There’s been a lot of welcome publicity these last few days about the increasing use of zero hour contracts for homecare workers, and of rushed 15 minute visits for people who need intimate personal care. Last night on Channel 4 News Rochelle Monte, a homecare worker, talked of the huge turnover of staff caused by poor wages and conditions of employment.
This reminded me of a question which the philosopher, Michael Sandel asked at a Labour Party fringe meeting last year: “Are there certain moral and civic goods that markets do not honour and money cannot buy?”
This is a fundamental challenge to many areas of social and economic policy, such as the re-organisation of the NHS, but it is particularly a challenge to social care policy.
The nature of our society is increasingly determined by policies based on the assumption that good choices are made and good services delivered through self-interest and financial incentives. The 1990 NHS and Community Care Act ushered in the ‘purchaser/provider split’ in social care services and after more than 20 years of privatisation, it is the market which determines the nature and quality of care services, rather than moral or political decisions about what kind of lives we want for ourselves and our communities.
But are there certain things that we value which cannot be delivered by market forces?
Can people who need help to go about their daily lives - help which involves intimate care, that enables someone to access the most basic human rights like privacy and communication - rely on the profit motive to deliver this assistance in a way which protects and promotes their human rights? Giving and receiving intimate care is not the same as having your car serviced. To rely on another person in such a way is inevitably associated with a vulnerability to abuse, unless the person providing the care holds and promotes values which in many instances are incompatible with the profit motive. Maximising profit requires holding down wages, increasing productivity by reducing the amount of time spent on each task to a minimum, only investing in training to provide basic competence, and minimising regulation.
This is not to say that services run by public authorities are necessarily any better at delivering our human rights. The devaluing of the lives of disabled and older people was manifest in the abuse and poor care standards of the old asylums and institutions. The mistake was to replace them with organisations motivated by profit and answerable to their shareholders. The desire to drive down costs leaves little room for the development and delivery of services which are motivated by values relating to the public good and answerable to their users.
The early campaign by disabled people for direct payments was always clear that giving individuals purchasing power was only a means to an end, not the end in itself. Disabled people’s local organisations (Centres for Independent Living) promoted a value system which would challenge vulnerability to dependency and abuse, and instead develop empowering ways of delivering assistance. But much of this was lost as organisations struggled to survive and the more traditional charities and private sector organisations competed for contracts in a commissioning process which values cost (‘efficiency’) more than quality.
As Michael Sandel said: “If market practices sometimes crowd out non-market norms and attitudes worth caring about, then, in order to decide where markets serve the public good and where they don't belong, it is not enough to consider standard economic efficiency considerations alone. It is also necessary to anticipate when values and attitudes worth caring about may be crowded out by market considerations, and then to ask how important are those values and attitudes to our society.”
When disabled people campaigned for independent living in the 1980s and 1990s, we were campaigning for a different value system to that which had dominated both statutory and charitable support services. Our tragedy has been that the progress we made on independent living coincided with the increasing marketisation of public services. While private sector organisations may often use the language of empowerment, the bottom line is whether they can make a profit out of us.
Earlier this year, the Equality and Human Rights Commission published Guidance on Human Rights for Commissioners of Home Care
These are the values which need to replace the pursuit of profit and the driving down of wages and working conditions.