Amid many accounts of Britain’s care crisis, the vision of the ‘caring economy’ presented by Emma Dowling or The Care Collective strikes an inspiring note. Could care become a collective responsibility of whole communities, uniting service users, their families, friends, neighbours and volunteers in a shared effort to provide quality, compassionate care? A drive based on both expansion of unpaid support and effective political pressure for a far better, well-funded professional service?
The pay crisis: Will the Casey Commission make a difference?
The Casey Commission on social care offers a challenge to put some flesh on the bones of this vision. It is mandated to address low pay for care workers, which clearly affects recruitment and quality. Whatever it recommends, will the government provide the 18 per cent pay rise needed? In 2024, the Home Care Association recommended at least £15 per hour to fill around 130,000 vacancies across England. In practice, the median wage was then around £12.79, little above the legal minimum of £12.21. My recent book, Radical Approaches to the Care Crisis, estimates that a huge budget, up to double current council spending, may be needed to tackle better pay and unmet need. The Commission’s terms of reference focus on paid-for (formal) care and preventive measures. But unpaid carers, who provide the bulk of support to both older and younger people needing care, must not be forgotten. Unpaid caring for over 50 hours per week is now the lot of 1.5 million people. Full-time carers can claim Carers’ Allowance only if their relative receives PIP (Personal Independence Payment). But if this autumn’s Timms Review reduces the number of people who can claim PIP, their carers will lose out too. Carers anyway,y deserve much better financial support than the flawed Carers’ Allowance with its ‘cliff-edge’ earnings limit. They also need more generous job leave than the current legal entitlement of five days, unpaid.
A shrinking support base: Who will provide future care?
A shortage of family carers is forecast over the next decade as both the very old and disabled people of working age rise as a share of the adult population. Families are shrinking and becoming more geographically dispersed. Around ten per cent of over-65s have neither a partner nor children to help them. They, and younger disabled people living alone, need friends to replace family. Friends can do things paid carers rarely do, especially in this period of ‘high needs only’ rationing: home cooking; helping people go out; supporting bureaucratic battles with landlords, repairers and care providers; shopping; little house and garden jobs. How can we revive the neighbourly support culture of the mutual aid groups that thrived in the pandemic period?
Aisha’s story: When the care system breaks down
Since an accident last year left her with paralysis of her legs and one arm, my friend – let’s call her Aisha – relies heavily on her friends for all but basic personal care. She’s a migrant, has been working here for 30 years, but without a partner, children or other UK-based relatives. Agency care workers come four times a day to hoist her between bed or chair and bathroom, help her wash, dress and serve her meals. She can go out in her electric wheelchair, but only if two carers hoist her into and out of it. There are so many things that their highly rationed time can rarely fit in: organising and cleaning the fridge; tidying clothes; washing floors. Carers from two agencies over several months said their time allowance for meal preparation allowed merely for heating and serving food, not ‘cooking’. Main meals should be in a ready-to-heat box, which is hard for someone on benefits to afford. As a diabetic, Aisha longs for simple fresh vegetables, but frequently the carers said they had no time to boil them or chop salad.
Aisha has seen the worst end of the quality spectrum in the English care industry, epitomising the crisis the Casey Commission needs to tackle. With her first two agencies, staff changed every week or two; Aisha had to brief each new person on her needs and limitations. Carer punctuality is crucial to her keeping appointments, or ‘having a life’ at lunch clubs, social events or classes. But carers often arrived late, sometimes refusing to stay long enough to deal with anything but toilet needs. They skimped on their allocated time because they were ‘too tired’ or rushing to the next client. One described starting at 7.30 am and ending 12 hours later, supporting four different clients several miles apart. She said she was only paid for eight hours. According to the trade union UNISON, three-quarters of care workers are not paid for travel time.
A third agency recently works better for Aisha. She now gets some help with cooking, working with the carers from her wheelchair. They stay their promised hours; she is getting to know a long-term team of carers who are kind and more reliable. Perhaps significantly, their employer is a charity. Corporate agencies, driving their low-paid staff as hard as possible to maximise profits, seem much less likely to deliver quality care than non-profits.
A better model: Non-profits, cooperatives and community-led care
Care cooperatives such as Equal Care put the service user firmly in charge of the ‘care team’. This reflects the much-admired Burtzoorg model, which is based on careful coordination between paid and unpaid carers and the client, drawing out service users’ strengths through flexible identification of what support they really need. The carer’s job is defined by desired outcomes, rather than a pre-determined task list. This often reduces the scale of the care package required. Another promising alternative to for-profit agencies is microenterprise. Self-employed individuals or small teams of carers have been shown to provide better continuity and flexibility of care than typical commercial agencies, co-producing care with clients, family carers and volunteers.
We need to grow a not-for-profit care sector freed from shareholder pressures, in which the values of compassion and user-controlled flexibility can flourish, supported by volunteers and community organisations.
Anne Gray, now retired from London South Bank University, has authored academic papers on older people’s social capital, sheltered housing and loneliness. She is also a campaigning activist for better services for seniors.
Radical Approaches to the Care Crisis by Anne Gray is available on Bristol University Press for £27.99 here.
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