Social care has made regular headlines in the past two years, usually relating to elderly care and its extreme vulnerability—on the part of both staff and residents—to Covid-19. This increased attention was one of the triggers for the Conservative government’s decision in September last year to increase National Insurance, a change nominally intended to prevent those who need care from having to sell their homes to pay for it.
In the sub-sector of care dedicated to those with life-long learning disabilities and developmental conditions such as autism, though, selling one’s home isn’t an option. People who spend their entire lives in need of care don’t have the chance to earn money in the prime of their life to pay for their care when they’re old. Instead, they must rely on the good grace of others: first, in some cases, a parent or guardian, then on the care system itself.
The situation of people in these homes—often sidelined or unmentioned in public conversations around social care more broadly—makes the failures of a private care system run for profit crystal-clear.
A Customer-Regulated Economy?
In the neoliberal imagination, corporations and industries rise and fall on customer demand. If a service or product doesn’t satisfy, the customer will withdraw their business and take it to a competitor. Economist Friedrich Hayek suggested that markets were a kind of mass democracy dictating the value, or lack thereof, of their products and services: in his argument, economic planning could never represent the varied values of the masses without leaving some dissatisfied.
Free markets, according to Hayek, allowed not just people but values to compete freely, meaning products and services that represented the values of the people would ultimately and democratically succeed. ‘If “capitalism” means . . . a competitive system based on free disposal over private property,’ said Hayek, ‘it is far more important to realise that only within this system is democracy possible.’
The reality is that for many members of our society, the power to ‘take their business elsewhere’, and thus to ‘democratically influence’ the quality of their service, is limited, or not an option at all. Residents of care homes for adults with learning disabilities are just one example. These individuals often have limited communication: some are non-verbal, and even if verbal may not have the words to express their dissatisfaction with the care provided.
Legal procedures such as DoLS (Deprivation of Liberty Safeguards) are often in place, nominally for the safety of those whose lack of danger awareness poses a danger to them in the outside world. Those Safeguards mean that far from simply ‘taking their business’ to another residential home, individuals may sometimes be prevented from leaving the building of their own free will altogether.
The freedom of private care companies as private entities does not, in other words, translate to the freedom of their clients. The quality of the service is not democratically regulated by those that use it: in fact, far from increasing the quality of the service provided through competition, the profit motive in care often harms it substantially.
I have worked as a support worker in learning disability-centred social care for over two years now, caring for people with severe learning disabilities—most commonly autism. One thing that often hampers the service is staffing levels, which are themselves a product of low pay.
Low pay means there’s a high staff turnover. Many staff members flee to better-paid jobs within just a few months of employment, and some care workers across the UK have even opted for work in the notorious Amazon warehouses to escape the low pay of the care sector. This turnover in turn impacts not just staff, but residents.
High staff turnover and frequent new faces is bad for the residents I work with for two reasons. First, longer-term staff not only have a greater connection with the residents, but understand their communication needs, routines, triggers, and even favourite TV shows better than new staff. This can reduce behaviours, increase mutual cooperation between staff and residents, and ultimately make for a happier living environment. Second, just seeing familiar faces is often calming to residents, many of whom prefer familiarity to sudden change.
But the staffing problem goes beyond high turnover. When higher-ups feel that a given home can survive on less staff (or that it must, due to last-minute cancellations), they often look to cut down on staffing levels permanently. If a home has run incident-free on what is essentially a skeleton crew, it can seem like a way of cutting back on ‘unnecessary’ costs.
The reality is that while a reduced staffing level may be able to sustain the life of residents on a basic level, it prevents staff from taking those residents out for activities, or cleaning the house properly, or simply giving them the one-to-one time we all need for emotional fulfilment.
Regulatory bodies like the Care Quality Commission (CQC) might do their best to ensure care services are kept up to scratch. But CQC are only offered a partial glimpse of life in the home. True responsibility lies with those who run the homes on a day-to-day basis.
Similarly, the parents and guardians legally responsible for choosing the best service for their son or daughter only receive a partial picture of their experience. They may thoroughly research the home, but without living in it they have no first-hand empirical knowledge of what life there is like. And while staff do their best to update them and communicate with them on the daily lives on their son or daughter, this too can never fully articulate the experience—because even staff do not know the all the emotions of their charges.
Parents understand their children better than anyone. But in cold terms they are only affected by the service as a third party, not as its primary receiver. Neoliberals say a service’s value is determined by the value it is given by those who use it: the residents, here, are the ‘consumers’.
In care, then, the interests of the workers and service users are not pitted against each other: instead, they coalesce. Better pay and less cuts to staffing levels promote a better standard of care for the residents who rely on it. It’s only the profit motive—which provokes cuts to staffing levels and keeps staff on low pay to protect the coffers of owners and shareholders—that prevents these easily solved flaws from being fixed.
The problems outlined here are not limited to the care of adults with learning disabilities. By its very nature, care is a service used by those whose power to ‘bargain’ within the ‘free-market democracy’ espoused by modern capitalists is severely limited. Physical frailty and conditions like dementia have the same effect on elderly care patients. The complex needs and lifelong vulnerability of learning-disabled care residents makes them a special case, but they are by no means an exception.
According to the Nuffield Trust, as of May 2020, around seventy-eight percent of adult residential and nursing care homes in the UK are privately run. This isn’t an inevitable situation—the public sector used to provide much of adult social care, with privatisation taking off significantly in the last forty years thanks to the free-market fanaticism of the Thatcher government. It’s also, for many people, not a desirable situation: according to a survey by the King’s Fund, forty-eight percent of the British public—the biggest segment of those surveyed—believe social care should be funded by the state.
Money is scarce, and subsidies for care homes already take up much of local council budgets. But a state-run care service that removed the profit motive entirely would put the focus centrally on providing the best service possible in a sector that by its nature cannot be regulated by customer demand and the competition to fulfil it.
There is, of course, no guarantee that a nationalised care service would provide flowing cash for better resources or well-paid staff, but the private alternative is fundamentally disempowering to those it pledges to help: put simply, profit should never be a priority when there are lives at stake.