Carers’ agency: Power, professionalization & decommodification (part II of V)

Summary

This essay is about how care work might come to be professionalized, and how such a process of professionalization might fits with a wider process of social and economic progress in the current UK political context.

Part I was a personal ‘testimony’, written back in the first phase of pandemic, about what it’s like to work in care, and what motivates care workers, along with some early reflections, also written at that time, about what professionalism actually is, the professionalism latent in care work and the barriers faced by care workers when it comes to such a process of professionalization.

This Part II delves further into concepts of power and powerlessness as it relates to careworkers, using the seminal work of radical psychologist David Smail as guide, before moving towards the core argument of the essay: that a way to resolve the powerlessness wrought by decommodification in the care ‘industry’ is to initiate a conscious, reflexive project of professionalization. The argument is underpinned by the insights from a recent Novara Media podcast, in which careworker testimony is balanced with analysis of what decommodification means.

Part III takes a step back, and looks back at the rise and partial fall of nursing as a profession. The central claim here is that, while a nursing elite professionalized quickly in favourable conditions, this professionalization was underpinned by the racial and class prejudices of the time which, because they were not challenged, have led to lack of solidarity within the profession under the more recent managerial assaults, although more recent moves from Nurses United offer promise of a brighter future. The experience of nursing, it is suggested, should inform the development of an inclusive and reflective caring profession.

Part IV grapples with the tasks of professionalization. Seeking to rise to the challenge of the RSA’s Anthony Painter & Joanne Choukier on the need to instil a “sense of agency” for the building of a new convivial future, I set out how ‘progressives’ might help facilitate the agency of careworkers, such that the latter are in a position to carry forward their own professional emancipation. Then, following a ‘pan out’ to review the challenges and opportunities offered by a new phase of Conservatism, in which a new ‘dual polity’ now offers more scope than widely envisaged for the building of alternatives to a commodified economy, I focus in on how careworkers as a profession can lead the development and embedding of new models of care.

Finally, a shorter Part V offers some reflection on how a process of professionalization and decommodification in care might act as a model for wider attempts to develop post-capitalist economy structure and convivial modes of living even within the interstices of the body capital, before a final afterword on my own agency, with the suggestion of a moral imperative to personal activism on the part of those who would have others deploy their agency for the wider good.

Part II Power and professionalization

Seven months on

I wrote Part I back in May. Seven months on, the piece comes over as melodramatic, but it is a product of its time. Back then when the virus was new and the number of care and health workers dying was rising rapidly, it seemed appropriate to write a testimony piece almost as testament; there’s an almost Villonesque feel to it, as I offer up a belated but sincere enough reckoning of the goodness of others as a way to offset my own failings.

Those were the days, now returned with a vengeance but affectively somewhat diluted by experience and a certain weariness with it all, when for many of us conscious nonchalance masked an ever-present anxiety, when the shift-arrival question of ‘any test back yet?’ brought a quiet sigh of relief before proper work began.

Still, Villonesque melodrama or not, that bike ride afforded me an opportunity to reflect on what caring really is, and I’m glad I wrote it; even offering it up to a mainstream news outlet for publication proved to be mildly informative, in that the editing process it went through, with any trace of a more radical political interpretation of what I sought to pay witness duly excised, seemed to confirm my suspicion that, while careworkers as humble heroes were wholesome media fodder, anything that smacked of careworkers as politicized agents of change was certainly not what was wanted.

So it’s with this personal background that, over the last seven months, I’ve read and listen to what thinkers and activist on the left and centre left have to say about carers and the nature of caring, the problems with the care ‘industry’ and what might be done about it. In the last few weeks, in particular, there’s been a spate of interesting commentary that’s been bouncing around in my head, as I’ve struggled to formulate a coherent take of my own, and in the context of which I now seek to bring some order to my thoughts.

First, and perhaps most immediately inspiring of confidence in my own uncertain insights, have been the articles by Madeleine Bunting about her new book ‘Labours of Love’.

As far as I can tell from the articles and before reading the book itself — one of the consequences of care worker pay is that the monthly book-buying budget is not as large as I’d like — Madeleine‘s care worker interviewees express the same kind of resilient acceptance of the cards they have been dealt in life, the view that it’s just not worth complaining about the overall situation, that it’s best to make the best of it.

There’s a bit more to it than that, though.

The question of agency

The more I think about the way careworkers tend to deal with their lot, the more I am reminded of the lives so sensitively depicted in radical psychologist David Smail’s seminal ‘The Origins of Unhappiness’. These are lives, mostly of women, lived under conditions of enduring powerlessness, and in which ‘power horizons’ are restricted to the most ‘proximal ‘ ones — abusive employers, violent father then abusive husbands. There is just no scope in these women’s lives, in spite of their sharp intelligence, for them even to see, let alone be part of a challenge to, the more ‘distal’ structural powers that have actually created and maintained the conditions in which the more proximal powers impose the hardship and suffering they endure.

This may sound like an overdramatic interpretation of Madeleine Bunting’s interviews, and of my experiences of care work. Smail’s work is, however sociological and political, rooted in clinical work with people who have been forced through whatever grey area exists between ‘a tough life’ and ‘true suffering’ (those who suggest no such dividing line really exists talk of ‘shit life syndrome’), and one of the things that marks the careworker community out from others that endure tough lives is that good-humoured resilience and solidarity to which I have tried to bear witness.

Nevertheless, I think it’s useful, if we are to make material progress, to view the experience of being a careworker through the lens of proximal and distal powers; as I have suggested above, and as I shall pursue further below, making material progress in the care sector will depend, to a significant extent, on the agency of careworkers themselves, and ‘agency’ is another way of saying ‘having power to change things’

In care work , lack of power — to slow down the pace so you can get the work done properly, to make suggestions about how things can get done, to say no to another shift because you’re just exhausted and need a day off but also really need the money — can have insidious side effects. From time to time, the need to exert some power of some kind, can display itself as pettiness. This pettiness might be about a new co-worker or an agency worker who does not get the routine quickly enough, or who forgets to load the trolley with wipes, or who hasn’t forgotten but who has not been given the code to the store room; or it might be about a resident or client who, it becomes construed, is not being as helpful as she might be at dressing time or, a step on towards abuse, is being deliberately obstructive to getting “the job” done.

Such pettiness is most often suppressed with a sigh or a grimace before the good-humoured resilience reasserts itself, but every now and then it develops into real disrespect and emotional harm, and it will exist in just about any current care setting. What makes a care setting good or less good in the current ‘industry’ is the extent to which these displays of frustration at powerlessness become normalized. The dynamics of this are complex, but I suspect have much less to do with management discipline than about relationships within teams and the leads that are given by longer serving staff.

At an individual level, though, this is all about agency. Where a careworker has no way of expressing agency positively in the face of even proximal power, then it can come to be expressed negatively towards co-workers and towards those cared for. It’s the same dynamic, over a shift-long time frame, as we see in generational cycles of domestic abuse and neglect.

The challenge then, if we really want to improve care work, for carers and for those cared for, is to facilitate a sense of positive agency.

From survival mode to professional autonomy

It’s important not to get ahead of myself. Before moving onto idea about how we do try to facilitate this agency, I want to move on from my own, inevitably limited testimony, to what we know of the realities of social care, including the lived experience of carers, and , and the frameworks we currently use to assess those realities.

Let me start with an excellent recent Novara Media podcast, ‘Tired from the Heart’, which carries the voices of a variety of careworkers, some intelligent rumination on the nature of care, along with an acknowledgment that simply introducing a National Care Service, as Labour proposed in its 2019 manifesto, will be insufficient to grapple with the need to redress power imbalance between those organizing care, those delivering it, and those in receipt of it.

At the heart of the podcast is a useful ‘explainer’ from presenter James Butler, who summarizes for a non-academic audience the concept of ‘commodification’, and applies it to the care ‘industry’, setting out how the human relationship inherent to one person caring for another, and looking after their range of needs, has been reduced to a transaction of labour time, in a way that is dehumanizing/alienating for both sides of the new transaction, and leaves nobody satisfied except the beneficiaries of that shift to capitalist exploitation. It is unusual to hear or read such a succinet exposition.

But the podcast finishes — I suspect quite deliberately — with a simple statement from a careworker about the need for the work she does to be properly recognized and paid; one interviewer makes the point that, from all that she has heard, one thing that strikes her is the extent to which carers operate in “survival mode”. Anyone, like me, who has quietly listened to a careworker using her precious fifteen minute break to go on the phone to try and resolve short term debt issues, understands that; there is just no time or space to wonder about what has been lost in terms of human relationships.

The same kind of narrative flow appears in Ndella Diouf Paye’s personal account for Red Pepper magazine of her work as a peripatetic careworker in London. Ndella talks primarily of the arduous terms and conditions imposed on her by whatever agency she grafts for, but mid-article she recognizes the absurdity of having to remain at someone’s residence even beyond the period that someone might want her there, because the agency system requires that all her time be accounted for — whether that be part of the ‘discipline’ they feel they need to exert on their workers, or because they in turn need to have a record of labour time to attach to their invoices as part of the complex commissioning process.

As with Novara’s testimony, what you come away with is the sense of frustration at careworkers’ lack of power to give the care they want to give, but alongside that the reality that nothing is going to change before basic terms and conditions of care work are improved.

But this kind of careworker-led statement of frustration, in which hope for a better future is also expressed, and facilitated by generous media outlets, seems relatively rare when it comes to the supposedly broader “what should we do about social care?” question.

More commonly, progressive media and policy organizations adopt a more directly structural analysis, devoid of any real feel for how recommended change might impact on those who currently work in care, or of what support might be needed from them to embed the kind of change they recommend.

The recent UK/US collectively authored Care Manifesto, for example, summarizes the agenda thus:

[F]irst, we urgently need to push back against the reckless and destructive marketization of all our care sectors and infrastructures; second, we have to start building more caring, equitable and eco-socialists alternatives to capitalist markets. (p.77)

As a general socialist feminist aspiration, this is fine, and it is hard to disagree with the broad objectives set out in the manifesto. But nor does it take us very far on the road to achieving those objectives.

For me, the key gap in the manifesto is any real analysis of how the current workforce fits in, if indeed it fits in at all; in the end, whether care is marketized are not, there are a set of physical and emotional caring actions that need to be carried out, or the concept of care would not exist at all, and “carers” — whether we use that term or not — will continue to exist, short of any major collapse in civilization and a total abandonment of the idea that the sick and disabled should not just be allowed to die.

The Gordian knot of care

There is, it seems to me, a Gordian knot of, in one thread powerless agency and on the other a structure for improved care that cannot be built without that power, which the Care Manifesto does not manage, or seek to cut through (at least in a UK context).

On the one hand, new models of care cannot be embedded without the everyday support and energy of those who currently make up the workforce. On the other hand, we can’t expect carers to become newly empowered agents in a radical new system of care co-production, without also addressing the immediate exploitations of care sector decommodifcation.

In particular, the failure of Labour to win the General Election in 2019 means that any notion of drawing care workers into an enlarged public sector, and delivering more than the minimum wage is gone for now, and the very vulnerability of the workforce means that collective industrial action against the larger employers is, for now also, unlikely (and of course, as with any public service the ethics of removing that service are always difficult when there is no longer and difference between ‘emergency cover’ and ‘normal cover’).

And as a result of this failure to cut through that Gordian knot, what we’re starting to see if a less-than-helpful dividing of energies, between those focused on the important but self-limiting goal of improving terms of conditions within a marketized sector, and those calling for radical change to what care looks and feels like, but without the institutional power to effect that change, short of limited experimentation.

The trade unions lead on the former, with a central argument on a raise in the hourly wage from £8.72 to £9.50. Campaigning journalists and policy organizations lead on the latter, with the central argument for a complete revolution in the ownership of the care industry and the way it is funded.

And frankly, they’re not talking to each other very much.

This may seem a downbeat assessment. I will admit that when I look across the range of policy solutions to the ‘social care’ problem, I do feel a sense of frustration about how an admirable desire to form new models of more respectful, less transactional care, and the creativity with which they have been developed and even piloted, is often not matched with a realism about our starting point. It seems to me, therefore, that any programme for change which does not take explicit account of both the current exploitative marketization of careworkers, and their potential to be agents of change, positions careworkers as a part of the structural problem. In turn, any programme that regards, even by omission, careworkers as part of the problem to be resolved, rather than part of the solution, is likely itself to become part of the structural problem itself.

Likewise, while we can’t expect carers to become newly empowered agents of their own in a radical new system of care co-production, without also addressing the immediate exploitations of care sector decommodifcation, limiting aspirations to a small improvement in pay won’t get us far in the long term; a 10% pay rise is eroded quickly enough, and doesn’t change the power dynamics.

There is, though, a way to cut through the Gordian knot, in a way which can draw unions and campaign organization together, and remove the tension between long and short term goals.

This way, as I’ve suggested in Part I, is through a facilitated professionalization of the carework sector.

Professionalism and decommodification

My core argument for putting the idea of professionalization at the heart of a common agenda for care is simple, and reflects what I have said above.

Being a professional is, more than anything, about claiming power over your own labour time, in the interest of the person whose needs you are looking to meet through your skills and expertise.

If you make a claim on your labour time, then you’re necessarily making a stand against the commodification of that time, because commodification is the appropriation of your time in the interest of exchange value.

Professionalization, through the setting of autonomous standards of performance in the interest of others, and the consequent claim on whatever time is needed to meet those standards, is therefore the most appropriate basis for careworkers, with the appropriate support, to become THE key agent for change in the removal of care from a deleterious marketization.

This is the (Habermasan) ideal [1], and we are a long way from the ideal.

In the end, though, we have to start what strengths we’ve got within a thoroughly commodified care sector, and those strengths are in those people who, to the extent they can, resist the impacts of commodification by holding on to their humanity.

That is why I started this essay with my testimony, in which I referred (long before I’d thought through what I might write here) to the ‘quiet’ professionalism of careworkers and which, in spite of everything, still largely holds true: the unifying idea that we “give a shit” about those we care for.

This is an affective professionalism which can retain a distinct religiosity (and there are many carers, as Novara’s podcast also sets out, for whom faith does remain a driving force). It’s an affective professionalism which, in most care settings at least, means that there is no descent into the abuse of power over the vulnerable, however great may be temptation of the devil-that-is-proximal power.

It’s also a professionalism which, for now, dare not speak its name, for fear of ridicule. The “I’m just a carer” idea runs strong amongst carers.

The challenge, for those who want to develop a better care system overall, is to promote the agency of carers as they start to speak their professionalism out loud, so that over time that professionalism starts to become publicly recognized to the point where we can say explicitly that the care profession exists.

By professionalism in this second, publicly acknowledged sense, I mean (as Michael Lipsky meant) the autonomy of the professional group to set and maintain standards of work performance, and where necessary, to exclude members of the group who do not meet standards.

At the moment, carers do not enjoy this autonomy. They operate under instruction, according to a routine laid down from them by a management claiming its own autonomy.

With a public acknowledgment of being a profession, comes autonomy, and with autonomy comes a receding of the most proximal power — the power of routinized, alienating, tasks imposed. That receding of proximal power, in Smail’s terms, leads to greater scope to view and challenge more distal powers, including those powers that impinge on the freedom of the one cared for to live the life they choose.

And acknowledging professionalism opens the way, via enhanced agency, to a questioning of why there are never enough wet wipes for the job in hand, why Mrs Smith is having to wait so long for the bed repair — all those things that so far have been tolerated as one those things you (and everyone in your care) just has to put up with, because that’s the way it is.

People thrive on agency, especially the agency they acquire for themselves. Before you know where you are, you’re questioning whether there’s really a need to write down the same thing every hour, just so that the managers have proof they need for when the Care Quality Commission calls, when the real proof is actually in the care outcome.

And beyond that?

Well, a set of empowered professionals, well paid enough to take notice of the wider structures within which they deploy their somewhat less exploited labour time, might just be the kind of agents needed to come together in cooperative efforts to break free of the current care model altogether.

How this might all come together is the subject of the rest of the essay.

Note to Part II

[1] For fear of further complicating an already somewhat complex essay structure, I have avoided in the main text any longer reference to Habermas.

However, not least since it will be the concept that unifies the structure of the book I am grappling with, and into which the professionalism and power themes will be integrated, I will add here a few words about how this ideal of careworker professionalization, towards which we might work while acknowledging that total fulfilment of the idea may be beyond us, might be best seen in Habermasian terms.

Two linked Habermasian concepts are important here: the communicative ideal of a lifeworld unfettered by systems of capital, and social progress towards the ideal via a willing validation of suspended disbelief. Chapter 2 of my longer essay sets out these concepts, as they might be applied to our current political juncture, in more detail, but in terms of the professionalization of care work we might say the following:

a) The professionalization of care work might be seen as the seeking, and attainment of public validation of a mission to draw what has been marketized back into the ‘lifeworld’. That is, careworkers as new professionals are stating to the public that they will no longer let the transactional processes of capitalism, which reduce their time to units and alienate from their work, get in the way of properly human interaction with those they care for. In turn, the wider public takes the new profession at its word.

b) But validation of an ideal like this is always balanced by what Habermas calls ‘facticity’. The public knows that not everything will be perfect, and that the perfect profession, in which communication is unfettered by bureaucratic systems, is an idealization. Nevertheless, this facticity does not overly impede improvement, because all sides have decided that the tension between ideal and fact is a healthy one, conducive to improvement over time; of course ongoing trust is not guaranteed, and that the stretch of facticity is finite, but as a normative process of social progress, such an arrangement of (seemingly) unconditional validation is preferable to the restrictive managerialism we now see within care.

For myself, I prefer the Habermasian language of Habermas if lifeworld, validation and truthfulness to the Marxian language of commodification, because it stresses the prospects for human relations important to respectful care co-production. As such it is more suited to a revitalized conception of professionalization, which is the heart of the argument in this essay.