Emma Ross
Good afternoon and thank you for joining us today for this hour, where we’re going to be talking with Author and veteran Guardian Journalist, Madeleine Bunting, about the crisis of the care system in the UK and her vision for change. She travelled the country over five years, speaking to Charity Workers, Doctors, Social Workers, In-Home Carers, Palliative Care Nurses, parents and other caregivers, to explore the value and humanity of care for children, people with disabilities or other special needs, and the elderly. Her book on the issue, called “Labours of Love,” was published in October. We, at Chatham House, thought it was a particularly poignant time to be exploring this, actually, given that the pandemic has raised all of our awareness, especially during the first lockdown, of who it is that really takes care of us, supporting our lives in the background, allowing us to function, and sustaining us as a society, and how undervalued they really have been. So, welcome, Madeleine, it’s really a pleasure to have you with us today.
Madeleine Bunting
Thank you, Emma.
Emma Ross
I’m going to start with housekeeping first, before we get started, if I may, Madeleine. The briefing is on the record and please ask questions at any time throughout this discussion by putting them in the ‘Q&A’ function on Zoom, and if you upvote questions, they’re more likely to be selected, and just please do it at any time. So, you’d – and anything you want, not necessarily related to what we – well, please have it related to social care, but not necessarily related to what’s come up so far.
So, I’m going to start, Madeleine, I was hoping you could walk us through an overview of what you’ve discovered about the state of care in this country, what the problems are, where it looks like it’s headed at the moment, and what you think needs to change?
Madeleine Bunting
Wow, that’s a lot of questions packed into one. I’ll give you a brief sense of what my approach was. As you mentioned, I used to be a Guardian Journalist and Columnist and stepping back from that journalistic, sort of, treadmill, when I started writing non-fiction full-time, I realised that there had been a, kind of, repetitive news cycle of scandal, followed by inquiry, followed by scandal, and these, sort of, spasms of anxiety about care in one way or another, whether that is, you know, care of looked after children, whether it was the care of the disabled, whether it was the care of the elderly, and I felt that the subject was, sort of, exhausted and had, kind of, fallen into a, sort of, political quagmire, where nothing really happened and yet, there were, sort of, lamentations that we had a dysfunctional care system, particularly for the elderly, and that there were various, sort of, fraying of the social fabric, if you like, around certain dimensions of care, such as, for example, within families, the raising of children, and so forth.
So, I thought, okay, I’m going to take stock, I’m going to stand back, and I’m going to really try and understand the whole, sort of, what I describe of as an empire of care. There are so many ways in which care is woven into dimensions of our lives, both we offer care, we receive care, from the minute we’re born until the last breath we take. So, it seemed to me that having written a book about work, which I wrote and published in 2004, that there was this other human activity, this central, kind of, human experience which was actually even more important than work, because it predates your working life and it postdates your working life, that care is the one, kind of, continuum, if you like. And that set me off in two directions.
One was a, kind of, desk-based research, reading about care, historically, and within many disciplines: philosophy, economics, politics, etc., and then the other dimension was, as you say, I travelled all round the country interviewing people, and I asked them a really simple question, and this is the question I would put to the audience now, those of you who are listening, “What do we mean by care? What do we think care means?” And actually, it’s a really deceptively complicated question, because the minute you start thinking about this little word, it’s only four letters, the more and more the meanings proliferate. And, in fact, when Emma and I were talking to just prepare for this discussion, she quoted her husband saying, “Well, how can you have a conversation about care, because care is the whole of life?” To which I, sort of, punched the air with delight, because I’m like, that’s exactly it, care is the whole of life, and yet, our entire intellectual and philosophical systems of thought over the last 300 years has managed to marginalise care in really systematic, structural ways. And I really do think you have to go back into the sort of, underpinnings, our intellectual underpinnings, to get some sense of just how structurally the bias is against care.
I was very struck by two American Economists who wrote “The History of the World in Seven Cheap Things,” it’s a terrific book, and I can put a reference later, and one of those seven cheap things is care, and they argue, as do many Economists and Philosophers of care in the last 30 years, argue that the way in which the, sort of, industrialisation developed was a, kind of, patriarchy in which care was either expected to be free, provided by women out of the goodness of their hearts, or cheap, paid for by low – very low paid work. And I think the kind of, historical conundrum we’ve got to now is that women have gone into the labour force in unprecedented numbers in the West.
The UK, since 1980s, the numbers have just steadily climbed and we’re at an all-time high. So, it has become absolutely accepted that most households depend on two wage earners and the problem is what happens to the care? If women have transferred a large part of their time and labour into the labour market, who then does the caring? And I just don’t think our society has really, sort of, reckoned with that in any way that is honest. What we’ve done is we’ve created a completely rickety childcare system, which is always on the verge of collapse, has chronic low pay, to the point that a Childcare Manager of a nursery is earning less than they would on a supermarket checkout till, with vastly more responsibility. So, at one end, the childcare system is rickety, and, you know, you only have to look at the current stories saying that COVID had – could well lead to the collapse of the sector, and you can look at the other end, which is around the care of the elderly and the stories over the last year I think have deeply, deeply shocked us.
The numbers of elderly residents who died in the pandemic is one aspect of it, but, speaking personally, almost as bad has been the horrific degree of isolation and lockdowns that many care home residents have not been able to see relatives or enjoy any kind of social life over the last year. So, a care system for the elderly, which was also deeply dysfunctional, extremely expensive and very patchy in terms of provision across the UK, has been exposed by COVID.
So, those are just two examples that I look at in the book, Emma, and we can talk about other dimensions of this, what I describe as a “crisis of care”, which it has affected the NHS. The GPs and the Nurses that I shadowed, that I interviewed, had a profound sense that their calling to care, that’s why they were in the jobs in the first place, had actually become almost impossible to do. They couldn’t do the job that they really wanted to do. So, that was a whole other dimension of this care crisis, and I think so much of this comes back to this marginalisation and lack of interest. You know, care is women’s work and I think there is a sort of, degree of contempt, disdain, and lack of insight into actually what care entails, which bedevils, bedevils this whole policy area. So, I’ve lost count of how many times a male Politician will suggest that working from home can help young mothers.
Well, I mean, it’s just ridiculous. How can a young mother work from home, you know, you don’t juggle a baby with one hand and, you know, tap on your keyboard with the other, it doesn’t work like that. And, similarly, the idea that women in their 50s and 60s should somehow take up the challenge of this new unprecedented situation of very long lives and many of those women are still caring for teenage kids, quite apart from holding down, very important to their family economy, holding down jobs. So, this is a sort of, neglected crisis, is a big part of my book.
Emma Ross
Okay. How – what kind of feedback did you get from women and how they’re feeling about balancing their work and care? Do – I mean, are they still happy to do the care, are they resenting the fact that they’re still expected to do it? What’s the vibe out there amongst women, or are men taking over the caring roles now that more women are working? What’s going on out there?
Madeleine Bunting
So, I would be very hesitant about summing up a, sort of, general view. You’ll find – you know, you gave a number of options as to how women might feel about care, and all of those will be evident in all sorts of places, that, you know, you can feel resentful, you can feel, you know, deeply, deep sense of responsibility. There’s the whole gamut of human emotion about what care consists of. I was particularly interested in the role of men, because I think it’s absolutely crucial. So, one of the things that really intrigued me is how is it that care has become so defined as a woman’s task? And actually, if you look at the history of care, men have played a key role and in two particular areas that I would identify.
One is on the battlefield, that the tradition of male Nurses and Orderlies that are required to, kind of, look after the wounded on the frontlines was absolutely part and parcel of the way this country fought wars for hundreds of years. And the other part was, of course, within monastic institutions, which is the origin of hospitals and hospices. So, that very, very early model of healthcare was actually just as much – just as likely to be run by men as it was by women. So, the way in which care was feminised, I think is a particular development of industrialisation and how, post-18th Century, you get this splitting of the private and the public sphere and men were allocated the public sphere, of a public voice, a public presence in the public square, as it were, and women became part of this very domestic, very private world, where their duty was to care, and actually, if you look back at that, kind of, that Victorian ideology of the family, you know, a whole set of characteristics were allocated to each gender. So, the man was supposed to be competitive, the woman was supposed to be tender, and you can see how it created all sorts of dualisms, you know, you were either one or the other. You know, you’re either a man or a woman and you’re either competitive or you’re tender and loving and self-sacrificial, and I think we’ve got ourselves in a bind between that kin – in that, sort of, dualistic thinking.
And this may sound abstract and kind of a little bit complicated, but if you talk to a Nurse, they are absolutely on that, kind of, that – entrapped in that dualistic thinking, and, indeed, all the, sort of, thinking around healthcare, around productivity, around efficiency. The point about a Nurse is that they have to be both deeply caring of the patients, and that means compassionate and attentive, but they also need to be efficient, efficient in the number of, you know, complex tasks they may need to proceed – to supervise and ensure happen on a ward. So, you can’t – you know, you’ve got to juggle both and that’s part of the complexity of care, that it requires both characteristics and it’s been fascinating. If you look at the history of nursing, the kind of – the sort of, understanding of the development of the education of nursing. You can see the pendulum swing as to whether nursing is a scientific, technical, medical profession, requiring, you know, skill and intelligence, or whether it’s, you know, a matter of the heart and having time to sit with your patient and hold their hands.
Well, if we don’t get that balance between those two right, you haven’t actually got a very effective healthcare system, because what we know, increasingly, from research, not only do you need the technical stuff right, but you also have to have the attentive, personal care right, otherwise it leads to, you know, the sorts of scandals and abuse that we’ve encountered, for example, in the Mid-Staffordshire inquiry, which revealed the hospitals there. So, that’s just to give you some sort of sense of the complexity here.
Emma Ross
Oh, that does sound pretty complex. You’ve talked about childcare being a rickety system, and we all know the elderly care system is a bit of a nightmare, that neither of those systems seem to work very well here. What are the main care deficits in the country, the main pinch points in the care economy, where the fallout is worst, and what is specifically going wrong, say, in childcare or elderly care, or disabled or wherever it is where the crunch points are?
Madeleine Bunting
Well, it’s a – that’s a good question and I think that the reason why my first chapter was around families with disabled children is because I think that is probably about the sharpest pinch point I could see. And I found that chapter, the researching of it, really, really demanding. I spent some time shadowing a, sort of, support – charity support that was providing help for families with children with disabilities. I think that we’ve got ourselves into a bit of a problem here where the legislation doesn’t seem to – the provision doesn’t seem to keep pace with the legislation, so our ideals and aspirations are often, in legislative terms, high. You know, we want disabled kids to have good quality of care, good quality of education, but the reality is that when that is translated into whether a local authority can provide the right package of care, you know, that’s where it, sort of, falls apart and becomes a really brutal lottery system in which the people with the sharpest elbows get the best care, and often it goes to tribunals and legal cases.
And I found all of that really, really difficult, because the charity I was shadowing works a lot with people in very deprived communities and the struggle they had was really painful to witness, the lack of support. I mean, I think it’s very, very hard, if you’ve not got a child with disabilities, I think it’s, you know, it’s a really big, imaginative leap to think what it’s like to be 24/7 sometimes, 24/7, caring for somebody perhaps with severe autism. And the parents were describing the sense of physical, not even being – feeling safe in their own homes, because their teenage children were capable of, obviously, getting very distressed. So, that is a pinch point that I felt deeply troubled by. And then, I’ve already mentioned the childcare system and elderly.
The conundrum that we’ve got with the elderly is that we have invested all these resources in extending life and that’s to be celebrated. You know, it’s wonderful that people now regularly live on into their 90s and, you know, that is a huge achievement. Our life expectancy has carried on climbing for decades. The problem is we haven’t put a fraction of the same resources and energy and effort into thinking, okay, how do you support these fragile lives? Because the maj – you know, it’s wonderful when you’re in your 90s and you’re still independent and living at home and managing fine, that’s wonderful, but actually, that is very rare. And the research indicates that if – in this extreme old age of post-85, the chances are you have about six years of a, sort of, fragile life, which you – you know, you’re really in this, sort of – you’re so fragile, you could – any number of circumstances could actually bring around – bring about the end of life. You cou – a fall, or – a fall is a very, very classic example.
So, it’s not right to say they’re dying, the – this kind of fragility, it’s not about dying. It’s certainly about the ending of life, because it will lead to the end at some point, but for anybody who’s ever been involved, or witnessed that stage, it’s almost continual medical appointments of one kind of another. The demand on the NHS, we know is enormous, I mean, I haven’t got the figure at the top of my head, but it’s a huge proportion of A&E visits are made by the post-85 age group. They need constant engagement with a health service. What we’re less willing to acknowledge is it’s not just the health service, there are – has to be family and neighbours and relatives who are stepping up to support and look after those fragile elderly and that can often be very challenging, because we have a degree of geographical mobility in this country, which means many, many people live hours and hours away from their parents in terms of long motorway drives.
So, you can see how we just haven’t thought through how do you support fragile lives? And, you know, what I think is really painful is, you know, if you have enough money, it’s fine, you buy the care in, but it’s extremely expensive, I mean, cripplingly so, and if you don’t have enough money, then you end up in a very, very desperate plight, and what’s happened in the last ten years is more and more restrictions on local authority budgets for social care mean that more and more elderly people are just about managing, if that. So, that, sort of, care deficit at that end, where, you know, family do not necessarily live close by, there isn’t the sort of, classic ‘loving daughter’ on hand and the state is refusing to step in, and there’s just a gap, we’ve just created this gap. So, you can see how various situations seem to me to warrant a greater degree of political energy and public engagement than we’ve so far managed to get.
Emma Ross
Yeah, why do you think the government doesn’t give the resources that it needs to? I mean, we’re – it’s well understood that with the miracles of medicine, we’re extending life way beyond what you used to be and be able to cope, on both ends, in keeping children alive and also disabled children and people with all sorts of conditions, let alone elderly, and extending that, that’s a huge burden. But why do you think it is that, you know, government is tasked with, you know, foresight, analysis, planning? This is not something that was, you know, a surprise. Do you have any thoughts about why it is that the resources have not been put to it…
Madeleine Bunting
Well…
Emma Ross
…by public resources?
Madeleine Bunting
Yes, yes, that’s right. Well, I think, you know, this is the key question. I think there’s been a failure of political leadership, to some extent, in being straight with the electorate and explaining how more money has to be raised to cover this, that means through some form of taxation, and you can see the last Politician who tried to do this was Theresa May, you know, she came a cropper. So, there is an issue here about that the Politicians haven’t managed to explain it, but I also think that the electorate is refusing to understand it, you know. There’s a kind of sticking your head in the sand thing going on and that’s the second bit of it, which intrigues me, because if you look over the last 20 years, there have been a number of Politicians on – from every political party, who have really, really wanted to get to grips with this subject and have put a lot of energy and effort into trying to do something, and they haven’t succeeded.
And I’m intrigued by the soci – one of the UK’s leading Sociologists of ageing has a comment at the beginning of a book in which he, sort of, surveys the UK policy on the elderly over 100 years, and he says, you know, “There is no tradition in our culture, in the UK culture, of respecting age,” that, you know, “in complete contrast to many Asian societies, who have a very profound sense of respect, but also in contrast with Mediterranean societies, where there is more respect and attention given to the elderly parent,” and the interesting thing is he traced that historically.
He said that actually if you go back to the Poor Laws, for example, of 1834, which were brought in as a kind of measure to, sort of, get the destitute off the streets by forcing them to work in Poor Law – in poor houses or workhouses, interestingly, workhouses, these were people who were supposed to be forced to work. Well, the workhouse system became filled up with the elderly poor, because basically, they would be dumped by their families and actually, workhouses became full of people who couldn’t work ‘cause they were too old. So, that’s one, sort of, scandal that developed during the course of the 19th Century by the failure of social policy in the UK. And then, you know, forgive the history lesson, ‘cause I find – I do find this very interesting, then what happened is another scandal developed.
So, as the hospital system expanded, geriatric wards became full of elderly people dumped by their families, and the scandal of the back wards, as they were called, exploded in the 1960s. It was shocking the conditions in which these elderly people were kept in wards that were literally, sort of, tucked out of sight at the back of your ordinary, average hospital. And interestingly, a young Barrister made his name in the 1960s working on an inquiry in South Wales into a particularly shocking back ward, and that was the young Barrister, Sir Geoffrey Howe, so that was the beginning of his career as a Barrister. And the 60s, you know, there was a massive sense of shame at what had happened.
So, my concern is we’re now running into a third example of this kind of complete failure of social policy in this country to deal with age and what’s happening now is our NHS gets filled up with the elderly, who are too frail to go home, there are no relatives available to take them in, and there are, increasingly, no care homes to take them in either. So, it’s a mis – again, a mismatch of provision. You do not want lots of elderly people in hospitals. If they – you know, if at all possible, you want them out of hospitals. It’s not a very nice environment to be in. You know, hospitals are designed for acute treatment, getting people better and getting them out. So, you know, we know they’re busy, bustling places full of, you know, noise and strip lighting and very impersonal.
So, you know, the last year has been a reminder to all of us of how much admiration the NHS commands in this country, the closest thing to a religion, as people say. And it’s true, the British don’t do religion really, but they definitely do the NHS, and yet, we don’t seem to appreciate that without an effective social care system, the NHS is just crippled. So, these two things have to fit together. You have to have a functioning social care system.
Emma Ross
That brings me to an interesting dilemma I was thinking that, yes, you’re absolutely right about the sacredness of the NHS and the admiration for it, and it is our special thing, but I’m also wondering whether you’ve seen or sensed whether there is some sort of distaste for vulnerability and dependence? And is it a British thing, or is it, you know, more universal than that, the fear of ageing and death? Is part of this story reluctance to face vulnerability and do something about it, some sense of embarrassment or shame over being vulnerable, and wanting to just sweep it under the carpet, or is that a little bit of a tangent?
Madeleine Bunting
No, I think that’s exactly right, I think that’s exactly right. I think, you know, if you look at the great, sort of, 18th Century Philosophers, the idea of the individual, of being – of independence, of kind of, the idea that then developed as, you know, that it was somehow women and children were dependent on the man and so, dependency became something that was, sort of, lesser. It was, you know, not – you were not – women were not an equal to men, they were dependents, that’s how they were described. It became therefore, something that was kind of shameful, you wanted to be independent.
I think there’s a very, very long tradition, particularly in Anglo-Saxon cultures, of this desire for independence, this aspiration, I would say, because I think the point about independence is it’s a fantasy, it’s an illusion. You know, we are profoundly interdependent and the pandemic, you know, like you were describing, this time last year we were clapping on our doorsteps because we suddenly realised that if the supermarket workers didn’t carry on turning up at work, we’d all be starving. I mean, that – it was – we were utterly dependent on some of the worst paid people in the country to ensure that we had enough food. So, I think it was an astonishing, sort of, moment in, kind of, recent history where we were brought absolutely, kind of, to confront our dependence. You know, the guys who were clearing away the rubbish, you know, our streets would’ve been clogged up if they hadn’t kept on coming into work.
Now, does that moment last? Does it lead to a shift? Who knows? You know, people were optimistic a year ago that it could. I think that dependence is regarded, as you say, as something shameful and we have a benefits system which is designed to make that message, that it’s somehow shameful to claim support, that there are times in your life where you need government assistance, that we’ve drummed those messages in, that it’s important to stand on your own two feet, and I think that the problem is that there are many moments in our lives when we are, in fact, dependent and I mentioned when you’re a child, when you’re elderly, when you’re sick, and rather than accepting that as just part of the human experience, it has become something that you try and make as short as possible, get out of as quickly as possible. And when it all – you know, the whole game comes – starts slowing down in your old age, it becomes a matter of shame that you can’t be independent, that it – you know, that I feel we’ve added a burden of humiliation to old age, which is really painful.
It shouldn’t be regarded as humiliating, that as you decline, you lose some of your capabilities, and there, it seems to me, that there is, you know, a necessary, a very necessary correction in our understanding of what it is to age, to try and expand our understanding of human flourishing, to recognise the perspective that the elderly bring to life. You know, it’s always absolutely fascinating to talk to somebody, it seems to me, who’s lived a long time, because they have a perspective that is so valuable to hear, you know. They can look back on various stages of life and reflect how they do or don’t work out. So, we all, as a society, suffer from the lack of that perspective.
Emma Ross
No, that’s pretty sobering. I’m, yeah, I’m going to go on to questions from the audience in a minute, but before I do that, I just wanted to bring up one other thing and ask your opinion. We are – seem to be – talking of dependence, we seem to be a little bit dependent in this country on the carers in our system coming from other countries, rather than – and I’m not sure how common that is to other Western economies, but I wanted to ask you is that a good thing that that’s happening, or a bad thing, or what? You know, should we be making a judgment? What are we to think about that, other than grateful that we can get that, so that somebody is doing it? But, yeah, good or bad, and why do you think we’re in that position?
Madeleine Bunting
Well, I mean, you know, I read yesterday about the crisis in India and 40% of Doctors in the NHS come from the subcontinents, from India, in the NHS. I mean, that’s an astonishing figure, 40% of our Doctors come from India. So, you know, there’s India absolutely on its knees, desperately in need of Doctors and every other aspect of medical care. It’s – there are – you know, it’s interesting, why Doctors come from India, why Nurses come from the Philippines, why we take Nurses from all over the world, you know, I find these really, really interesting. What we have constructed is a global care chain whereby many, many less developed countries export carers and it’s a form of – lucrative form of remittances. The Philippines has been doing it for decades and the result is that Filipinos have an extraordinary reputation for being very, very loving and gentle and patient, and I’m sure many people, and myself absolutely, have seen the quality of the care from people who just have a gentle patience. I’ve seen that in Filipinos, and there are obviously – there has long been concern about the stealing of Nurses and medical professionals, stealing, because it’s – you know, it strips out those care professionals from their own countries.
I think that it’s partly reflects this issue that I was talking about, about Anglo-Saxon cultures never having given care the respect or status that it needs, so that I think there are other cultures that have a much, much better understanding of the significance and importance of care. Funnily enough, while I was researching this book, a friend, who was a young Doctor, went off to work in a hospice in New Zealand and spent quite a lot of time with Maori people, who – you know, who were using the hospice, and we had some fascinating conversations about Maori understandings of care and how central it is in Maori culture.
It’s not, sort of, tidied away into the corners as women’s work, it’s absolutely regarded as a central activity of the whole community. So, I think that’s part of the answer. Part of the answer is that it’s about an unequal world, people go where the salaries are, they go where they only – you know, where they can find a way to make a living. And the – another part of this very, kind of, complex story is that nursing has played a very, very interesting role in social mobility. So, it has been, and this is greatly to its credit, when it’s organise – you know, structured and the training is structured well, you can go in as a, sort of, Nursing Assistant, with not necessarily many qualifications from school, and if you take to the work and you enjoy it, you can actually train and then train and train again. So, one of these Nurses that I shadowed at a hospital, who was a superb Ward Sister, very – I mean, I thought quite young, you know, in her early 30s, so calm and capable, and she told me that 11 years before she’d been a shop assistant and she’d, sort of, drifted into nursing and she wasn’t quite sure it was her thing and she didn’t have the academic background, and it had just worked magnificently for her. And there’s plenty of stories like that of women who’ve been able to build really rich, rewarding careers from nursing.
So, there’s many different reasons, but, I mean, it’s true in Italy as well. It’s not just Anglo-Saxon cultures now, there’s a huge number of Romanian and Bulgarians in Italy looking after the elderly, and it’s predominantly Romanians, and that is about, you know, a poor country where young people are looking to earn money and the best chance of that is by going abroad. So, you know, that creates a whole set of problems for Romania because, of course, you’ve got the elderly people still left at home with none of their offspring to look after them. So, every time you have a global exp – you have an export of care, it leaves a deficit behind.
I remember talking to one Filipino nanny who had 18 children back in the Philippines and she and her husband were working for a very rich Italian family and she basically – it was the mobile phone, she was parenting by mobile phone, and the elder children were looking after their younger siblings. And without the mobile phone, you know, I don’t know how any of that would have worked, but it struck me as doing a lot of damage to the social fabric of the Philippines when you have such an extent of expatriate care labour, you know, moving abroad.
Emma Ross
Hmmm, yeah. Speaking of which, vacuum and who is going to take care of them and filling the hole in general, there’s a question from the audience that actually speaks to something I wanted to ask you about robots, and it’s from Kamil Hussain, who says that, “In the UK, the need for care is going to increase significantly, with demographic changes and other factors contributing to a rise in cohort of older people. If we agree that traditional support networks are less robust or available than in previous generations, will we have to rely more on technology to provide care, as seems to be the case for other countries with similar or more extreme demographic shifts towards older populations?”
Madeleine Bunting
Well…
Emma Ross
So, I hope you can address that…
Madeleine Bunting
Yeah.
Emma Ross
…and weave in the robots.
Madeleine Bunting
Yeah, yeah, no, that’s a really, really interesting aspect. So, Japan, as we know, has a very elderly population, or the eldest in the world, and they have very strict migration policies. They don’t want inward migration. So, they have absolutely gone wholeheartedly down the robot route. The robot route always, kind of – everybody gets – you know, immediately has some sort of sci-fi vision of some sort of, you know, kind of, anthropomorphic, kind of, robot-looking figure wandering around, kind of, providing care. In fact, I just read “Klara and the Sun” by Kazuo Ishiguro, which is one very vivid, very powerful, fictional version of what a carer of a child could look like in robot form, and this is, for anyone who’s not read the book yet, it’s a fascinating read, because the robot has been developed with an enormous amount of empathy. So, the robot can understand the child that they’re tasked to look after and to become their friend and this extraordinary relationship between the robot and the child.
I think that, when people say, “What’s going to happen in the UK?” I think it’s going to be robots and carers, I don’t think it’s going to be one and I also don’t think robots in, sort of, anthropomorphic shape really makes sense. It’s actually much more likely to be all sorts of really supportive forms of technology. And I think that, you know, if we imagine growing old in 25 years, for example, I think it will be standard to have machines that help you in and out of showers, machines that help you with eating and food. I think that there will be a lot of investment into how to make – help people to remain independent in their homes for longer. But, at the same time I think there is another dimension to this kind of question of the future, which is that automation is going to remove a lot of jobs. That is the prediction that everybody agrees on.
The one area where they are not predicting a decline, a serious decline in employment, is in care, because the tasks of care are so complicated, it’s a bit like plumbing. Apparently, there are – it’s unlikely that automation can actually replace the Plumber. It requires a degree of flexibility, physical flexibility, as well as a set of emotional characteristics which is quite hard for technology to match. And I also think that we need to think because care is a growing source of employment now, and is predicted to carry on growing, we need to think much more seriously about care as a really good job and as one that actually provides people with a lot of sense of meaning and purpose and job satisfaction, if it’s done in – you know, if it’s constructed in the right way.
I mean, if you’re rushing in and out of a home, you’ve got ten minutes to feed somebody with dementia, that’s stressful. That is not job – going to provide job satisfaction. But there are plenty of carers who I interviewed who said, “I love the work, you know, I know I make a difference to someone’s day, and that is deeply rewarding.” I mean, there was a wonderful 21-year-old carer, care worker, and she said, you know, “I’m going to carry on having a job. All my friends who are working in beauty parlours or, you know, on shop tills, you know, do they get job satisfaction? Will they have a job in ten years’ time? I don’t know, but I’m going to have a job.” And I thought, you know, the person who agrees with that Care Worker is the Chief Economist of the Bank of England, Andy Haldane, who wrote – who gave a terrific speech to Oxford University in 2018, saying that “Care is going to be a major source of employment, so what are you, Oxford, going to do about that? How are you going to support and develop the understanding of care as a meaningful, important, form of work?” I thought that was a fantastic challenge to give a really elite academic institution.
Emma Ross
Yes. So, do you think there is any waning? Given the stresses of care work and the lack of resources, it seems it is still a popular career choice and maybe that’s why the Politicians are not investing, because they know people will do it anyway. The job satisfaction replaces, you know, resources, or pay, or, you know, aspects like that.
Madeleine Bunting
Well, no, actu…
Emma Ross
Or are we really seeing a crisis in not being able to find people to do it?
Madeleine Bunting
Well, I’m glad you mentioned that, because I would say, actually, that one of the reasons why the system, you know, care, both, you know, in terms of professional institutionalised provision of care, whether the children or the elderly, is in crisis, is because there is such a rate of churn. That people don’t stay in the jobs, they are so badly paid, and they are so stressful, that something like a third of care workers are resigning every year. So, every single care company is having to invest a considerable part of their workforce in a constant process of recruitment and training, which makes these care companies, you know, very, very precarious, because their profit margins are so – are small. So, they’re having to – you know, in a care comp – in a company that’s trying to provide – an agency that’s trying to provide home visits, for example, maybe they have ten members of staff, and, you know, maybe a quarter of those, or a third of those, are all about recruitment and retention.
So, the churn makes it almost impossible to run, you know, a care home efficiently. I mean, you know, I’ve seen this. My mother is in a care home, and I cannot tell you the number of emails we’ve had about new Deputy Managers, new Managers, new this, new that, it’s – you know, we never know who’s in charge, this constant carousel of personnel. Well, that is not the way that care can work. You know, both children and the elderly have one big thing in common, which is a need for continuity, continuity of relationship.
Now, into that already precarious situation, we now have a huge additional challenge, which, given our dependence on importing care workers and the new restrictions on immigration, there’s just this kind of yawning gap, so more and more vacancies, I mean, about 150,000 vacancies has been the case – I mean, most institutions are, kind of, operating, you know, on skeleton staff, or not enough staff, or having to permanently cover for the shortness of staff. So, I think the gaps are already becoming really, really evident in all sorts of ways, and the latest – I haven’t read the – what’s happened to this, but one proposal was that care workers from abroad would get a year long visa, but they wouldn’t be able to renew that visa. And that proposal seemed monstrous to me, absolutely monstrous, because it just exacerbates the churn. Imagine you get somebody coming from Poland or Hungary, who’s, you know, really good at the job and then you’re telling them, after a year, “Sorry, you’ve got to go now, and you can’t come back.”
Emma Ross
And not mindful of the people they are caring for that need the consistency in the relational.
Madeleine Bunting
Yeah, exactly, yeah, yeah.
Emma Ross
Well, I’m going to go to the most upvoted question next, so please do keep the questions coming. We have time for more. But this one upvoted is from Mitch Watkins and it’s about the Kruger Report, “What are your views on the Kruger Report and how comfort – confident are you that its recommendations being implemented?” If you could first explain what the Kruger Report is.
Madeleine Bunting
Yeah, well, actually maybe Mitch could explain, because I’m not familiar with that one.
Emma Ross
Ah, okay, so, Lauren, can we get Mitch on the microphone, maybe, to explain the Kruger Report, or we’ll leave that – or maybe he can type it in, and we’ll come back to that in a minute? Probably that’s best. I’ll go onto – this is an interesting idea from Leida Amrula. “It’s somehow unconventional, however, I think it can be an option to have the chance to adopt the elderly, meaning that those families who have great respect for the elderly and have the potential to take care of them, have the opportunity to come in and help.” What do you think of that? I think that sounds lovely.
Madeleine Bunting
I think it’s a great idea and what’s more, it is happening, it’s already happening. I mean, I always joke about the fact that I’m adopted and they’re not exactly elderly, but they’re parents of a friend of mine and I said, “Okay, I’m going to adopt you.” It’s a reflection of a very, very fond friendship on both sides. But Shared Lives is, I think, one of the most interesting organisations that is really trying to rethink care, and they’re based in Manchester and they have this model whereby they will arrange, kind of, matches, if you like, where it’s not a formal adoption, but, you know, you do effectively – you know, it can be a child with special needs, or with some kind of health issue, goes to live, almost like in a fostering relationship, with a family. Or it could be that the family adopts the granny or the grandfather, you know, an elderly woman or man living nearby and, sort of, commits to supporting them. So, Shared Lives is now providing care to about 14,000 people.
It’s a very – it’s a really interesting model and they’re very closely allied with, I think it’s Homeshare, where younger people get housing in return for living in an elderly person’s home and being a bit of a support, providing a bit of help here or there. Not so much care, but help, you know, like taking the rubbish out, or something like that. and I feel that those kinds of ideas are great, because the reason why they can be so powerful is they put relationship right at the centre of it. Instead of it being a sort of, bureaucratic arrangement, it’s about, okay, how do these people get along and how do you support them in that relationship? Because inevitably, there can be mismatches and you’ve got to find the right people so that the relationship works. And it’s quite – so, I think it’s quite sort of, labour intensive.
I don’t think one should see it as a sort of, you know, cheap solution, but if it’s supported properly, I think it could be amazing. I mean, I’ve heard the testimony. I was at a conference where two young people, both of whom had had – with mental health and they’d both moved into families under this scheme, and it had just turned their lives around completely and it was the first time that they had felt cared for. So, they had been in mental health institutions and in, you know, kind of, children’s homes most of their lives, and this was the first experience that they’d had of actually really being cared for, which is so foundational. It’s so important to our sense of wellbeing and our confidence of, kind of, working in the world. Care is what we all, sort of, stand on, the care of parents to raise us, the care of, you know, family members and partners, etc., and friends. So, it was – that was a very, very inspiring example.
Emma Ross
Yeah, it sounds like it would be a good thing for fostering a culture of care, in the first place, among, you know, society.
Madeleine Bunting
Yeah.
Emma Ross
For that to be seen as a norm and to become more of an opportunity. I would think it would go a long way in changing attitudes and, you know, normalising the cross-generational thing, multi-generational households, or cross-generational living. Are we – I mean, is that part of the story here, relative to other countries that have a multi-generational household thing? Obviously, that seems to be that it would make it a lot easier for care to be given.
Madeleine Bunting
Yeah, I mean, you know, it’s really interesting. I mean, the Historians say that, really, the UK has never had, or not for a very long time, multi-generational households. That that sort – the sort of, granny in the corner by the fire was always a bit of a myth, actually, ‘cause they didn’t live long enough, and it can be a bit, sort of, rose-tinted. I mean, this – the problem about this whole subject is, you know, the policymaking can get really wrecked by a kind of, romanticisation, or sort of, sentimentalisation. Multi-generational houses depend on having a house that’s big enough, you know, and…
Emma Ross
Yeah, yeah.
Madeleine Bunting
…you know, that runs into a whole other problem around housing. So, you know, I’m just reviewing a book at the moment, a beautiful book by Kate Mosse, the bestselling Author, who has, over the last 20 years, looked after three parents, for a good chunk of that time all three in her house. And, you know, it’s a lovely story of a family who were lucky enough to have a house big enough and to have a family that all really enjoyed being together, but, you know, not all of us are as lucky as that.
Emma Ross
No, no, and not Kate Moss the model, right?
Madeleine Bunting
No, this is Kate Mosse with an E.
Emma Ross
Okay, hmmm hmm.
Madeleine Bunting
Author of “The Labyrinth,” the wonderful bestsellers.
Emma Ross
I hear from Lauren that we can actually bring Mitch in to explain what the Kruger Report is. So, are you with us? Yes, I see Mitch up on the screen. Hi, Mitch.
Mitch Watkins
Hello there, how are you?
Emma Ross
Oh, great, thanks. Thanks so much for the question, and so, please go ahead.
Mitch Watkins
Good, thank you. Well, agree with so much of what you have said, Madeleine, and what it occurs to me is that what you’re saying is what Danny Kruger has actually reported in his – the Kruger Report, and it was commissioned by Boris Johnson in, and reported on in 2020, and, sadly, the cynical part of me goes, how wonderful this would be if it were implemented. And I would strongly recommend that you read it, because it actually puts into its recommendations a whole range of systemic and structural changes that you were, in that sense, advocating, although I haven’t read your book. In your experience though, you know, when these reports are made, how often will it just end up in a filing cabinet and not truly be implemented, given the current political scenarios?
Madeleine Bunting
Well, I’m really grateful, Mitch, for you pointing that out, that report out to me. I mean, I did wonder whether it was Danny Kruger. I mean, I’m curious, obviously, I want to, sort of, ask you, kind of, subsequent questions as to exactly which bit of care he’s identifying. I mean, Boris Johnson is also being advised by Camilla Cavendish, who did a superb piece of work in 2013, where she did work about care workers, their level of qualification, how they’re trained, how it works with Healthcare Assistants in the NHS, and, you know, I mean, hats off to her, she really, really got down – that was – she was commissioned by Cameron, and she really got to grips with the subject and was deeply, deeply, sort of, moved, I think, by the way in which hundreds of thousands of women work with such passion and commitment to what they’re doing and get so badly paid for it.
Now, she put forward a set of recommendations, some were taken up, some weren’t, but the latest I heard from her is that she is now doing work for Boris Johnson. The point is it doesn’t really seem to, kind of, shift the dial enough. You know, they seem – these Politicians get good advice, I mean, you know, we’ve got no shortage of, sort of, really superb expertise, the Dilnot Inquiry. There’s been all sorts of proposals about how we fund, better fund social care. So, you know, I share some of your scepticism. But can I put that question back to you, Mitch, what – in what way is Kruger saying care is relevant to the levelling up agenda? I mean, I can imagine, but I’m just curious as to what Kruger says.
Mitch Watkins
Well, if you look at the report, I mean, it puts in a whole range of recommendations and I can’t be that specific, having read it only the once, but primarily, what you’re saying is that it needs a wholesale reappraisal of our understanding of what care really means, and, like you said earlier, a serious shift of resources, and put it at the forefront of government thinking, and more important policy and recommendation. So, I mean, sadly, of course, the only real time when we’ve done this in this country has been back to things like the Beveridge Report when we’ve had to have a World War to get the sense of urgency. And that’s what concerns me, how are we really going to make a change unless that level of urgency and a real direction from Politicians that really are truly affected, both personally and from their constituents, that this is a real national crisis? That’s my thinking.
Madeleine Bunting
Yeah, well, I couldn’t agree with you more. I mean, I wonder, in the Kruger Report, whether it drew on the thinking of foundational economics, which is this, sort of, model that any economy has absolutely essential needs, utilities, you know, your gas, your water, your electricity, and then, your care economy. And they analysed how money comes into communities and how it goes out of communities, and how it circulates within the community, all of which is crucial to the prosperity of that community, and I think that that’s where Economists are – you know, paint a really fascinating picture that the more money you put into care workers’ pockets, the more you benefit their families. So, in terms of a, sort of, levelling up agenda, this is a very, kind of, direct way to ensuring that children are not living in poverty. That is, you know, a really, very kind of direct link, ‘cause a lot of care workers have children.
So, if they’re getting paid properly, then their kids are not going to be in poverty, and we know there’s a huge body of academic research about the damage to children growing up in relative poverty, I’m not talking about absolute poverty. So, I’m really grateful for you alerting me that care has, kind of, come into that part of the levelling up agenda, because I think that’s very far-sighted and it gives me heart that that is on the – you know, that thinking has got through into the Conservative Party, as indeed, it has done into the Labour Party. So, there’s a potential here for a kind of cross-party alliance. I mean, I’m not being naïve, I think that’s quite a challenge, but, you know, can we get to a point where there’s a, sort of, political consensus behind this?
Emma Ross
Yeah, and the report has been posted, a link to the report, the Kruger Report, has been posted in the chat, so if anybody wants to follow up on that, and – by Stephen Andrews. Thank you, Stephen, for posting that link to the report, and actually, Stephen, you get the last question, because we’ve already gone over, as the conversation has really dug down to quite a deep level here. Stephen’s question, Madeleine, is, “You cited the conflict between the technical aspect and the caring aspect of nursing. This was brought together in order to professionalise the profession. Should we be splitting things back, SEN and RGN, with perhaps crossover of SEN into adult social care?” That’s your final question.
Madeleine Bunting
I’m not sure I understood that last bit about SEN and…
Emma Ross
Splitting it – SEN and RGN, splitting out the technical aspect and the caring aspect of nursing that were brought together to professionalise it, should it be separated again?
Madeleine Bunting
With perhaps a crossover into SEN, yeah, into – yeah, I mean, I presume this is the different qualifications of nursing and I feel is about three questions, actually, kind of, conflated into one there. So, let me just take the most – the one – your first one, really, is that I think that Florence Nightingale is an extraordinary historical figure, precisely because she managed the dualism. You know, one of the things that I find fascinating about Florence Nightingale is she was a brilliant statistician, but she is – the legend, the myth of Florence Nightingale is “The Lady with the Lamp”. So, she was both projecting the caring aspect of nursing, and that was a revolution because if you remember what the context of nursing that she was reforming was, kind of, you know, alcoholics and, I mean, alcohol was used routinely by Nurses to cope with the, kind of, horror and trauma of the, you know, condition in those early hospitals, which was disgusting, appalling. So, Florence Nightingale, with her emphasis on hygiene, her emphasis on order and management, ‘cause that’s why she was so interested in statistics, was bringing technologies of various kinds into the labour of care, but at the same time, because of her Christian background, she absolutely insisted that it was work that always, always was about compassion. And so, you know, you can – there are – there’s a – she has left a very complicated legacy for Nurses, because the emphasis on the Christian self-sacrificial dimensions of nursing have meant that the profession has struggled to get the pay that they deserve, unlike Doctors, they’re required to do it from the goodness of their heart type thing.
On the other hand, where I think Florence Nightingale absolutely had one of those dramatic, sort of, paradigm shifts was to put the combination of technology and compassion right at the centre of healthcare, and that’s what our healthcare systems have been built on, at their best. So, I would be very nervous indeed about splitting things in the way that you’re describing. I think the splitting has been happening, because I think so much of the patient focused care has now been taken over by Healthcare Assistants, while the Nurse is often so preoccupied with, sort of, managing things on screens and so forth. So, I would be saying, actually, no, let’s revive that, sort of, Nightingale insight that it is always where these two things meet, the technology and the compassion, that they’ve got to go together and wherever you split them, you ends up with problems, such as the Mid-Staffs situation. So – and, sorry, if I haven’t quite answered your last point about SEN and RGN, but I think we’re running out of time, and it probably takes us a bit too long to cover.
Emma Ross
Yes, yes, yes, we are, but, for the audience, I was just going to say, SEN, as in – was called a State Enrolled Nurse and it was abolished, it offered a less qualified route into nursing, and there was actually a petition a few years ago to bring that position back. So, just for others, RGN was a Registered Nurse, I think, just for those who weren’t familiar with the terms. So, I think unfortunately we have to wrap up on that. Sorry for anybody who was hanging in there over the hour, but I think it was worth it to squeeze in a deeper conversation. And, Madeleine, I want to thank you so much for joining us and raising more awareness and discussion about this really important topic and leaving us with – yeah, I don’t know whether to be optimistic or not, as to what the prospects are for improving the situation on this, but it seems to be a long way to go. So, thank you so much.
Madeleine Bunting
Well, thank you very much, Emma, for a really interesting conversation, and thank you very much for the comments. I’ve posted a couple of things I’ve referred to. Sorry, I haven’t got…
Emma Ross
Oh, yes, yes, go ahead.
Madeleine Bunting
…more references, but both of those are quite easy to find, and I’m optimistic, because I think, just to end on a very, very brief optimistic note, the capacity and the desire to care are innate, and it’s extraordinary how people can find those – that capacity and that desire at moments of their lives. And, you know, every time a parent falls in love with their new child, that is what’s happening, they will care for that child for you know, the rest of their lives, and many, many people describe caring for another person, their elderly parent, as a deeply, deeply powerful experience and a deep privilege, which is the verdict of Kate Mosse in her book that I’m reading at the moment. So, you know, this is a really – it’s not just a problem area of human experience. I think it’s really important to keep the focus on it being, you know, a vital and deeply meaningful part of human experience.
Emma Ross
On that note, thank you very much.
Madeleine Bunting
Thank you, Emma.
Emma Ross
And it’s good to end on the human experience and the reality it’s woven into all of our lives at the end of the day, so whether paid or unpaid. So, thank you all for joining us and thank you, again, to Madeleine, and have a great rest of the day. Thank you, bye.
