be extracted from the care home sector by charging high administration, consultation and management fees; taking advantage of tax legislation for the purposes of avoiding corporation tax; loading high debt obligations and interest payments onto providers as a consequence of leveraged buyouts; and paying dividends to shareholders. In the case of residential care home chains, in 2019 the Centre for Health and the Public Interest estimated that around 10 per cent of funds “leaked” out as rent, dividend payments, net interest payments, directors’ fees, and profits before tax, amounting to an annual total of about 1.5 billion pounds. 

The digital service has been particularly popular with a population that is young, affluent and relatively fit. Older people, those with more complex health needs, or those with caring responsibilities have been less likely to use it. Medical professionals repeatedly raised concerns that by taking the younger, healthier patients away from NHS GP practices and leaving those with more complex health needs behind, the company took away the resources GP practices needed to treat these patients. The concern is that the kind of business model introduced through the contracting of digital services like Babylon Health undermines both the principle and the material base of cross-generational collective solidarity that is fundamental to a public healthcare system. 

This kind of financial wealth extraction happens off the back of the care home workers who are dealing with low pay and unacceptable working conditions. Repeatedly, the employment and working conditions for care workers are pitted against the fears of those who require care. This was evident in the proposed 2021 Health and Social Care Levy, which increased national insurance to fund health and social care. This was not accompanied by a fundamental reform of the way that care is funded, provided and regulated. Indeed, not much of the newly raised funds were to go to improving the situation for the workforce. Instead, the government’s motivation seemed to be more orientated towards responding to voter concern over the cost of care in old age, and wealthier care recipients’ fear of losing financial assets. The Health and Social Care Levy has since been reversed. However, to date there is still no substantive and sustainable solution to the social care crisis on the table. 

Solidarity across generations 

In Britain, the responsibility for care has been increasingly off-loaded to private households or relegated to the privatised market. This has only served to entrench inequality and deepen divides, while also creating a system for profiting from care, with those who provide and receive care footing the bill. Addressing the care crisis will require a two-fold strategy based on principles of solidarity across generations. 

First, we need a radical rethink of how our everyday lives are organised across generations and beyond the confines of the nuclear family. Right now, we are most likely to interact with one another across generations either in the workplace or within the family. What might friendship across generations look like? Can we dare to imagine what a society would look like that places care at its core? Experiments here would involve creating more collective infrastructures at the level of neighbourhoods for childcare as well as assistance and support for adults who require it. This is already happening where nursery schools and care homes are finding ways to interlink and interact so as to develop intergenerational models of care. More communal and intergenerational living arrangements, including new kinds of housing, would offer an alternative to the proliferation of individual, often very isolated, households. Designing new and more communal kinds of housing would also be a chance for more ecologically sustainable ways of living too.

Currently emerging ideas and initiatives for caring cities could also be an inspiration here. One first step could be to set up local ‘care councils’ to bring residents together – both as care workers, informal carers and as people with current or future care needs – to discuss their needs and collectively design ways to transform and improve local care infrastructures. As envisaged by remunicipalisation movements, this can also involve bringing privatised services back into public ownership to improve not only access, but pay and working conditions in the sector. 

Second, we need radical reform of the ways in which solidarity is institutionally anchored through public services and mechanisms for wealth redistribution. Concretely, this means reforms towards universal basic services that include all aspects of care, funded by progressive taxation. And all in all, this means transforming societal care structures so that they no longer prop up private profit, but sustain both people and planet. 

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