Care workers are not saints This year we've paid a bitter price for our indifference to care — a change in attitudes is urgently needed

My project started with a simple question: what is care? It’s a short word, and widely used, but people never seem to stop and ask what, exactly, it means. I have criss-crossed the country interviewing parents, charity support workers and social care workers; I’ve shadowed nurses and GPs. And I have been humbled by their insight: how they hold steady to a set of values which receive little wider social affirmation — indeed can be at complete odds with a consumer society fixated on image and pleasure. Listening to these care workers, I felt that their understanding of care cast them in the unlikely role of rebels arguing for a basic truth — the importance of relationship.

At times, this role puts these carers in extraordinarily difficult positions. One carer, called Blessing, described an occasion which had happened several years earlier, and as she spoke she found herself crying: “The care agency was all about money; they would tell me who to visit and that was it. I worked on my own most of the time. Once I noticed an old lady in her nineties had bruises on her arms. She told me that her previous carers had been rough. She was very co-operative — I couldn’t see how the bruises could have happened. I was distraught. She asked if I could come back again, and I said I would try my hardest. I called the office and told them about the bruises, and they said they would deal with it. I was crying so I called my mother. I was in so much emotional pain.”

The agency never allocated her the lady again. “On the phone my mother told me: that’s why people need someone like you. She told me that it is the type of work you do with mercy in your heart.” Too often, care workers such as Blessing were drawing deep from their own cultural heritage to support their work; her inspiration was her mother and her background in West Africa. There is no tradition of respect for the elderly in the UK, concluded one sociologist of ageing; that disturbing insight must be part of the explanation as to why this country has repeatedly cut back care services for the elderly, falling behind other European countries’ expenditure.

At one point I shadowed a senior community nurse who was tasked with the job of explaining to six NHS care workers that the patient they looked after in shifts would most likely die of the disease he suffered from. The carers had come to know this brave patient and his wife well, and I watched their faces as they struggled to hold back tears. Afterwards the nurse admitted to me that he felt so bad for them: they didn’t have his training or professional support to cope with the trauma. The emotional labour of their work was immense, yet they would have been paid more on a supermarket checkout till.

As I listened to stories of caring lives — of men who had taken on care jobs late in life and loved the work, of women who had spent decades in the sector — I felt I had stumbled on a vast aquifer of knowledge and experience: one that is usually hidden, but on which the wellbeing of millions depends.

This is one of the paradoxes of care: the action can be small, but the impact and significance immense. A smile or a squeeze of a hand, at a moment of acute vulnerability, can mean so much. It’s part of what makes care so hard to measure in a health and social system obsessed with measurement and regulation. Care is often about spontaneity, and yet it also requires protocols, and competence; care cannot be easily summed up, because it straddles many of the dualisms we use: it is head, heart and hand.

A long history lies behind the invisibility of care, and one witty book title says it all: Who Cooked Adam Smith’s dinner? While the great political scientist wrote his tomes on capitalist theory, his mother ensured he was fed. The great man took for granted the care work of women — raising the next generation to work the factories; supporting the sick, elderly and dying; conducting the basic social processes of sustaining human lives.

The nursing profession has been dogged by this history. Florence Nightingale was a brilliantly clever strategist and she devised the first independent career for women — but it came at the cost of depicting the job as the work of the self-sacrificial hand maiden of the medical establishment. If women were to deal with vulnerable sick bodies — of men and women — they must be paragons of Christian virtue; they must not be assertive; they should not make claims for authority, recognition or decent reward.

Since it has traditionally been expected to be unpaid (in the family) or badly-paid (as servants, governesses, companions to the elderly), the expectation persists that carers do the work out of the goodness of their hearts. Private sector domiciliary care providers promise that their staff “will go the extra mile” for their clients but as my interviewees explained that entails going over their allotted time, and racing to the next appointment. While the carers are expected to offer emotional labour — to be always cheerful and warm-hearted — their working conditions can entail long, split shifts and sometimes hours spent sitting in their cars between calls, as coffee shops are too expensive.

Nowadays care is either idealised — as the work of angels — or belittled as simply about having the right instincts. In my interviews, I was interested to find people who discovered very unexpectedly their capacity to care — such as a 23-year-old Oxbridge graduate in need of a job, or a female senior IT consultant who had always had a horror of doing the “caring clucky thing” and yet came to see her years of supporting her partner as the greatest achievement of her life.

In the last few decades, senior nurses have made determined and valiant efforts to shake off the narratives and histories that have cast a long shadow over the profession. Professor Anne Marie Rafferty, now president of the Royal College of Nursing, explained that her aim is to acquire authority as graduate nurses. Her cause has dominated her career since she joined the first nursing degree in Edinburgh in the seventies.

But success, admitted one director of nursing in an interview, has often required nurses to emphasise clinical competence over the care dimension of their relationships with clients —touch, presence and time. She described a recent incident where “when visiting a ward, I saw a nurse who was sitting on the bed, and she jumped up and said, ‘Sorry I was just talking.’ She felt she had to apologise. Perhaps we don’t value relationship enough, socially and culturally.”

We urgently need a paradigm shift in our understanding of care: a reimagining of care as a vital human activity which spans our lives either as giver or recipient, from birth to death. It urgently needs to be recognised and valued, and the starting point has to be curiosity. Instead of assuming we know what care is, we have to look again and look deeply. Professor Rafferty describes care as “dark matter”: vital and immensely complex.

When I listened on my doorstep in April 2020 to a cacophony of drums and clapping in honour of carers, that paradigm shift really seemed possible. But there is also a very real danger that yet again, we idealise those who do care work as heroes and saints, and thus reduce the subject to a matter of individual character. As a professor of nursing, Alison Leary, said to me, we don’t assess airline pilots in that way, so why do we apply that criteria to an inherently risky endeavour such as care?

Time and again, I was told by wise old hands that good care is not rocket science: it emerges from people having enough time to do their job, decent pay and working conditions, and a supportive team around them. Carers cannot work alone — not without feeling overwhelmed and ultimately burning out, which means their clients are at risk of neglect or abuse.

We have paid a bitter price in the UK for our indifference to and ignorance of care in the last six months of pandemic: we have one of the highest death tolls in the world of care homes residents (19,000), as well as of health and social care workers. Surely this must spur to us to reckon with care workers’ historic legacy of invisibility? Surely, now, we can invest the necessary resources, imagination and inspiration to build systems of care that put relationship at their heart? That is the care people want at times of vulnerability; to provide it is an enriching and meaningful form of labour.

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Madeleine Bunting is a writer and Visiting Professor at the International Inequalities Institute at the LSE. Her book, The Seaside, England’s Love Affair, will be published by Granta in May 2023

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