Care is about looking after others. All services (cooking, cleaning, nursing, etc.) involve care – in the sense that providing services to others requires paying attention to them. According to Pascale Molinier, providing care involves providing an adequate response to the needs of others. Perceptual skills are integral to this work, as it is based on a proactive process (requiring the sustained attention needed to see or hear another) focussed on finding solutions adapted to the needs of the person in question. Indeed, the need is not always clearly expressed. “Care” therefore requires paying attention in order to interpret this need. It may be defined as the “art of adapting to situations that are always specific.” [1]

Drawing on empirical exploratory studies on care home staff in Wallonia and Brussels, this article will seek to summarise the main impacts of privatisation [2] on this definition of care work.

The studies were carried out against the background of a pandemic that devastated the care home sector [3]. Hospitals made the decision to filter patients, turning away care home residents [4]. Consequently, as of 1 August 2021, 74% of residents in care homes have died from Covid-19 since the beginning of the outbreak [5]. There was a media scandal in response to these decisions in the first wave of the pandemic, and regional authorities had to speak out publicly against them. However, we can now deduce from the figures that most residents who died from Covid-19 were not transferred to hospital [6]. Care homes were forced to carry out the role of hospitals despite being ill-equipped for such a role, lacking the required equipment, human resources and expertise. During the first lockdown, several factors exacerbated this situation. These included GPs having limited access to care homes, rationalisation policies in care homes, inadequate public funding and the failure of the government to provide adequate guidelines, such as the recommendation that surgical masks should only be worn by “patients with suspected or confirmed Covid-19 [7].”

The fatal impact of Covid-19, exacerbated by the poor management of the pandemic, has highlighted the structural dysfunctions of the healthcare model as well as of the working conditions in the care home sectir characterised by insecure and flexible contracts, understaffed homes, overworked staff and a gradual reduction in funding. Most workers interviewed, irrespective of whether they work for public, non-profit or for-profit operators, refer to an ongoing deterioration in working conditions, increased focus on new public management methods and inadequate government funding.

Care work in the for-profit sector

Profit-driven care homes are focussed on forms of management that aim to cut costs and maximise profits. Lean management, specific to the productive sector, is becoming the norm in the care sector. Inspired by Toyota’s production system, this way of managing and organising the workplace aims to reduce costs by producing only enough to meet the demand. Since the 1990s, it has become ubiquitous in all sectors of the economy. Its leitmotif is “performance”, aiming primarily to cut costs, increase productivity and increase labour. Under this management system, greater performance can be achieved by “eliminating waste”. This requires: increased production (produce more in less time), elimination of “downtime” (management concept that refers to the time when workers are not producing goods or services) and “zero inventory”. In the care sector, the latter means not having the equipment required to deal with a pandemic, or closure of care homes, or reducing accommodation capacity when the occupancy rate is too low for the “operation to be profitable”. Continuing on in the vein of Taylorism [8] , with an emphasis on rationalising and standardising tasks, lean management also seeks to reduce costs and increase individual responsibility of workers for company results.

This system of management seems to be at the root of difficulties faced by care home workers. The great majority of workers interviewed refer to budget constraints and shortage of resources, preventing them from being able to do their work effectively. They mention the pressure to constantly revise budgets downwards, even at the height of the pandemic, when the management team was trying to cut costs on protective equipment and cleaning products. These cuts have as much impact on working conditions as they do on the quality of care, and often impact upon the health of workers and residents. For example, a nurse working in a care home owned by a transnational corporation gave the following explanation in regards to a shortage of slide sheets in good condition:

• “We’ve been using them for years. They’re small sheets that you use to move the person. So they’re extremely important to move the person concerned, ensure they’re in a comfortable position and protect the nurse and caregiver’s back... Now, if you want a slide sheet, you have to ask the manager, and the department head has to look into it.”

An account given by an occupational therapist from another care home, where the supply of slide sheets was not an issue, explains the typical process that leads to such a shortage.

• “There was a rumour going around our care home that they were going to remove the slide sheets, the boss told me that there were too many slide sheets being used, and that we couldn’t use this many because it was very expensive (…) So I talked with our boss and he said that he wasn’t going to remove the slide sheets. But he was going to talk with the head nurses and quality control officers about doing a case-by-case assessment to evaluate each resident and see whether they needed a slide sheet or not.”

In addition to constantly seeking to reduce equipment costs, institutions are also looking for any opportunity to cut staff “costs”. Understaffed care homes have become standard both in for-profit homes and in public and non-profit institutions. This is primarily due to the fact that assumptions on required staff numbers, on which government subsidies are based, are inadequate. In 2019, in Wallonia, public care homes employed an average of 43% more staff than that required. This figure falls to 32 % in the non-profit sector and 21% in the for-profit sector [9]. These figures confirm the issues noted by the workers interviewed, and serve to provide an overview of the staffing situation in the respective sectors. We can see that for-profit homes, which sell services and therefore have a bigger profit margin, invest the least in staff. These are the institutions that are driving a productivity-focussed, fast-paced work environment, preventing workers from being able to care for people properly, as illustrated by the following account given by a kitchen assistant working in a care home owned by a transnational corporation:

• “...I work in the kitchen and when you’ve only three nursing assistants for forty people, I sometimes help them distribute the food trays… and, unfortunately, sometimes I do things that aren’t part of my job: I feed the residents… there are two in particular that really need help eating… They need to be fed, but it’s very slow, and it takes time, they need time… [One of them] has trouble expressing herself and she needs help… I know that if I help her, she will eat all the food on her plate... really, I make sure she eats every last bit… So when, sadly, I sometimes hear other nursing assistants say, “that woman doesn’t eat enough”… I don’t buy it. All she needs is a bit of time! She actually eats really well… What I do for her is, I dip her toast into her coffee, adding sugar and milk, she eats up all her desert, and I give her a glass of water to finish with and she’s all good.”

This account highlights the gaps that workers are routinely faced with: first, the gap between the prescribed work and the real work, and second, the gap between the work done and the work that can’t be completed, in other words, the "impeded activity” [10]. It illustrates the extent to which it is impossible to standardise the time required in care work, defined as work which involves providing an adequate response to the needs of others, according to specific circumstances. The allocated time for feeding residents does not always allow for the fact that the time it takes for one resident to eat may be very different to another. If this kitchen assistant manages to interpret that the resident eats the toast when she is “given the time to do so”, taking the time to dip the toast “in coffee”, and “add sugar and milk”, this is primarily because she does this work outside of the allocated time given for this task (with the assumption that the task can be completed within a specific amount of time). She gives up her break time in order to interpret a need which, as Pascale Molinier points out, is often “silent”. Interpreting a need involves taking one’s time, observing, “walking around [11].” The time required to interpret and carry out a task doesn’t fit into the standard rules because it varies depending on the situation and needs of the person being cared for. However, management-based reasoning that seeks to rationalise care work according to a “productivist” model of labour, is preventing care workers from taking the time they need to do their work properly. Such a model involves standardising specific tasks as well as standardising the time required to complete these tasks, based on calculations that are being constantly pushed lower. And yet if there is one key feature of care work, it is that it is “immeasurable work”. This concept, coined by the psychoanalyst Jean Oury, and which refers to the notion developed by Karl Marx (in the Grundrisse), denotes living work which is neither measurable nor tangible and which is therefore immeasurable. The professionalisation of care implies a market valuation, which entails an attempt to standardise activities (work pace and results) which are, by definition, immeasurable.

In addition to staffing shortages and overworked staff, there is the more structural issue of work practices based on job fragmentation and the differentiation of qualifications. Specific to Taylorism, this labour model is focussed on breaking up jobs into specialised tasks. Dividing up the work required for one dependent person among a myriad of workers means that not only is there limited closeness between workers and residents, but also limited closeness between the workers themselves, as a nursing assistant at a home owned by a transnational corporation explains:

• “Where I work, it’s zero communication, all the jobs are broken down into tasks and everyone just does their thing on their own. Um, yeah, everyone knows what they have to do, they’ve got their list and we don’t communicate. The head nurse never comes up to see how we’re doing, the managers don’t either, they stay in their office and, yeah, everyone does what they want, that’s how it is. The residents never speak out because they’re scared. If they complain, there’ll be reprisals. Do you think this is normal?”

Breaking up the tasks involved in care work and intensifying work schedules is to disregard an essential aspect of what this work is. It creates workers that have an individualised approach to work, and means they are unable to “walk around”, “take a break” or talk, preventing workers from being able to share important information, knowledge, know-how and experiences. This makes it difficult to build a shared vision, which consequently impacts upon the standard of care, and also creates a breeding ground for the mistreatment of residents as well as conflicts between workers.

These numerous constraints are destroying one of the fundamental aspects of care work: the relational element. This often results in workers losing sight of the meaning of their work, or even suddenly deciding to opt for a different career path. The following discussion is between the regional secretary of a trade union, who explains some of the organisational factors that has resulted in such a situation, and union representatives, who talk about institutional abuse on or by staff:

• “When you choose a career as a carer or nurse, kitchen assistant or cleaner in a care home, deciding to work in a care home is not a decision that’s made lightly (…), you do it because you want to help people.... But when everything has to be done at breakneck speed, and you feel like you’re being squeezed dry, this job begins to lose its meaning because you’re no longer able to offer high-quality care to people and really be at someone’s bedside and take time with them... As institutions are understaffed, the social and human aspect of the job is becoming extremely rare, and this is why there are a lot of people who, at some point, say … Well, if this is how it is, I’m out of here.”
  (Regional secretary)

• “With the schedules they give us, most jobs are part time. There are moments, several days during the week, between midday and 4 a.m., when there’s no one... There’s no one to help residents go to the toilet.”
  (Nursing assistant)

• “We’re forced to wash the residents like it’s the car wash, because, yes, we need to talk about abuse, I can’t accept that this is what we’ve come to. We have to wash them without hardly talking to them, we have to treat them like shit because everything has to be done quickly and we’ve only got ten minutes to clear away lunch! It’s getting worse and worse... We’re going crazy!! There are only two of us for each floor!”
  (Nursing assistant)

Among the sector’s main issues, insecure employment conditions and task specialisation are repeatedly mentioned: these include part time hours, unpaid overtime, having to hold down several different jobs, temporary contracts, unpaid work and subcontracting. Although most workers have part-time contracts, according to a regional trade union secretary, sometimes they don’t even get these. Employers sometimes use abusive methods which involve integrating overtime hours into backdated contracts, so as to avoid updating them. Flexible work contracts also suit employers, as this is a way for them to use controlling methods to silence workers who protest against excessive working hours, another common practice in the sector.

New Public Management: care work in the public and non-profit sector

The increasing number of for-profit institutions in the industry, the funding shortages for public and non-profit care homes, as well as reforms such as the reform on integrating non-profit organisations into the Code on Companies and Associations (which allows them to carry out for-profit activities), and the Walloon Decree of 14 February 2019 (encouraging collaboration between the public and private sector), are all creating prime conditions for the commodification of the care industry, compromising high-quality care and decent working conditions [12]. This process is being accelerated in a neoliberal context where there is increasing competition between for-profit, public and non-profit institutions, pushing the latter towards New Public Management (NPM) work practices.

NPM involves managing public and non-market services in the same way as private companies, using a “cost rationalisation” approach and encouraging competition between private and public institutions. According to this management model, which originated in the industrial sector, competition encourages institutions to operate more “efficiently”. However, as we have seen, the notion of efficiency in the production sector is incompatible with that of care, which requires relational and contextual skills and which are, by definition, anti-productive. From this point of view, “efficiency” really only means cutting costs; in other words, understaffing institutions, overworking staff and reducing investments in equipment and infrastructure.

In this context, workers in the non-profit and public sector are raising the same issues as those noted by workers in the for-profit sector, even if these are still to varying degrees. Thus, during a private sector trade union meeting (concerning for-profit and non-profit homes), a nursing assistant from a non-profit nursing home highlighted that the working conditions at her non-profit care home were not significantly different from those described by her fellow workers in the for-profit sector. She also pointed out that the business plan being implemented was similar and required workers to hierarchise care in order to attract more “clients”:

• “There are two of us [nursing assistants] for 42 people, we have to give out the lunches, wash them and get everyone into a room. On a typical day, there will be 15 or 16 people to wash. Over the two hours in the morning, with giving out the meals, there’s only time to make the beds, we have to forget about the showers. We have to finish everything by 11.40. [Then] we need to set the tables and clear them. We feed the residents. And if one of the cleaners dares come help us, she gets in trouble. In the morning there are five cleaners for 106 rooms! And they talk about how we should “advertise” the residence. People who come to our residence are only there for short stays (…), when they leave they’re going to talk about the residence. So they have to put the good people with a good nursing assistant and a good cleaner who’s going to clean the bedroom properly... But it’s all appearances. As soon as they settle in for the long-term, that’s all over. They have to adapt to “hurry up, rush, rush, rush”.

Both in the public and non-profit sectors, NPM is mentioned as one of the main sources of tension. Although care homes used to be managed by professionals trained in care work, now most homes are managed by people with a business background. According to a public sector union representative, these managers and directors are quick to use the threat of privatisation as a way to justify decisions that represent a shift towards “rationalising” institutions: “If we ask for too much, we might be privatised” or “closed down”. These managers also compare the working conditions of staff in the public sector to those working in private institutions, as a way to convince them that “they could have it much worse”. It’s true that public care homes offer more permanent, full-time contracts than for-profit homes and even non-profit homes. However, staffing shortages, which mean accelerated work schedules, are still common, as is the increasing use of non-standard contracts and various insecure employment arrangements (sub-contracting, professional reintegration contracts, "active work search contracts", etc.) [13].

A strong focus on monitoring tasks, schedules and spending is another feature of NPM. Coding systems designed to standardise tasks and quantify healthcare costs have been introduced. These overload workers with administrative tasks, robbing them of the time they need to carry out care work, and contribute to high-paced work schedules and job fragmentation. According to a union representative, while management of public care homes used to be built more or less on trust, rationalisation is creating administrative requirements where every cost and procedure has to be accounted for. Added to the failure to update managerial standards and demographic changes (an ageing population, resulting in an increase in the number of dependant residents), this has led to work overload and burnout. In such conditions, there is an increased rate of absenteeism, which exacerbates the issue of staffing shortages.

In addition, workers see tighter controls as being counter-productive to effective care work due to the fact that such systems are incompatible with the sector’s specific needs. The introduction of a clocking in system in public care homes serves as an example of the sorts of problems created by this push towards standardisation. It causes a number of issues, particularly during the shift changeover time. As a union representative explains, if a resident suffers a fall fifteen minutes before a worker’s shift is due to end, and if fifteen minutes is not enough time to resolve the issue, the worker must stay until the problem is resolved. This time will not, however, be counted as overtime. As this sort of incident is not infrequent, these extra minutes can add up to a significant amount of unpaid work. This can result in employees choosing to leave such incidents unresolved.

Lastly, outsourcing certain services, particularly meals, cleaning and laundry, is another way in which public care homes are being privatised. This not only impacts significantly on the working conditions of the sector’s employees but also makes it difficult for staff to rally together and make collective demands.

The commodification of care

The development of care homes has emerged in a neoliberal context where the sector has gradually shifted from the public to the private. The state’s divestment in public services for the elderly has opened up new opportunities for the for-profit sector, attracting major investment corporations, representing the financialisation of the elderly accommodation sector.

Private companies and transnational corporations have invested massively in this sector, and with their investments there has been an emphasis on commodifying public and non-profit services. The privatisation of the sector has resulted in competition between public and non-profit companies and private companies, as well as New Public Management practices focussed on profitability and efficiency.

In a neoliberal context characterised by deregulated working hours (increased flexibility), intense work schedules, “polyvalence”, cost-cutting, insecure contracts, sub-contracting and outsourcing, care homes are becoming an extremely profitable sector that relies on low-skilled, primarily female workers who carry out care work in insecure working conditions, with flexible hours, intense work schedules and low wages. Although conditions vary among institutions and sectors, all staff, whether they work in the public, private or non-profit sector, are being forced to follow procedures specific to “productive” work, aimed at increasing the work load in order to increase profits and cut “costs”. Such a market logic is preventing workers from being able to carry out care work while also subjecting the bodies of workers and residents to constrictive “productivist” work practices, which are taking a heavy toll on their physical and psychological health. This is what workers express, visibly pained, when they talk about the institutional abuse that both workers and residents are being subjected to within these care homes.

Maria Cecilia Trionfetti and Natalia Hirtz
Translation : Susanna Gendall