Tanya Serisier investigates the concept of ‘violence’ and considers the insights and limitations...
The crisis of capital itself, the environmental crisis and the housing crisis have all been creeping into everyday conversation, onto the TV and into mainstream print media. But there is another crisis that is still relatively unknown and rarely spoken about. It is decades in the making and threatens the lives and wellbeing of millions. This is the crisis of care homes and elderly care in the UK.
The fastest growing demographic in the UK is the 85s and over. Think about that statistic for just a minute. Medical advances and the welfare state (fast becoming a thing of the past) have given many of us an unprecedented longevity. But despite our desires to live longer we are not prepared for this longevity. In a time of austerity ageing presents working class (and also middle class) people in the UK with a complex set of problems. These problems are also structured by dramatic changes in family life, labour mobility and crucially the increase of female employment. To give just one example: with the cost of living having steadily risen, fuel poverty is at epidemic proportions. Every winter 25,000 elderly people die from the cold: that’s an average of 206 deaths a day.
As the number of elderly continues to rise so too does chronic illness. Dementia affects 850,000 people in the UK and that number is set to reach one million by 2025. Unlike arthritis or heart disease, the symptoms of dementia are not uniform symptoms, making standardisation of care virtually impossible. This requires a drastic change in the way we think about care and treatment. Ultimately we are faced with a health crisis that does not simply affect the state of our bodies, but our state of mind. Although medical progress is being made to slow down the effects of Alzheimer’s (the most common form of dementia, accounting for 62 per cent of those diagnosed) there is no sign of a cure.
These factors mean more and more people are moving into residential or nursing care homes, often under the advice and encouragement of their close family. Elderly people are encouraged to make the move on the basis that there will be better health-care access and support from a community of staff and other residents. Sadly for many this is not what they find.
In the past five years it has become increasingly clear that a tragedy is playing out in care homes across Britain. A simple Google search reveals countless stories of severe neglect, consistent failings to look after the health of care home residents and a disturbing prevalence of physical, verbal and emotional abuse. A month doesn’t go by without a new investigation, video exposé, editorial or reports of older people being failed by the current care system.
Considering the seriousness of this unfolding crisis, we urgently need to get to grips with what actually goes on in care homes and how things have developed the way they have. From the outset it is obvious that it is more complicated than paying lip service to building ‘community’ or increasing ‘respect’. At the core of the problem is a separation between much of the public’s perceptions and the actual experience of those living and working in care homes.
The birth of the care home
Before the emergence of what we now recognise as residential care homes, life, work and care were structured in significantly different ways for the majority of the population. Before the turn of the twentieth century older family members would live in the family home, medical care was severely limited and the extended family was a key institution for providing wellbeing and care in the community.
For the working class, not only was life expectancy much shorter, but death was literally close to home. Most old people died in the family home and the body would usually stay in the home until the funeral. This way of life and death obviously is connected to poverty and there was much unnecessary death and suffering as a result. But at the same time this geographical intimacy of community care was also key to the development of solidarity and transfer of intergenerational knowledge. The cruel aspects of capitalism and its effect on our own wellbeing – particularly at the end of our life and in our death – were right in front of us. Capitalism’s cruelty was evident in the over-worked arthritic limbs, the coughing and laboured breathing of lungs scarred by fumes and chemicals and the overwhelming madness brought on by industrial Britain’s factories.
However, this intimate arrangement, the sheer visibility of it all presents a serious problem for capitalism. In times of war, economic turmoil and industrialisation this proximity created an unsustainable level of grief and trauma in the population. There was an excess of the presence of suffering and death in the home and community. Of the multiple responses to such excess one was anger and also revolt, the refusal of work and the refusal to fight and die in capitalism’s wars.
One of capital’s responses came after the Napoleonic wars of the early nineteenth century, when many men returned home to Britain seriously injured and faced only unemployment and poverty. Capital’s response was an amendment to the Poor Laws which required groupings of parishes in the UK to come together and provide central workhouses for the housing and pacification of these ex-servicemen. Workhouses continued to develop and mutate throughout the 1800s and into the early 1900s. They created a framework for the ‘care’ of the unemployable and undesirable. Over time the population of workhouses became older and fewer and fewer young people entered them. Eventually they were reformed, many becoming specifically designed to house poor elderly people.
To this day there are care homes in the UK on the site of former workhouses. This is one of the first hard truths: it is difficult to talk about care homes being more like ‘home’ or involving a ‘community’ when their history is rooted in institutionalisation and the cruelties of the workhouses.
The pressures that produced changes in how workhouses operated only intensified throughout the twentieth century. After the First and Second World Wars the population of Britain (and the rest of Europe) suffered a collective trauma. An entire generation of men, women and children had not only been exposed to death, but a gross excess of death and suffering. Of course the experience of death is a vital part of any person’s experience of life (and to have a healthy sense of it we usually ritualise and organise it to some extent so that it does not overwhelm or become unbearable). But in the case of the world wars there was no relief from death: not for the soldiers fighting nor for the civilian population. Developments in modern warfare during World War II saw war being waged not just against opposing military forces but also against the civilian population. The bombing of cities and urban areas was now accepted strategy.
With this in mind, the creation of a national health service can be seen, not just as the great success of social democracy fought for by the working class, but also a mechanism which promised a traumatised population relief from the burden of death. In many ways it was a means of pacifying the working class in general, not only ex-servicemen and women.
The NHS now functions as not just a health service but as a mega institution. One that sterilises our public spaces and sanitises the public mind. It guarantees that some of the worst suffering in our society is removed from public view and relieves us of the familial duties of care by employing an army of health workers, experts and physicians to do it for us. The existence of the NHS, along with public and private care homes, allows individuals to opt out of much of the caring work required for elder care. But not having the time (or desire) to care is one of great sources of personal guilt of our time. And guilt is one of the defining feelings of late capitalism. Despite the fact that the medical establishment usually affirms the necessity of such places, the family of the elderly person, usually the son or daughter, in the care home cannot help but feel guilt for leaving their mother or father in institutional care.
The sense of complete abandonment felt by so many older people living in care is still unspoken. The depression and anger that follows when a person feels they have been abandoned by their own flesh and blood can be easily diagnosed as some kind of disorder and treated with a cornucopia of pharmaceuticals. Sons and daughters cannot find the time to visit. They are too busy struggling against their own poverty, poverty of time and attention brought about by the digital age of precarious work. Family networks have broken down, not because we wanted them to or we found a better way, but simply because it has become such a struggle to even find time to care for ourselves. It’s now completely unremarkable for somebody to forget to eat all day because they are so busy rushing between work tasks. Or for people to constantly take caffeine tablets and other stimulants just to deal with lack of sleep, while the accumulation of hours without sleep mounts up in their brain like debt in their bank, increasing the chances of dementia later in life.
Care homes in the UK currently house on average fewer than fifty residents each, but this is gradually changing. In the US larger homes (80+ residents) have been common for quite a while and this is now becoming a trend in the UK, particularly in the private sector. There is also a noticeable push in the media towards the design of entire towns or ‘care communities’ complete with mock 1950s shops and housing for the elderly. The latter option is not necessarily a terrible idea and there are already other forms of specific communities like this not just for the elderly but also for other groups of people who need acute care. However the option of just creating larger and larger care homes seems more likely: it is cheaper and rather than rethinking systems of care it simply requires the scaling up of pre-existing structures.
Most people already know that they don’t want to live in care homes. And the larger they get the worse the issues that currently arise will become. However, there are other possibilities that we can begin to think about and which other people have already began to experiment with. One is the option of creating our own communities again. A couples of years ago there was the news story of a group of women who pooled money to buy homes together in a co-operative fashion with the specific intention of avoiding having to go into care homes. They created their own community where they can collectively look out for each other and help each other as they get older. Their aim was not to create a commune or reject care services but simply to create a situation where they would not be institutionalised as so many people are as they grow older.
With this crisis comes new territories of struggle that concern the principles of freedom and a person’s right to choose how they live and die. The question of death is talked about by the government and the NHS, but in a way that completely removes the question of personal choice. There is no political discussion around death in the broader sense of how we die and how we would like to die. Instead the topic is euthanasia, which forces us to talk about the freedom to die as if it was all about illness, doctor’s opinion versus the patient’s and so on. How would we like to die and what would a progressive system of death look like?
At the moment the crises is one in which we have a huge number of people living with chronic and terminal illnesses but no satisfactory process by which they can make choices about their death. When asked, most people say they would like to die in the place they live but the majority do not: they are forced to die elsewhere. Public opinion also shows a desire for a serious rethinking of euthanasia and assisted suicide in this country. Euthanasia is ultimately framed around the need for somebody to be suffering to legitimise their choice to die, suicide on the other hand is a about somebody having the right the make that choice regardless of illness or suffering.
Alongside the experiences of the elderly people in institutional care, it’s also important to recognise the situation of care workers: workers who provide care for a living. It’s not just that the poor work conditions of care workers in Britain are rarely spoken about, it is that the actual existence of care workers is rarely acknowledged. National Carers Day and the numerous charities focused on care are dominated by a dialogue around unpaid carers and those who care for family members. For the general public and the media those who care without pay for their family relations and love ones represent mythical ideals – they are the dutiful wife, the loving son or daughter and the courageous sibling. The paid care worker on the other hand is viewed with suspicion. Anybody who earns a wage as a carer will be familiar with the awkwardness that follows after admitting this fact to anybody who is not familiar with the care industry.
The ruling class and the right wing media know that the care system in the UK is going to have to grow to deal with the growing ageing population. In simple terms that means an expanding care workforce and larger individual care institutions. But with expansion comes the possibility and also danger of a more easily united and organised workforce that networked neoliberalism has so effectively removed from most other forms of work in the UK.
For care workers to continue to be paid poverty wages, to be overworked and routinely exploited the public must not talk about care workers unless they are talking about ‘bad’ care workers involved in a news story about abuse. This keeps care workers in a state of intense alienation; they are workers who cannot talk to other working class people about the conditions of their work. To complain about anything is to be seen as one of the bad ones, unhappy with their job and therefore as someone who might take that anger out on the people they are supposed to look after. Even day-to-day tasks that a carer might perform are often considered too gross or sad to fit into even serious conversation. This alienation leads to an emptying out of the discussion around care. This dissonance creates a deep sense of anger, mistreatment and helplessness on the part of care workers. And it is a dangerous state of mind to be in when your job involves being so physically close to vulnerable individuals. This is how abuse becomes such a widespread problem.
The fight for care workers starts with actually being able to talk to other people about the specific practical aspects of the work and with the breaking down of the abstract character of care in people’s minds. To be able to clearly and precisely say what it is that we do in a day with all the uncomfortable and gross details left in. Then tell them how much you got paid for it and how many hours a week you do it for just to get by. Only when we collectively reconnect with the reality of care work will carers have the sense of self-respect needed to take action and change these conditions and counter the right-wing narratives that frame how the public view us.
Under current government proposals the Care Quality Commission, an organisation tasked with the inspection of care homes and the regulation of care standards in the UK will be ‘beefed up’ in the same way Ofsted was under New Labour. Just as teachers became the victims of box ticking-style inspections, an almost Stalinist approach towards the use of documentation and paper work, endless assessments and targets, so too will care workers. We need a new organisation that is based around the provision of care for older people, not simply the assessment and judging of those who work in care. An organisation that visits communities to find out what support they need — not just what the staff are doing wrong.
The dismantling of the NHS and public access to health and care services is already well under way. With the massive growth in the older population over the next decade it won’t take long for the private sector to gain a greater control over the care home system in the UK. A completely privatised system with varying levels of cost and corresponding levels of ‘service’ for people and their families is certainly on the horizon. Council run care homes will be the first to become overburdened and reach breaking point, with the right wing press waiting in the wings to capitalise on the most horrific aspects of this crisis. Scandals will follow more scandals.
So this is the crisis of care we face. It is already well under way and in many ways it is too late to prevent all the damage it will cause. But as this crisis develops and deepens there will be moments, struggles and spaces in which there will be chances to change the care system in the UK. The situation is urgent and requires creative and militant strategies. For now there is not much but complex questions and possibilities. The only sure thing is that there will be no victory without care.
postscript: As a care worker I wrote this article as an attempt to start discussion, so that we might start to understand what exactly is going on in UK care system and begin planning things we can do for a better future. I’ve focused on the elderly residential care in particular because that is what I do for work, not because the crisis discussed is limited to that specific area of care.