A care crisis
The appalling stories we have heard from the Royal Commission into Aged Care Quality and Safety and in the lead up to the upcoming Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability are just the tip of the iceberg. People with disability, older people, families, advocates, providers and workers have been talking about a care crisis in Australia for a very long time.
The ethical crisis in the care sector is compounded by unprecedented demand for care services. The life expectancy of older people and people with disability is increasing, and expectations about the quality and convenience of care services for clients are also increasing. Meanwhile, the supply of informal care may be decreasing dramatically into the future. Informal or unpaid carers, who are usually female family members of the person they care for, still provide a huge proportion of care labour hours in Australia every year. But as the life expectations of successive generations of women changes, this is not something we can or should depend on in the future.
A changing support paradigm
The major rehaul of the disability support system represented by the National Disability Insurance Scheme (NDIS) aims to provide support tailored to individual needs and increase the choice and control people with disability can exercise over their services. Likewise, reforms of the aged care system have aimed to make the system more ‘consumer directed’ by increasing choice and transparency (as well as user contributions to care costs).
These changes have done a lot to signal there are very different expectations of the care sector now than there were in the past, and that clients, their families and the community will hold providers to higher standards of accountability now than ever before. They have also moved the Australian care sector to a significantly more prominent position in the media and public psyche, signalled by the current and upcoming Royal Commissions.
But the benefits of these changes for clients have been unevenly distributed, with those best able to advocate for themselves, or who have a strong network of supporters, more likely to experience choice and empowerment, and those with cognitive disabilities, complex support needs, and who are isolated more likely to experience significant barriers to good conditions and support.
And despite new policy settings and rights-based legislation, and an associated shift in the language and marketing used by care organisations, these changes require a cultural transformation that many providers are struggling with.
The care workforce
The major changes currently being implemented in the disability and aged care sectors have had some dramatic implications for the care and support workforce, including:
Increasing demand for workers
Changing expectations of service flexibility, and
Increasing casualisation and low job security.
One study found that about 60% disability workers said they did not have enough time to do their work under the NDIS, and about 72% were worried about the future of their job. It found that prices for disability support work set by the NDIA “do not account for what is required to deliver high quality services, and arrangements are not fully enabling disability support workers to deliver services which are personalised, co-ordinated, responsive or safe”. Another study found that workers under the NDIS were consistently underpaid for travel and overtime. Perhaps unsurprisingly given these findings, the National Disability Services’ State of the Disability Sector Report 2018 found that providers are finding it increasingly difficult to recruit more disability support workers to a sector that desperately needs them. Low wages, limited opportunities for training and career development, and a lack of staff to resident ratios in aged care facilities have also been reported in coverage of the Royal Commission into Aged Care.
Despite these systemic problems, there is a growing body of research that demonstrates that positive relationships with paid support workers can make a big difference to people’s lives – particularly people from groups that are more marginalised in society, such as people with cognitive disabilities, people with complex support needs, and people with limited social support networks. Providing enabling and empowering care and support requires complex skills in augmenting and supporting a person’s ability to communicate and make decisions, managing social and emotional dynamics and boundaries, as well as personal traits such as patience, flexibility, attentiveness and responsiveness.
So why is care and support work so poorly valued in our society, when it is clearly so important?
Feminist theory and the care economy
The branch of feminist philosophy known as the ethics of care holds that one of the reasons care work is undervalued is because of the systematic under-privileging of the aspects of morality and ethics that have conventionally been considered ‘feminine’, such as the practices, emotions and virtues associated with care. Feminist political economists have also addressed the value we place on care by scrutinising wage equity and gender divisions in the workforce.
Because caregiving has traditionally been seen as a feminine responsibility, workers in the care sector (whether male or female) experience the low pay and low status associated with ‘women’s work’ (Hughes et al, 2005). The skills required to care – and care well – are seen as somehow natural, emotion-based, and spontaneous. Investigating how the Australia’s aged care sector justifies continued low pay for care work that is in high demand and highly skilled, Palmer & Eveline (2012) argue that employers represent care work as unskilled and natural for women and therefore not deserving of higher pay. As a society, we’re not particularly good at even articulating the interpersonal skills central to care work, such as the ability to interpret behaviour and build trusting relationships, but this doesn’t mean they aren’t acquired and developed through discipline, skill, practice and self-reflection (Cortis, 2000).
Quality care and support matters to the Australian public. For the benefit of both employees and clients of the sector, the specialised forms of practical knowledge and expertise that are central to supportive and empowering care work need to be recognised – and invested in.