Labours of Love: The Crisis of Care 
by Madeleine Bunting.
Granta, 325 pp., £9.99, May 2021, 978 1 78278 381 7
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The Care Crisis: What Caused It and How Can We End It? 
by Emma Dowling.
Verso, 248 pp., £9.99, March 2022, 978 1 78663 035 3
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Cannibal Capitalism: How our System is Devouring Democracy, Care and the Planet 
by Nancy Fraser.
Verso, 190 pp., £20, September 2022, 978 1 83976 123 2
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Recent NHS​ figures suggest around 14,000 people in hospital no longer need to be there. Forty per cent of them are waiting for a care plan – either in their own home or at a residential home – and another 24 per cent intermediary care. Social care budgets, outsourced and administered through local authorities, collapsed during George Osborne’s austerity decade. In October, the County Councils Network, representing 36 mostly Tory administrations, warned of care providers abandoning contracts, chronic staff shortages and an impending £3.7 billion in additional costs as a result of inflation. Adult social care supports the disabled, the chronically ill and the elderly: it is that last, ever expanding category that presents the greatest challenge. More than a sixth of the population, or 11 million Britons, are over the age of 65; by 2043, it will be a quarter. According to Age UK, millions of people over the age of fifty already have unmet care needs: 1.2 million have difficulty bathing, 930,000 have difficulty getting in or out of bed. Those numbers will only rise.

The first doctor to attempt to treat and rehabilitate elderly patients systematically was Marjory Warren, who worked at the West Middlesex County Hospital and the former workhouse infirmary there in the mid-1930s. The 1948 National Assistance Act gave a patchwork of institutions, divided between NHS geriatric beds and local authority homes, responsibility for old age care, but the specialism evolved slowly: the first professor of geriatric medicine wasn’t appointed until 1965 (William Ferguson Anderson at Glasgow). The treatment of geriatric patients was the subject of intermittent campaigns. In his 1964 study, The Last Refuge, the sociologist Peter Townsend stressed the frequent affronts to dignity and the lack of privacy and basic sanitary standards afforded to older people. He reserved special contempt for the former workhouses, where inmates wore institutional clothing (sometimes bearing the names of dead former residents) or which had lavatory blocks without doors or even toilet seats, their ‘stone floors … saturated with urine’. The Jungian analyst Barbara Robb’s book Sans Everything, published in 1967, describes her visits to – and eventual prison break of – an elderly friend trapped and abused in a geriatric ward. Accounts such as these have, over the years, made a compelling argument for care as a site of fundamental questions about the limits of the welfare state. As Townsend put it, ‘the ultimate test of the quality of a free, democratic and prosperous society is to be found in the standards of freedom, democracy and prosperity enjoyed by its weakest members.’

As with many of Britain’s social ills, the architecture of today’s care system is a product of Thatcherism, essentially unaltered by the Blair administration: an archipelago of small firms, each owning a single care home, alongside huge chains backed by venture capital. Long-term NHS geriatric beds are gone, and local authority homes have almost vanished. Residential homes depend on a combination of public and personal funding: about 400,000 people live in them, roughly half of whom pay for their care, with the rest partly or entirely funded by local authorities. Roughly the same number receive social care at home commissioned by local authorities. This care is means-tested in England and Wales but free in Scotland and Northern Ireland. The starvation of local government during austerity (between 2010 and 2020, 60p in every £1 of central government funding disappeared) made the fees for residential homes extremely burdensome for councils. And those who pay for their own care face fees up to 40 per cent higher than the bulk deals agreed by local government. In 2010, Eric Pickles, then secretary of state for communities and local government, announced a government ‘commitment to adult social care, providing councils with sufficient resources’. He even promised ‘extra money’ for social services. Few believed it at the time; by the end of that parliament, charities, trade unions and even the National Audit Office were warning of a crisis in the sector, made more malign by the uneven distribution of local authority cuts, which fell most heavily on deprived areas. Boris Johnson’s 2019 promise of an ‘oven-ready’ plan for social care only departed from Pickles’s promise in its greater flimsiness and transparency.

The 1981 Department of Health report that initiated the boom in private social care provision declared that ‘we are all growing older … this White Paper concerns everyone. What is more, a larger number of us can in future expect to live longer. There will be many more very old people.’ Anxiety about funding care for an ageing population hasn’t gone away. Inquiries are commissioned, and their unpalatable conclusions largely ignored: the 1999 Royal Commission was followed by the Wanless (2006) and Barker (2014) reports, both commissioned by the King’s Fund (a health charity); the government commissioned the 2011 Dilnot report into care and the 2013 Cavendish review of the care workforce. Each recommended a major overhaul in funding and provision. Andy Burnham, health secretary in the dying days of the Brown government, proposed a National Care Service, to be funded by a compulsory levy on estates. This remains the closest Britain has come to a solution. The plan collapsed in a cynical act of political arson, as Osborne saw a potent campaign tool in the ‘death tax’. Once the Tories had been safely delivered to office, they continued to ignore the problem. A bill for a National Care Service is currently before the Scottish Parliament, but even this would create only a relatively modest commissioning body.

Unlike the NHS, social care in England and Wales is not free at the point of use. Anyone with savings or assets worth more than £23,250 (or £24,000 in Wales) is expected to fund their own care, either home or residential: this limit was supposed to rise to £100,000 in October 2023, when an £86,000 cap on total lifetime spending was also due to come into force. These changes were delayed for two years in Jeremy Hunt’s Autumn Statement, saving around £2 billion (Liz Truss’s mini-budget cost £30 billion). The current system will therefore outlast the current government – and pensioners requiring residential care will continue to be forced to sell their houses to fund an unpredictable, badly regulated and unnecessarily expensive service. Care work is hard, and the workforce shares the problems of morale common across the NHS. Many are agency workers, often migrants and often exploited. Vacancies in the sector currently stand at 10.7 per cent and rising – 165,000 empty roles. Employee churn is high, zero-hours contracts common, and at £9.50 an hour, the sector’s median wage is in the bottom fifth of the economy. Operators complain they lose staff to supermarkets, which not only offer better pay but also free or discounted food. One case recently investigated by the Gangmasters and Labour Abuse Authority found nine Indian care workers in the UK on student visas, sleeping in cold and cramped conditions, with evidence their recruiters controlled their wages. Coworkers had raised the alarm after noticing them eating leftovers from residents’ plates.

Labour had its revenge on the Tories for the loss of the National Care Service: Theresa May’s proposal to include the value of an individual’s home in calculating their full social care costs – it currently counts only towards residential care – helped destroy her majority in the 2017 election (the media called it the ‘dementia tax’). In September 2021, Johnson announced a Health and Social Care Levy, funded by an increase in National Insurance, which was supposed to pay for his detail-free plan. One of Kwasi Kwarteng’s first acts in his brief tenure as chancellor was to cancel it, and it remains the most significant decision not to be reversed by his successor. The Health Foundation estimates that between £6.1 and £14.4 billion in additional funding will be required to meet future demand in social care by 2030. Nobody, at the moment, has any idea where that money will come from.

The NHS and the social care system are the centres of the care crisis in Britain. But the problem of care extends beyond them, to the more coercive areas of state-led provision, from psychiatric services to ‘troubled family’ interventions – and, given the threadbare state of mental health and addiction provision, often including the police as carers of last resort. It includes the NGOs and peer support charities, many of them facing closure, that help disabled people and their families claim the support to which they are entitled – a thicket of forms for care that comes with the threat of retraction and reassessment. (Working-age disabled adults make up a third of social care users; half of all people living in poverty live in a family that includes a disabled person.) It includes childcare: the UK has the second most expensive early years system in the developed world. Only parents in Switzerland pay more. It also includes the family, where the vast majority of unpaid care work takes place. Informal, unpaid care work in the UK was recently valued at £59.5 billion annually; this is a conservative estimate. The carer’s allowance is the most underclaimed benefit in Britain.

Care is big business of a kind increasingly familiar in Britain: dependent on large subventions of public money, but operating in the interzone between public and private; low-wage with high staff turnover, attractive to speculators and property magnates because of its guaranteed client base, with fees ratcheting upwards annually but surprisingly little return to the exchequer. Private companies provide 84 per cent of residential care beds, but at least a quarter of the firms are at serious risk of insolvency, a risk sharpened by high inflation. This is as true of large chains as of single-home operators: Four Seasons, once the largest provider in the UK, went into administration in 2019, and put its 111 care homes in Scotland, England and Jersey on the market last June. Its collapse could be seen a long way off. A 2016 report from the Centre for Research on Socio-Cultural Change at Manchester University called the company the ‘poster boy for the coming crisis’, decrying its use of ‘cash extraction tied to the opportunistic loading of subsidiaries with debt; and tax avoidance through complex multi-level corporate structures which undermine any kind of accountability for public funding’.

At the time of its collapse, Four Seasons was a subsidiary of a Guernsey-registered holding company called Terra Firma and comprised 187 companies, 14 of them offshore, across six jurisdictions. Private equity’s love of these mazy structures is notorious, and the dangers of debt-laden corporate structures to the care sector was obvious after the collapse of another chain, Southern Cross, in 2012: sale-and-leaseback schemes returned quick cash, but left the company exposed to unsupportable rents. Blackstone Capital, which at one point owned both Southern Cross and its largest landlord, had already exited by the time it hit the rocks, taking close to £500 million with it.

Four Seasons acquired some of Southern Cross’s homes, but the majority were bought by HC-One, now Britain’s largest operator, with about 20,000 staff and 321 homes. Like Four Seasons, it is made up of a web of companies – more than eighty of them in 2021 – spread across the globe. One analysis of its operations carried out by the Centre for International Corporate Tax Accountability and Research accused it of creating a pattern of artificial losses in the UK while making significant dividend payments to investors and shareholders, and to subsidiaries in the Cayman Islands. The dividends of £48.5 million it paid over 2017-18 were accompanied by complaints that increases in the minimum wage would make its business unsustainable; begging letters to government followed over the pandemic, even as it paid out at least £4.8 million to its owners in 2020. The company claims that it has since simplified its corporate structure and that it pays tax in the UK. Its current CEO, James Tugendhat, cousin of the Tory politician Tom Tugendhat, says it’s important ‘to be seen as having a transparent structure’, perhaps because ‘we are the only major provider seeking to make local authority care the core of our operating model.’

The residential care sector has an annual income of £15 billion, half of which is public money. Care chains, families and trade unions are united in arguing that austerity wrecked their capacity to deliver good care, and that the state underfunds the places it pays for. This much is evident. It isn’t the full picture, however. As the Centre for Health in the Public Interest puts it, the sector is leaky: 10 per cent of income – £1.5 billion – goes on rent, dividends, director payments, debt servicing and profit. Maybe that’s just what private businesses do. But the details are troubling: the CHPI points out that the largest 26 providers spend £261 million on servicing their debt, 45 per cent of which flows to related companies, many of them offshore. Despite posting an £83 million loss in 2021, HC-One paid one of its directors £592,000.

Reforms instituted after the collapse of Southern Cross require large care chains to disclose financial information to the Care Quality Commission, but given the complexity of these firms’ financial structures, their international ownership and the commission’s negligible power of sanction, this doesn’t qualify even as light-touch regulation. The money flowing offshore comprises not just public funds, but also private savings, often built up from decades of work or the sale of assets people once intended for their children. When one considers both the increasing dependence of the British middle classes on intergenerational patrimony and the unpredictability of care needs, it is surprising that self-interest alone hasn’t spurred greater pressure for reform.

In its early medical meaning, as today, ‘crisis’ denoted the turning point of a disease – before death or recovery. Its juridical and political senses also signify a decisive moment precipitating fundamental change. But the care crisis doesn’t seem to have a turning point. And the crisis isn’t just in care homes. ‘They say it is love,’ began the Wages for Housework 1974 campaign manifesto. ‘We say it is unwaged work.’ The group’s point was straightforward: everyone in society, not least profit-making businesses, depend on a matrix of care work – largely unpaid, unregarded and carried out by women. Not everyone liked the slogan, or the campaign: its demands were too expansive, it relied on over-extended definitions of work and ‘social reproduction’, and by placing money at the centre of the argument, other motives and sources of meaning were eclipsed. But the starkness was the point, its defenders argued: only a bold statement could denaturalise care work, and make it visible as work. Fifty years on, much more care is carried out as work, for a wage and for profit. Three features remain unchanged, however: the centrality of unpaid care work; its apparent invisibility; and its stubbornly gendered quality. Many of those who write on the subject are women whose work is still marginalised.

How invisible is care? In some ways it has become ubiquitous, the default rhetoric for corporate communications. Airlines, intelligence services and budget supermarkets all boast their caring credentials. Injunctions to practise ‘self-care’ long slipped their activist origins to justify commodified indulgences from scented candles to luxury holidays. Care work itself features in media primarily as a budgetary crisis. This cultural doubleness, which combines abstract praise with practical neglect, is not unique to care: we treat nature in the same way. Of the many recent books on the subject of care, the better ones struggle with this question of visibility. Madeleine Bunting’s interviewees thank her for noticing the problem, or remark that she is the first person they’ve talked to about it. Labours of Love is an ethnography of the world of care. The implicit premise is that if we pay sufficient attention to lived experience – a fashionable phrase – we might be able to grasp the extent of the crisis. In The Care Crisis, Emma Dowling also relates various experiences of the care system, but with an eye to the wider political-economic causes of the crisis and its strategic implications, especially for the left.

Both authors see these accounts as more than just a way to make tangible a vast and amorphous subject. The stories are ordinary: Dowling’s Mick, who cares for his mother and can barely admit he needs a break; Emem, whose privatised caring job robs him of the time his patients need and whose new manager sneers ‘if you’re so clever, why are you working as a carer?’; Bunting’s Blessing, who sings her patient songs from a favourite musical, repairing – so it seems – some of the damage of dementia. As they accumulate, these vignettes acquire a strange ethical gravity. Both authors say they felt an obligation beyond diligence – a modern version of the impulse that led Townsend and Robb to their campaigning work.

Part of what is so effective (and affecting) about the stories lies in the work itself: caring is repetitive, unattached to a product or, very often, a goal. People who need help bathing or eating usually need it every day; caregivers sometimes speak of feeling as if they were living in a different kind of time, cyclical rather than progressive. Their work is antithetical to many of capitalist modernity’s chief virtues – novelty, convenience and, above all, acceleration. It does not move fast and break things. Were we to take stories of ordinary decency as evidence of common behaviour among humans, we might develop a political anthropology that doesn’t assume we are intrinsically violent, solipsistic and destructive.

Some cold water: care has rarely been universal, unconditioned by ties of kin or creed. Its history is intimately linked with the history of domestic oppression; it hardly diminishes the great treasury of human violence to argue that altruism is an equally venerable force. Translating ethical urgency into a politics of care would not lack for pathologies: it would be potentially suffocating, conformist, a licence for moral scolds wielding duty as a cudgel and inclined to conceal abuse. But the urgency remains.

All of us depend, in early age and often at the end of life, on the care of others. We are shaped by individual, consequential but highly contingent acts of care, or their absence. To think about care is to shuttle back and forth between social totality and the irreducible complexity of individual needs, from feeding or washing to dignity or meaningful attention. Because it concerns the state, care must be thought of in the aggregate – unit costs, labour time, population trends – but many carers worry that such categories miss everything significant about their work. It doesn’t help that so many definitions of care are vague or tautologous, constituting the entire range of social activities that allow human beings to exist in the world. Bunting knows that words for care are made banal through overuse, or have been tainted by the abuses they conceal. Who now would argue for a revival of ‘pity’? In her final chapter, she quotes an epigram of Simone Weil’s: ‘Attention is the rarest and purest form of generosity.’ Weil, who herself often rejected care, seems a strangely appropriate philosopher for this moment. Attention has been lost, or misdirected, or was never there.

The crises​ of the welfare state are also symptoms of its success. We live longer, more of us enjoy longer retirements and so suffer the frailties of old age. Annemarie Mol’s The Logic of Care: Health and the Problem of Patient Choice (2008) grew out of a study of diabetic patients, whose condition required lifelong management. She counterposes the logic of care and the logic of choice, arguing that a narrow focus on choice can amount to patient neglect. The reality of care exposes our dependence on others and shows how constrained, even illusory, our choices are. Mol’s point isn’t just that unthinking market logic is bad for human health, or that choice is not the sole good, but that these may be incommensurable ways of thinking. She recalls a panel on patient choice in which medical ethicists and psychotherapists were confronted by the case of a patient who didn’t want to get out of bed. No problem, some of the ethicists thought: his choice, if it harms nobody else, should be respected. Some wondered about the patient’s capacity to make choices, the value of shared rules or the need to learn to make choices. But Mol quotes one participant, a retired professor of psychotherapy, who argued that forcing the patient out of bed and giving him the choice to remain are both forms of neglect. The institutional context matters. ‘On a ward with enough staff, I’d send a nurse to sit next to the patient’s bed and ask why he does not want to get up. Maybe his wife is not coming for a visit that afternoon. Maybe he feels awful and fears he will never be released from hospital. Take time for him, let him talk.’ For Mol, this approach is occluded by the emphasis on choice. But even in this apparently individual case, the injunction to care quickly reaches the systemic and political: it’s a question of enough staff, enough time, enough money.

The ease with which theorists of care oscillate between the specific and the structural can annoy those at the sharp end. Generalisation risks losing what is distinctive about care work in a cloud of sentiment. The novelist and former care worker Andrew Key confesses to irritation whenever he reads ‘about an exhibition by some cool young artist or a new book by a full professor of sociology, or whatever, which takes “care” as its subject’. His essay ‘Late Sleep Early’, published in the online magazine Lugubriations in 2021, concerns what’s called a ‘sleep-in’ shift, where workers are on site and available to residents, but only paid in full for the hours they are awake. These shifts are common across the care sector and are paid at a flat rate. Of course, sleep often proves elusive under fluorescent lights, on pleather sofas, even if the night is quiet. This working pattern sparked a lengthy court case, Royal Mencap Society v. Tomlinson-Blake, with workers seeking a ruling that they were, in fact, working and therefore entitled to be paid at least the minimum wage for the whole shift; some care homes warned that, if awarded, back pay (estimated at £400 million) would bankrupt them. Key describes coming home from shifts wired, exhausted, ‘feeling like all the wrinkles in my brain have been smoothed over with Polyfilla’. In March 2021, the Supreme Court decided that ‘sleep-ins’ didn’t qualify as work.

Key cared for people with psychosis, and confesses to his naivety when he started the job. He detects a similar naivety in artists or professors for whom care is a fantasy of universal benevolence, a weakly secularised Christian caritas. Where’s the wiping up of blood or piss, the frustration and resentment, the sheer exhaustion? It would be easier if the fantasy were baseless, but the attention to the individual that care work requires does generate love, of a kind, sometimes. It isn’t a reward – that would be better pay – but a contradiction in the work itself, not something that can be reasoned out of it. ‘The love I feel in fleeting bursts at work is painful and complicated,’ Key writes, ‘and it would probably be better to not feel it. It’s a job. I scrub a lot of toilets.’

Bunting quotes a professor of nursing who argues that the work is stochastic: ‘Every process produces lots of different probabilities, like a firework going off in different directions.’ Education and experience is required to spot all possible outcomes and decide how best to deal with them. Such work is inherently unpredictable, and runs counter to market drives. A route to efficiency has been tried with home care, by compressing the time allotted to the work: in the 1970s, a morning home care visit lasted three hours, including time to light a fire, dress the patient and prepare breakfast. Typical visits today last between fifteen and thirty minutes. This isn’t the utopian result of central heating: the quality of care is diminished by the time constraint, a situation made more arduous in places by the refusal to pay zero-hours contractors for the time they spend travelling between appointments. One dementia care agency was recently caught delivering visits as short as three minutes, though logged as much longer. As a respondent to a Unison survey put it, ‘the service is run on emotional blackmail and goodwill.’

In the most affluent nations, the care sector depends on cheap migrant labour to fill its lowest-paid roles, but as that supply falters (and international remittances lose their shine) that strategy reveals itself as unreliable, as well as unjust. One low-paid care worker told Bunting that there will ‘only be care jobs in the future’. Gabriel Winant’s chronicle of the transition from steel mill to healthcare work in Pittsburgh, The Next Shift (2021), describes a transformation now familiar across modern working-class labour – these new jobs are more atomised, worse paid and offer less control of shift patterns, hours and little of the prestige once accorded manual work. It also tracks a broader demographic change in those working and those being cared for. Our ageing population is the most obvious demographic driver of the care crisis, but the revolution in women’s work is equally significant. Women’s entry into the workforce may not have ended the disproportionate share of domestic work expected of them, but it did spur recruitment into feminised roles – some of which might previously have been done at home. Winant quotes a 1986 proposal for care worker recruitment: ‘The displaced homemaker is tailor-made for the homemaker/home health aide position and could be said to have been in training for the position for years.’

The rapacious spread of​ capital into all domains of human life is a common motif in socialist thought, but in Cannibal Capitalism, Nancy Fraser is interested in four background ‘conditions of possibility’: race, care, nature and a crisis prone but economically circumscribed political order. ‘Capitalism is something larger than an economy,’ she writes: increasingly it incites social conflict at the interface with non-economic reservoirs – boundary struggles, in her terms. She is especially good on the ‘critical-political possibility’ of these zones, which provide values – love and care, or global equality, or ecological stewardship – that might turn against the profit motive, even as capitalism professes those values. (The protest slogans of the 21st century consistently demand ‘real’ democracy, equality or freedom.)

Parallels between care and ecology are instructive. ‘No society, capitalist or otherwise, that systematically cannibalises social reproduction can endure for long.’ Both constitute ‘free riding on the lifeworld’, but whereas ecological destruction has been a feature of fossil capitalism since its inception, the care crisis is distinctively modern, a result of the movement of women and care into the sphere of labour. Observing that the end of the ‘family wage’ – earned by the male ‘breadwinner’ – and the diminution of the male share of the labour market brought only a partial emancipation from kitchen and nursery is to stress that feminism’s triumph is far from total.

This can be tricky terrain. The hollow inclusivity of contemporary capitalism spurs nostalgia on right and left for their respective foundational myths: the traditional family and the male industrial worker. Bunting observes that the birth of her children upended her feminist certainties. The implication, common in care writing, is that certain kinds of obligation – above all, motherhood – prompt a profound epistemic shift, one rarely explicitly valued or even communicated.

The intellectual tradition of the left has tended to value ‘productive’ work in the technical sense of work that creates profit – though the word’s moral dimension always lurks. This was strategic: productive workers were thought to possess special agency to upend a political-economic system built on profit; hence the particular attention paid to the 20th-century factory worker. In The Making of the English Working Class, E.P. Thompson notes that in 1831, domestic servants comprised the second-largest category of workers after agricultural labourers, but they barely figure in the story he tells.

Fraser doesn’t imagine that the pillaging of care (or any of its other zones of spoil) by capital will automatically produce a social force capable of defending it – her book is an explicit plea for a political project. The identification of ‘boundary struggles’ is an attempt to work out firm predicates for radical political action in the post-industrial age, though the current wave of strikes suggests the old industrial channels might be revived too. Contemporary Marxist thought countenances a possible future of general fracture and decay, in which forces of opposition fail to cohere because each disaster proceeds slowly and by degree rather than in explosive confrontation. The cannibal, devouring his own kind until none remains, is a reminder that Marx and Engels also warned of ‘the common ruin of the contending classes’.

The wider economic questions raised by care work appear from one angle like a subset of the problems of ‘immaterial’ labour or postindustrial economies in general: how to value intangible goods; the importance of affect; the transformative role of digitisation and automation. Whereas prophets of postcapitalism see in these phenomena auguries of an abundant future society underpinned by the near-zero marginal cost of immaterial commodities, Dowling sees care pulling in the other direction: ‘The more people need to be cared for, the more costly it is.’ Care, in this reading, is an activity with infinite marginal cost.

Marxists and feminists are not the only ones to have noticed an issue here. In the 1960s, William Baumol, a respectable neo-Keynesian, described a phenomenon now known as Baumol’s cost disease, in which productivity growth in one sector affects wages and prices in other sectors. Service sectors, which aren’t particularly amenable to technological efficiencies, can’t easily increase productivity. In the long term, we should expect the cost of these services to increase, with obvious implications for government spending – not least of which is that governments can’t reform their way out of spending more money on care (or education). Baumol was an optimist: in a global economy in which technological progress and productivity gains are real, we should always be able to afford these rises, just as we have always been able to in the past. But in a single national economy with stagnant productivity and rising need, replete with opportunities for the wealthy to avoid taxation, reasons for optimism seem fragile.

One of few avenues for productive gains in health is the use of technology. Lord Darzi argued in a recent Institute for Public Policy Research report that moving to ‘full automation’ in the NHS would save 10 per cent of its running costs, free up human clinical time and bring a £6 billion gain in social care productivity. This vision is unlikely to be realised any time soon. It’s difficult to imagine a British government of any complexion capable of the long-term strategic investment and reform such a shift would require. But care automation raises much broader questions. As Dowling puts it, when ‘a machine takes on a task, it does not simply do the same thing a human being did … The task is transformed in the process.’ If it replaces or supplements the ‘stochastic’ processes central to nursing, who encodes the ethics of its triage system?

Care is a hard problem. It is unattractive to politicians because it involves the two human certainties most unpopular with voters: death and taxes. As the joke goes, if you wanted to solve the care crisis, you wouldn’t start from here. The revival of austerity at Westminster is dangerous. Public services have seen no improvement since the first iteration in 2010; some will cease to function in this second round. Opponents of austerity, and especially care theorists, often do politics in the subjunctive: ‘what if’ we were to govern differently and ‘what would it mean’ to really care? Politics without such utopianism is a dismal enterprise, but it doesn’t help with immediate problems and disdains the messy question of political strategy. ‘Not this’ is only the beginning of a political project.

Given the narrowing pale of acceptable policy in Westminster, it’s easy to forget that solutions are possible. The shadow health and care brief has been handed to the neo-Blairite cargo cult strand of the Labour Party: their most recent interventions rely on the notion that capacity in the private sector can be used to fix the NHS. Spare capacity of this sort usually turns out to be a mirage in healthcare; the problem in social care is the atomised, inefficient and sometimes extractivist private firms. What is missing is not policy but political will. There is a great degree of consensus that the solution to the care problem requires significant short-term spending to stabilise the system, and the implementation of mandatory social insurance to fund care in the longer term. Consensus also exists on the need for more aggressive regulation of care providers, especially residential homes; there is less agreement on the future role of private care homes within a new system. It is no accident that this sounds like an analogue of the NHS, and the debates that accompanied its founding: as a model, arrived at after decades of experiment, it remains the most successful and humane approach to shared, unpredictable social risk. Political differences persist over where the funding burden ought to fall. The loss of popular faith in state capacity is a stumbling block. It may help that the regulatory crackdown, tax enforcement and strategic investment required to solve the care crisis are also remedies for some of Britain’s other ills.

It would be a failure if the only answers sought were economic. The problem of care raises questions that lie outside the typical bounds of policy work, although Beveridge was unafraid to confront them. What degree of indignity, pain, degradation or abuse are we prepared to see the people around us suffer? And what, if we are unable or unwilling to do it ourselves, are we prepared to pay for the work most intimate and essential to human life? Politicians may not wish to acknowledge these issues, but circumstance will force them on us regardless.



Listen to James Butler discuss this piece on the LRB Podcast

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Vol. 45 No. 7 · 30 March 2023

James Butler describes the Scottish Government’s proposed National Care Service as a ‘relatively modest commissioning body’ (LRB, 2 March). Not so. The National Care Service (Scotland) Bill attacks the principle of public delivery of public services on a scale unseen in Scotland since the Thatcher era. The legislation going through Holyrood will transfer statutory responsibility not just for social care but social work and community health away from local government, and where necessary the NHS, to new ‘care boards’. These will deliver services by procuring and contracting from the private, voluntary or public sector. The only transfer of ownership envisaged is out of the public sector. Should councils wish to continue providing services, they will have to enter, and be successful in, procurement exercises. That’s assuming they are allowed to bid: Section 41 of the bill will allow care boards to exclude local authorities and health boards from tendering for contracts.

The impact will be immense. The memorandum issued with the bill is costed on the basis that 75,000 staff will be transferred out of local authority employment, with an estimated one-third of current council spending going to the care boards. Members of the boards will be answerable only to ministers in Edinburgh. The proposals do not tackle the failing that is the constant thread in Butler’s piece – the treatment of care as a commodity not a service. Any similarity between the NHS and what is being sold as a National Care Service is purely nominal. Instead the NCS will expand market mechanisms and further encourage the reaping of profit from services to the vulnerable.

Stephen Low

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