During my chemotherapy I would swathe my bald head in a scarf and totter, slightly queasy, to the shops. White vans juddered to a halt to let me cross the roads; the beleaguered assistant in the Co-op came out from behind the till to help me pack. I was being cared for by innumerable people during those months; the kindness of strangers would often overwhelm me.
What “care” means is a vast subject. It happens everywhere. In the daily maintenance of life in homes and families and in public institutions or social organisations imbued with their own histories and traditions. It is at once deeply intimate and profoundly cultural. Paid or unpaid, the quality of care in our lives is nothing less than sociality itself: it is an index of how we survive as a society and a species. It tells us the value we place on human life.
These essential, existential questions are at the heart of Labours of Love. Madeleine Bunting’s book could easily have become either a furious polemic or a vale of tears. It is neither, though it is angry and very moving. She meant it as a warning in the face of “a crisis of unprecedented proportions” in the provision of health and social care across the UK. With the advent of the coronavirus, its eloquent plea for change has become even more urgent.
Labours of Love combines the techniques of social investigation – Bunting was formerly a Guardian journalist – with a deeply felt ethical inquiry. Over five years the author shadowed care workers, nurses and doctors across the public and the private sectors, in health care and what is known as “social care”. She sat in on staff meetings and GP consultations; she talked to charity workers, to parents of disabled children, to those running small businesses in the care industry, and to agency and in-home care workers. She volunteered for short stints in care homes and spent time in hospices.
The testimonies she gathers constantly confirm what is meant by “good” care. Listening, her interviewees say, is nine-tenths of the job. Care is about attentiveness. It needs time and focus, and trust. It is not always about action; it is often wordless. It cannot easily be measured. Care, in other words, is often beyond price. Yet in a modern, industrialised society like ours, with an increasing population, it must often be paid for and given to us by those we do not know.
Bunting believes, as do her interviewees, that the urge to care is innate in human beings. It works reciprocally and is a therapeutic use of the self. Vulnerability, she writes, is a form of connection. One of the prompts for the book was her own experience of loss of control and autonomy as a young mother, caring for a newborn while her father gradually died. Her fantasy of complete independence collapsed. Her feminism needed to be rethought.
Bunting outlines the erosion of care as a principle and a practice on many fronts. She gives detailed statistics but much of the overview will be horribly familiar. Austerity policies have culled social services and cut funding to the bone; shortages in the care workforce have reached critical proportions. Personal contact is constantly squeezed by the market mechanisms of “efficiency” and financial accountability. “Compliance” and new regulations increase impersonality. (One nurse goes on calling everyone in the ward “lovely”, despite a well-intentioned ban on endearments from the hospital team.) Computer technology puts everyone behind a screen and lands the burden of “data management” on to care workers or claimants. A nurse fills in a form for each patient every hour. Kate, the mother of an autistic child, despairs at having to treat her son as a failure in order to score highly on the 50-odd pages of the disability living allowance application.
The marketisation of care treats it as a product. “Care packages” are “delivered”; satisfaction questionnaires are ubiquitous – nurses are accused of not showing enough “empathy”. “Convenience” and “availability” become the mantras; GP surgeries, open seven days a week, are now a “service industry”. As society has become more medicalised, a consumer mentality encourages the sense of entitlement: a patient clicks her fingers at the nurse to get attention.
Care work has historically been women’s work (nursing has long suffered from its association with an idealised feminine role of self-sacrifice). Deemed purely intuitive, relational and routine, it is frequently devalued by medicine’s emphasis on the rational or scientific. This “crushing” opposition reinforces hierarchies of pay and inequalities of status. Yet care involves complex activities. Pete, a community nurse, needs medical knowledge as well as an understanding of individual needs to order the right mattress for a patient. He spends hours on paperwork. Every aspect of his job is shaped by technology and by budgeting.
Care workers are exhausted by excessive workloads and long shifts. John, a healthcare assistant (nursing auxiliary) for more than 15 years, is paid £10 an hour. He supplements his hospital pay by working Sundays at the supermarket. Agency work in particular can be very lonely as well as precarious. As an agency care worker, Kelly was endlessly moved around. She got no sick pay, holiday entitlement or travel expenses. After only three hours’ training, she found herself bathing, lifting and medicating strangers. Moving on to residential care, she was appalled by the regimen, shocked to see a worker wash the face of a client still fast asleep. Eventually she left to take a job in a shop.
Many of the lowest-paid care workers Bunting talks to come from faith backgrounds. Can secular humanism, she asks, see care as an ethical imperative?
Short sections between chapters on the history of individual keywords – care, empathy, kindness, compassion, pity, dependence, suffering – offer food for thought. As Labours of Love progresses, we learn to listen. Bunting draws on an impressive range of quotation and argument, from Rilke to Paula Rego; from Walt Whitman (who worked in the crowded military hospitals during the American civil war) to Martha Nussbaum and feminist philosophers of care.
Asking how care has come to be devalued, Bunting does not idealise the past. Residential care, she maintains, has long been “custodial”; the welfare state was not designed for our ageing population. The history of domestic service in the UK and abroad casts a long shadow over care work. After trying her best to cope, a frankly disillusioned graduate, felt obliterated by her job in high-end homes. One client addressed her simply as “carer”.
More of us are living longer. The “slow dying” of our times, with a long old age punctuated by falls or stroke, puts increasing pressure on the NHS (increasingly, too, the deaths of the elderly happen in A&E). Nearly a third of day care centres have closed and “care deserts” have opened up in other parts of the country. Yet “elder care” remains a source of rich pickings in the private sector, apparently recession-proof, especially for overseas investors.
As we face a second wave of Covid-19, there are more proposals for reinvestment in the care economy, for the redesign of welfare, for collective solutions that might revalue jobs in care. Bunting can touch on this only briefly. The need to make places and names anonymous in the book also has its drawbacks. But campaigners will find plenty of grist for their mill.
Labours of Love is a fine achievement. It is full of humanity. I found it utterly absorbing and, unpopular though the word is, humbling. Though they are frequently worn out from the Sisyphean labour of “rolling back anguish”, the care workers she speaks to remain endlessly curious about their patients or clients, wanting to hear life stories. They often belittle their efforts – “it’s nothing”, they say. “It’s a privilege.” But they are doing the work that really matters.
• Alison Light’s A Radical Romance: A Memoir of Love, Grief and Consolation is published by Penguin. Labours of Love: The Crisis of Care is published by Granta (£20). To order a copy go to guardianbookshop.com. Delivery charges may apply.
