Carers’ Agency: Power and professionalisation

A year into the pandemic, Renewal is publishing a series of essays by careworker Paul Cotterill on power, professionalisation and decommodification in care work.

This first essay looks at power and powerlessness in relation to careworkers, moving towards a core argument of this series: that a way to resolve the powerlessness wrought by decommodification in the care ‘industry’ is to initiate a conscious, reflexive project of professionalisation. 

Back in May 2020, I wrote a personal testimony of my experiences as a careworker in the early days of the pandemic. Back then, when the virus was new and the number of care and health workers dying was rising rapidly, it seemed appropriate to write that piece almost as testament. I’m glad I wrote it, and I even offered it to a mainstream news outlet for publication. That proved to be informative, in that the editing process it went through, with any trace of a more radical political interpretation excised, seemed to confirm my suspicion that, while careworkers as humble heroes were wholesome media fodder, anything that smacked of careworkers as politicised agents of change was certainly not what was wanted.

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.

So it’s with this personal background that, over the last year, I’ve read and listened to what thinkers and activists 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. 

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’.1   

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, fathers and 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.

I think it’s useful to view the experience of being a careworker through the lens of proximal and distal powers; 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 – 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 is felt, 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 normalised.  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 on to ideas about how we 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 the frameworks we currently use to assess those realities.

Let’s start with an excellent Novara Media podcast, 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 imbalances 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 summarises 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 succinct exposition.

But the podcast finishes – I suspect deliberately – with a simple statement from a careworker about the need for the work she does to be properly recognised 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 recognises 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 organisations 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, summarises the agenda thus

[F]irst, we urgently need to push back against the reckless and destructive marketisation of all our care sectors and infrastructures; second, we have to start building more caring, equitable and ecosocialist alternatives to capitalist markets.2

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 it does not 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 marketised or 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 civilisation 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 powerless agency and a structure for improved care that cannot be built without 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 any 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 is a less-than-helpful dividing of energies, between those focused on the important but self-limiting goal of improving terms and conditions within a marketised 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 such as Ian Birrell and policy organisations like Social Care Future 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 marketisation 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 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 organisation together, and remove the tension between long and short term goals.  

This way is through a facilitated professionalisation of the carework sector.

Professionalism and decommodification

My core argument for putting the idea of professionalisation at the heart of a common agenda for care is simple.

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.

Professionalisation, 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 marketisation.

This is the ideal, and we are a long way from the ideal.

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

We see this in the ‘quiet’ professionalism of careworkers and 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 the 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 recognised to the point where we can say explicitly that the care profession exists.  

By professionalism in this second, publicly acknowledged sense, I mean 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 routinised, 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 of 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 given.

And beyond that?  

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.  

Paul Cotterill works in care and lives in Lancashire.  He is treasurer to the New Economy Organisers Network (NEON) and founder member of West Lancashire Resilience Society.

[1] Smail, D (1993) The Origins of Unhappiness: A New Understanding of Personal Distress, Harper Collins.

[2] The Care Collective (2020) The Care Manifesto; The Politics of Independence, Verso, p.77.