This is the first of about 6 posts on Social Care that are part of the Politics of Care forum. For more on Teresa Pocock who plays a central role in the efforts of a few of us to define what care is about – see Teresa Pocock.
The technological revolution that took place around 1800 brought with it an awareness of the need for standardisation. This need is inherent in technologies rather than in markets or private enterprise per se. It is critical to efficiency and ultimately trumps, subsumes, swallows both private and public enterprise.
When the first railways were laid in the 1820s, it quickly became clear they had to have the same gauge in different parts of a country and internationally or transport between places would be at least temporarily interrupted. This was more than an irritation when the transport of troops in a time of war was involved.
The nuts, bolts, and screws, and the tools that would manipulate these nuts and bolts, all equally need standardising, as did the later machine tools that led to automation, which by definition, if it works, is completely standardised.
Without standardisation the chemicals, and recipes for mixing chemicals, central to the development of chemical and pharmaceutical industries, wouldn’t work any more than computers can work without standard languages. Chemical reactions require adherence to a recipe, in the way algorithms require adherence to a logic.
Standardisation is an element of logic – it’s a defining of terms. Once defined the terms apply globally, regardless of local factors. This global application supports ‘scaling up’ and quickly became a feature critical to investment by both private investors and public investment in the military, research, and infrastructure.
Once the gadgets and goods that would be consumer goods came onstream, especially those that would be electrically powered, the same logic applied, and common measurements further facilitated both trade and development.
The best options were not always adopted. In early video-recorder days, Betamax was competing with VHS. Betamax was technically superior, but VHS was installed as the standard consigning Betamax to the dustbin of history.
Standardisation is critical to mechanization and a broader operationalism. The advent of mechanization put paid to an artisanat and substituted an unskilled proletariat in their place.
Computerization brought operationalism into view – the broad technique underpinning all technologies. Operationalism can also be taken and applied to organizations and to people and some claim you cannot be scientific without being operational.
Operationalism facilitated further mechanization, increasing the opportunities to shed the skilled workers previously needed to operate many machines. Shedding workers was seen as politically desirable in many industries, even a matter of national security, as the ability of workers in key industries to strike could compromise defence and government.
After 1945, with the advent of computerization, there was a steady fall in employment in manufacturing industry from 80% of workers to less than 10% now. Iconic industries like American Steel and British Coal shut down and with their closure union power collapsed.
This gave rise to a political need to find work for newly unemployed multitudes. A profusion of new goods and machines supported the development of service industries, which had the capacity to absorb large numbers of staff. The service industries had to absorb not just those laid off from manufacturing but also their partners (usually wives) as the collapse of union power meant a collapse in wages making it necessary to have two wage-earners to support a family.
The Second World War and its aftermath also saw a replacement of entrepreneurs by managers. Just as military engagements had, the operations of factories, often huge corporations, essential to defence and government, needed standard operations – processes, and oversight of the implementation of these processes by managers.
In manufacturing industries, this gave rise to tensions pitting managers ‘against’ well-paid skilled workers. The managers might know the on-paper processes better, but the workers knew the idiosyncrasies of machines, even though these were increasingly standardised, and how to make the interface between workers and machines work best.
The managers won out. Skilled staff and bottom-up inputs (entrepreneurial) to development vanished. The business of America was no longer business in the sense of risk-taking – opening up opportunities in a market and moving nimbly in the way that it had been. It was now about risk-management.
The new entities were focussed on a refinement of processes that allowed for outsourcing and disarticulating the enterprise into components. See The Neoliberal Deep State (in 2 weeks time).
From 1950 through to 1980, the service sector from fast food to retail, hospitality, banking and other services lent itself even more readily to these operational processes than manufacturing had done. Standardization made staff interchangeable and allowed brands like McDonalds and Pizza Hut to scale up and globalize.
With Pizza Hut and McDonalds, the focus was on delivering standard products to people. Quality in these new services changed meaning from delivering the best possible hamburger or pizza to delivering the same product every time. In terms of interactions with the people receiving these products, this could also be standardised into a few ‘Have a Nice Day’ soundbites, with metrics introduced to get feedback on how often staff smiled and how smooth the service had been.
Around 1980, the service industry began to extend to education and both health and social care. Managers were brought in to run these ‘services’, touted as bringing private enterprise into a formerly public sector, or the new public service management as it was termed.
In these cases, however, the services are not simply a matter of delivering standard products to people in a standardized way. People themselves rather than pizzas or hamburgers are the object on which these services can act. Operations on bodies can scale but operations on people can’t, at least not in the same way – the outcomes are too variable.
The changes that took place however transformed universities into an educational services sector, healthcare into health services and social care into social services. They have led to a deskilling of university, health and social care staff, and an increasing number of temporary and poorly paid posts. They have produced tensions between faculty and university management, between medical staff and health service management, and almost universal concern about social non-care.
The changes brought a shift from nuanced education to standardised products. A shift from treating serious disorders for which patients sought help whose outcomes even with the best care were often unreliable, to giving patients disorders for which medical services can offer reliable but irrelevant (and potentially life-threatening) interventions. A shift from bad social care to an even grimmer social non-care.
For centuries up to 1980, the long-term care sector for children, the elderly, the vulnerable and the disabled was run by a range of players from religious orders to other benevolent bodies, private owners, and later with public input from Welfare State Aid through local councils.
The Welfare State input started in England in a rudimentary way with a Poor Law around 1600, which after 1945 evolved into Departments of Social Services.
Unlike Britain’s National Health Service, which from 1948 was free at the point of delivery, the post 1945 Social Care sector continued to have a mix of State provision mixed with personal payments and voluntary service inputs.
If health delivers effective treatments for disorders that impair people’s ability to work, it will in principle fully pay for itself. Social care was different in this sense but, as was recognized in the French Revolution, even though born deaf or blind, with technologies like Braille and techniques like sign languages, it was possible for people to contribute to society, live a fuller life, and at least partly defray the expense of supporting them.
This principle was adopted on an even broader basis after the American Civil War with services for veterans, and then with the creation of rehabilitation services, a mixture of health and social care, after World War I. Broadly similar arrangements applied in most countries.
[There are differences between countries that readers will have to give me some leeway on. These differences have been as great as the differences between American and British medicine, one initially private and other public, but both now close to identical. The concern in these posts is about how two so different systems health systems could end up close to identical – the care sector was never as different between countries but shows striking similarities now – one’s that it shares with health.]
In all countries, pressure to organize the different elements of the social service sector into a functioning unit grew for several reasons.
Societies have always made some accommodation for the indigent. This need was originally met by religious orders and voluntary bodies. In addition, however, by the 1980s the prospect of a larger scale provision of residences for people who needed support with bodily care and disability management was growing and had two novel features.
Public health nursing had emerged in the United States around 1908, and social work as a profession in the 1920s, with slower developments elsewhere. Comparable developments took place in Europe after 1945. There was however no central body with responsibility for or training in the provision of social services. In addition, to some extent many older people could pay something toward their own care, even if only by surrendering the benefits they were otherwise receiving.
To respond to growing concerns about how to support the indigent, the elderly and the disabled, in addition to providing preventive educational and health services, there was a turn to community care in the 1960s. This led to staff paid by social services calling to people’s homes to support basic meal provision, hygiene considerations and some health issues if the visitors were district nurses. This provision aimed at keeping people in their own homes longer, which was viewed as better for them and more economic.
This turn to community care in social services was accompanied by a de-institutionalization of people with learning disabilities to ‘homes’ where they would be supported by staff, as well mental health patients to hostels or other rented accommodation and elderly persons to ‘places in the community’.
In a number of countries, there was a trans-institutionalization of some, particularly mental health and handicapped persons, from hospital warehousing to prison warehousing rather than to the community care, envisaged in the 1963 US Community Mental Health Act.
A growing number of people in community residential facilities led social services to generate standards for these facilities. Between generating standards, employing some visiting staff, and paying some of the benefits like old age pensions that helped defray the costs of accommodation, social services became a focus for the sector and had to find answers.
Reforms put in place in Britain in 1990 endorsed the idea of a purchaser provider split in both health and social care. The purchasers of ‘care’ would put standards in place and would expect to see evidence of these being met.
This made it possible for social service (and health) departments with a brief to fund social care to contract out to groups who claimed they had expertise to do the job. This included private sector operators. In Britain in 1975, there had been 18,800 private sector residential facilities. By 1990, there were 119,900.
The introduction of standards helped lead to a consolidation, which increasingly after 1990 was billed as bringing private sector responsiveness to ‘caring’, an openness to innovation, a culture of quality improvements, investments, and services that would be economically sustainable.
Corporate development of this sort requires managers whose focus is primarily on bureaucracy rather than enterprise. This focus can produce apparent quality improvement as the tick-boxes get checked. If we neglect the aphorism that not everything that counts can be counted, the operation can appear to be functioning well, even improving, and evidently appear to be value for money.
Introducing standardization made staff interchangeable, which supported downward pressure on wages. It also opened up the possibility of a group taking over a number of facilities, financed in part by introducing efficiencies/economies such as standardising meals which allowed for bulk buying with unit costs becoming cheaper the more facilities were part of a corporation.
In Britain, research by Sheffield Hallam University found that around 2017 care homes with mainly council-funded residents were spending less on average on food and drink per patient per day than the cost of a high street coffee.
This corporate development in response to regulation fits a pattern found from food to drug regulation. Regulations/standards promote corporate development and with this comes a greater focus on operations that support scaling up, calling for further corporate growth.
In this case there was an expansion into retirement homes, assisted living facilities, and nursing homes, offering a one stop system for the elderly, the infirm and the disabled (and their families).
The developments included contracting out from the centre. The parent company can contract out the hiring of staff to work with residents to one company and cleaning staff to another company etc. In all cases, this contracting out leads to competition between providers and depresses wages but also inhibits the ability of anyone to notice things that may be going wrong and to push for them to be put right.
On the ground, families concerned about a relative were increasingly faced with managers whose job was to resolve complaints rather than solve problems. Families no longer got to meet someone who could make a meaningful difference in the way that taking an issue to a voluntary body or owner once could.
In Britain, and likely everywhere else, there is evidence that when relatives complain about abuse or neglect, care homes ban visits, or residents are evicted.
The charity Action on Elder Abuse estimates that around 100 elderly residents are abused in care homes every month, including physical and sexual assaults and theft. Very few of these are reported.
In most countries in the years between 2000 and 2020, there was a consolidation of the ‘market’. In Canada four major chains now own a majority of facilities (Revera, Chartwell, ExtendiCare, Sienna Senior Living).
In Britain, 5 companies do – HC-One 21,000 beds, Four Seasons Health Care 17,000 beds, Barchester Health Care 12,500, BUPA 7,700, Care UK 8,000, with many of these companies effectively owned by Hedge Funds, who extract as much profit as possible in order to pay down the debt incurred on purchasing these businesses with guaranteed revenue streams. Four Seasons declared bankruptcy just before Covid creating a real crisis in terms of where their residents and staff might go.
In the US eight companies dominate: Brookdale Senior Living, Genesis Healthcare, Golden Living (owned by GGNSC Holdings), and HCR Manor Care, along with Bupa (UK), ExtendiCare (Canada), Korian and Orpea (France).
By 2020, many of these companies were making tens of millions of dollars profit annually and their share price and director compensation was beholden to these profits. The directors had backgrounds in real estate, hospitality, finance, insurance, pharmaceuticals, or other private health service companies (service sector backgrounds). Virtually no-one on any of these boards knew much about care home coalface issues. See Press Progress.
In 2020, the Covid crisis put excess deaths in long term care facilities on the public’s radar, exposing rotting fixtures behind apparently quality facades. See Ryan Tumilty.
Emergency staff (the military in some Canadian cases) put into the facilities found rotting food, insanitary conditions, not enough staff, and arguments between staff that interfered with care. There was a lack of PPE, and staff were so poorly paid that many had to do several jobs, in the process tracking from facility to facility, almost certainly contracting and then spreading the virus.
The response of management to the crises was to offer to:
“implement additional measures, processes and protocols”.
But also noting that:
“Any shortage of qualified personnel and general inflationary pressures may require the company to enhance its pay and benefits package to compete effectively,”
“An increase in labour-related costs or a failure to attract, train and retain qualified and skilled personnel may have a material adverse impact on the business, operating results and financial condition of the company”.
Another more recent response from management and politicians has been to focus on vaccinating care home staff as the answer. This technical solution to a people problem in between the lines blames people whose behaviour has been dictated by poor pay. A solution more appropriate for bodies than for people.
Another longer-term technical solution to Care Home issues mooted has been to introduce robots as companions for older people and others in LTC.
Technical solutions like these mirror Geo-Engineering suggestions as a response to climate change – let’s blot out the sun with reflectors. If believing in technical processes to the point where we allow them to trump judgement calls, as Shipwreck argues, has landed us in the mess we have, then these technical solutions are not the way to go, unless applied within a framework which sees the need to ensure that techniques enhance rather than diminish us.
In terms of Canadian LTC deaths, these have been two-fold greater in for-profit facilities compared with non-profit facilities and four-fold greater than in municipal facilities. The non-profit sector demonstrates that there are other ways to keep costs down than outsourcing staff. If facilities are local, it becomes possible to have family members or others in as volunteers, keeping staff costs down but also having someone able to spot problems and willing to speak up before a problem becomes costly.
On July 21 the Care Quality Commission in England released figures on deaths in Care Homes in England between April 2020 and March 2021 – there were over 39,000 which was close to one third of all deaths in England during this period.
See Worst Affected Care Homes and Nearly 40,000 Care Home Covid Deaths. The CQC give the Breakdown for each Home, while stressing that Deaths are not a good indicator of Care. There are some very bad ‘private’ home figures and equally bad ‘public’ home figures.
A huge factor in this case appears to be have been the Conservative Government with Boris Johnson apparently saying Its only the over 80s who are dying and the Government creating the biggest super-spreader event of all time by dumping thousand of elderly people out of Hospitals and into Residential Facilities where they were being looked after by people so poorly paid they were working in several different facilities. The government now plans on making vaccinations mandatory for Care Home staff.
Before Covid happened, a growing number of people had been drawing attention to the crisis in this sector. The books below outline a crisis as intense as the climate crisis but one receiving less, almost no, attention.
Lynne Segal and Colleagues wrote the Care Manifest0.
Emma Dowling The Care Crisis
Greg Gonsalves and Amy Kapczynski put together The Politics of Care
Madeleine Bunting wrote Labours of Love
These books reflect on a catastrophe unfolding in front of us. Before things became this grim there was Joan Tronto’s Caring Democracy
And perhaps the greatest ever book about Health and Care – Annemarie Mol’s The Logic of Care. The Dutch cover of her book is much better than the English one – once you read the book you realise this cover tells you a lot of what you need to know about Care.
These books tackle the crisis and the meaning of the crisis. Pat Thane has been the person who has done most to put the history of the care sector on the map and the linked need for us to do something rather than just let things drift. She has been a driving force behind many reports on the issues while keeping her name in the background.
This Politics of Care forum was born from a sense there is a connection between what happens in institutional ‘care’, or settings where racism and class bias come into play, and our abilities to help when someone has an adverse effect on a drug.
In all cases there is a growing invisibility, the answer to which is not a wiping of bottoms, but a standing up to something. Wiping bottoms can be slave labour rather than care. And we seem increasingly enslaved.
How do we restore Care? Read Ways you can Save the World and ask yourself if you have the guts to do any of this. If its not scary, and you think it doesn’t take guts, you don’t understand what’s going on?
If you don’t actually do it, do you think you can Care?
If your doctor doesn’t respond by taking your side, do you think s/he can Care?
If the politician you might vote for hasn’t got the guts to call out a ghostwritten literature and lack of access to clinical trial data, is s/he going to perpetuate the system rather than make the kind of difference we need?
(There is at present no politician or party that has stepped up to the plate – not the Labour Party in Britain, or Green parties in Europe, or Sinn Fein who began life as a co-operative movement – we will keep you posted if this changes).
We need to find a way to marry the wonderful analyses of caring cited above, with things that might seem technical and not much to do with care until you realise that there is something badly wrong with techniques like randomized controlled trials and evidence based medicine, when they leave Carers (doctors and nurses) dismissing, even laughing at people who have been made intensely suicidal on antidepressants or had their ability to make love wiped out permanently.
You may know psychologists, social workers and others involved in care, who are happy to ventilate uselessly in the abstract about the problems drugs can cause. You might think they are on the right side, but you won’t know that almost to a person they are scared silly to speak up about the problems they see treatments causing specific people. This may be because they too are trying to understand what is going on and establish where they can really make a difference – but Rome continues to burn while they grapple.
It would be good if anyone reading this can draw the forum and its issues to the attention of as many people as possible – not as an answer to what we should do. but as offering some specific to-dos that might shed some light on what it is we are grappling with – if someone tried them out.