All take and no give? It can feel like that for care worker and mother, Suzie, in Bridgend. Photograph by Matthew Horwood

Worked to the edge: inside the care industry

Boris Johnson promises a bold overhaul of the way we pay for social care. But amid that row, we risk forgetting the precarious conditions of the people who provide it
September 27, 2021

Susie is smiling broadly as she tucks her legs under her on the sofa in Bridgend, South Wales, and begins to describe how she manages to bring up two boys on a care worker’s pay. She has just come off a 28-hour shift, and when I comment on her smile, she admits that she’s tired but laughs.

“I got a few hours’ sleep on the sleep-in shift (which requires being on call from 11pm to 7am) and it brings in £62. The extra money is lovely, what with both my boys’ birthdays coming up and Christmas not far off,” she says although we’re speaking in mid-summer. “This is the longest week I’ve done in a while—it will be a total of 71 hours.”

Susie has red hair swept up in a ponytail, a pair of earrings that are miniature yellow ducks, and an instant warmth. She often finds herself picking up extra shifts above her contracted 35 hours: “I usually do 50 hours a week, but at the moment we’re short staffed, so I’m helping out colleagues.”

She’s been working for the same care company for 16 years, supporting four adults with severe learning disabilities, and challenging behavioural issues in their own dedicated home. When her boys were younger, she had to juggle night and weekend shifts with their father’s availability. But now a single parent, she feels confident that with the eldest aged 14, they can manage and if need be, cook themselves dinner. 

On 50 hours a week, she estimates she can take home £1,900 a month which covers the bills and the mortgage, but the boys are growing fast with big appetites, and towards the end of the month, she can run short. “They are very good and understand that I work such long hours to make sure they have what they need. This week I did have to tell them they couldn’t have their pocket money until pay day.”

She gets around £25 a week tax credit, but has to do extra shifts to cover the cost of school uniform. The boys’ birthdays—just nine days apart—require especially careful planning over the summer. She says she feels bad sometimes that she has to work so hard during the boys’ holidays, but is hoping to do some day trips.

“My best friend is a waitress and makes more money. Another friend is a teacher and both of them can’t believe the rubbish pay given how tough [my] job is. I’m dealing with life and death issues such as epilepsy, but it wouldn’t suit me to do waitressing or a supermarket. I love my job—I love people,” she says and adds with a wry chuckle, “I’m a nurturer and I need to be needed. It’s more important to me to be happy than to get lots of money. I enjoy my job and that’s how I can manage. As long as I can get through the month.”

On her salary of around £22,000 a year, she is paying £500 a month on the mortgage she took out with her former partner. She thinks they will have to sell the house soon because she hasn’t been able to manage the upkeep on the property. But as so often with families scraping by on low pay, the real killer is the unexpected things that crop up: her smile falters when she explained how her boiler broke down last winter, and she had no savings for the repair; she was lucky, her ex-partner’s family stepped in and helped. She needs a car for her job—employers need drivers to take service users to hospital appointments and on outings—and that adds another headache if it breaks down.

article body image Gilda in Gloucestershire has worked 30 years as a carer, and reports that the terms have got far more punishing. Photography by Rob Lacey

Gilda in Gloucestershire has worked 30 years as a carer, and reports that the terms have got far more punishing. Photography by Rob Lacey

The over-employment trap

Not so long ago, the discussion about hardship in Britain was all about unemployment, and then under-employment where workers couldn’t get enough hours. More recently, though, the focus has shifted again, because most people below the breadline—and the overwhelming majority of poor children—are in working households, and often toiling flat-out for long hours. Amid post-lockdown and post-Brexit labour shortages in various industries, urgent demands for extra shifts are only to be expected. In the care sector, however, the problem of being short-handed is more structural. With an ageing population, it is a growth industry—but an unusual one in that its revenue in large part comes out of fixed and over-stretched public budgets.

A big political development in September sounded like it might have provided relief on this front, when Boris Johnson unveiled a National Insurance rise to “pay for” care. But on inspection, it turned out that much of the tax, some of which will come from the low-paid themselves, will initially go to the NHS rather than care. Further ahead, one of the main reforms is all about capping what patients pay (and protecting middle-class inheritances). The Institute for Fiscal Studies cautioned against assuming the new money would be enough to reverse all of the consequences of the cuts made during the 2010s. And although the plans do earmark something for training, there is no reason to think the terms and conditions of the workers at the sharp end will appreciably improve any time soon.

Back in the present, Susie says, the one thing that can get her down is the constant pressure to do more hours. “The company is always short-staffed and however much work you do, they want more. Often you feel guilty because you care about people and you know that if you don’t help out, a service user won’t be able to get out or do something. It’s challenging work, but you just have to do it.”

The low pay is a struggle—Susie’s mother comments that she doesn’t know how her daughter manages—but what drives her to the point where she really can’t cope is more often the demands of the job. “I’m looking after a service user at the moment who is verbally abusive, and he shouts and slams the door. All the staff deal with it differently and I’ve asked for training, but nothing has happened. It can be very stressful. You feel like you do loads for the company, but if something goes wrong, they blame you. Plus, important issues I’ve raised don’t get addressed. Last year I went off sick for two weeks. I told my manager: I’m burning out. I kept telling them I couldn’t cope with a very aggressive service user. He headbutted me and because I’m short, he hit my head. I begged them to move me, but I was told to just get on with it. I’m entitled to sick pay but otherwise there was no support from my manager.”

A few years ago when Susie had an operation, she went back to work too early and the wound re-opened and she had to go off sick. But apart from that one incident, she counts herself lucky that she is strong enough to manage the workload. She doesn’t know of many others who do the hours she does. “My friends tell me I’m a pushover,” she laughs. 

“The company is always short-staffed and however much work you do, they want more”

Adult social care—such as Susie provides—has been largely contracted out since the eighties, and the way the competitive tendering has often worked has led to pressure on pay and working conditions. Although, as we’ll see, Wales (where Susie lives) is trying to refine the way public procurement works, she still believes council jobs are a better bet, and after 16 years, she has had enough of the company’s demands, and has found a new job with a council-run support service for mental health and addiction. The pay is not much better, but she thinks the hours will be more manageable and she will have a better pension. She’s hoping she will get some training and wants to progress in career terms; at her old employer’s, management positions entail a lot more responsibility but the pay is not much better—around £11.50 an hour. 

Caring, not cared for

A hundred miles away across the border in the well-heeled town of Cheltenham, Gilda knows well the struggle Susie has had to raise children with a careworker’s long hours and low pay. Gilda came from a farming family in Madeira in 1990 and has worked in care ever since. While her husband was repeatedly made redundant from factory work during the 2000s, Gilda kept working while looking after their three boys as the couple juggled shifts. She worked nights and looked after the kids in the day. She admits it was exhausting but she needed to work and she preferred care work to being a cleaner; she wanted to help people. 

Back in 1990, she says terms and conditions as well as pay was much better. She worked for a good company with a council contract that recognised the union, and treated their staff well, but they lost the contract to a non-profit organisation. The warping effect of the competitive tendering environment proved more material than its charitable status: workers were not, in Gilda’s experience, treated with dignity, the organisation wouldn’t recognise the union, and she claims the quality of management deteriorated.

Gilda says pay and employment conditions in the care sector have steadily declined over her 30-year career. Management became progressively more demanding and more inflexible about imposing rotas and shift changes—and also more remote. “When I started, there was no bullying and managers were often trained nurses who knew how to look after patients and staff, but now you have managers in high heels who never work alongside us.” 

Photography by Matthew Horwood. Photography by Matthew Horwood.

Under constant pressure. Photography by Matthew Horwood.

Gilda is a hard worker and her laughter is well known around the care home. She says her disciplinary record is “squeaky clean,” but even she couldn’t avoid the pitfalls of care work. On one occasion, she went in to work not feeling well, but was anxious not to let colleagues down—or antagonise her manager. It was a night shift and for a few minutes, she accidentally fell asleep in the office due to the painkillers she had taken. The next day, she was summarily taken off her night-shift rota—with its £400 worth of enhanced pay—put back on days, and her application to be a shift leader was rejected. 

The incident was over 10 years ago, but Gilda is still furious, her pride in her work deeply wounded. This, rather than her £16,000 salary, is what she wants to tell me about in detail: a burning sense of injustice that the job has asked so much of her in terms of patience, kindness—many of the people she cares for have dementia—and flexibility, and yet offers little in return.

“Several times, I have nearly walked away from the job, I was so upset,” she recounts. On one occasion, she was expected to step in at short notice and cook for 50 people because no chef had turned up, but rather than any appreciation, the management hauled her in to complain about graffiti on a noticeboard and threatened her with the sack. She felt picked upon, and feared it could be because she belonged to the trade union, Unison.

“The treatment of that boss made me question myself, and you start to believe you’re no good.” She couldn’t leave the job without a new one. Eventually, a former manager who thought very highly of her persuaded her to move over to a care home run by a different provider in Gloucester, even though the bus ride ate into her pay.

“Gilda reached rock bottom after the premature death of her six-month-old granddaughter”

Because of her experience, she often found herself working as a shift leader with younger colleagues relying on her for advice and support, but it was rare to be paid for such extra responsibilities; at one point, she even went back to college to learn how to be a moving and handling trainer and loved the work. But several times, her efforts to progress in her work and earn a better wage were set back by incidents that brought her into conflict with managers because, she says, she stood up for herself. Something her colleagues were often too fearful of doing in case they lost out in the allocation of shifts. 

The point where she reached rock bottom was after the premature death of her six-month-old granddaughter. Utterly devastated, she turned to the union for advice on compassionate leave. She got five days off, and on her first shift back, she was ticked off by her manager for involving the union. “They were not human, there was no mention of my bereavement. They care for the clients, but not for the staff.”

As Gilda’s story unfolded, what emerged alongside the financial struggle as a single parent with three sons and a loan of her former husband’s to pay off, were two other forms of precarity: the first was around the care worker’s mental health. “Burn out” is a constant risk, referred to by interviewees, and best understood as the cumulative distress of managing the challenging emotional and physical needs of clients. The job can require immense amounts of “emotional labour” ensuring a cheerful friendly demeanour while repressing irritation, impatience, frustration and even, at times, revulsion. The second was a theme echoed by others: care work is risky. It entails highly vulnerable people many of whom are on complex medication regimes and have demanding behaviour. Add in staff shortages, poor training and the constant problem of staff churn with newcomers having only a couple of days watching video manuals to guide them, and the chance of something going wrong is high. 

Punishing regime

A care worker with 30 years’ experience, Peter Garland, described the tightrope walk involved. “You stay within the framework of the company’s policies, but in the end, you have to use your own judgment. Suspensions and disciplinary procedures are common—and can be life changing—and few companies allow union support.” Even the most diligent care workers like Gilda and Susie are aware that one false step and they could see their carefully-balanced finances collapse. Suspension is on full pay, but if your contracted hours are substantially less than the hours usually worked, it amounts to a devastating blow to the household budget. The price of survival could then be stepping into a spiral of emergency loans with usurious rates of interest.

Steve went into care work two years ago after a career in IT for retail, taking a massive pay cut, and he is still astonished by the complexity and level of responsibility. “I’m a shift leader now and there’s not much difference between my job and that of a district nurse. In the residential home, many clients have dementia and the only trained medical support is the district nurse’s visits. What I’m asked to do is very stressful. I have to monitor diet, personal care, blood pressure readings, oxygen levels and I have to judge when to call in medical intervention.” 

Administering powerful drugs is a routine part of the job, agrees Pat—she is Susie’s mother, and another care-worker, but combines her part-time shifts with work for Unison. You have to cope with very challenging abusive behaviour, she says. 

Another big concern is the use of minimal hours contracts of just five or eight hours a week. Managers have got savvy that people don’t like the term “zero hours,” explains Garland. The minimal hours contracts ensures that employers have a reserve of labour to call on without having to pay much sickness or holiday pay; it means they can manage the inevitable variability of need for care—as people go in and out of hospital—with flexible shifts and rotas. The downside is that staff have no way of knowing from one week to the next what hours they are working; arranging childcare or medical appointments becomes nigh on impossible.

“The sector has become much more fragmented over the last 30 years,” he expands, ‘We see a lot of fly by night companies that get bought out or closed down suddenly. Care workers end up bouncing across several companies to make up their hours and each company has different policies.” There was obvious stress for the workers in keeping abreast from that even before such multi-employer working proved so dangerous in propagating Covid-19. As Garland explains: “Few staff stay in one place long term, so you are lucky if you are working alongside someone with six months’ experience; there is no chance to build up good practice, and this kind of work needs people to collaborate closely and know each other and the clients well. It’s disheartening and experienced staff end up not bothering to invest in the newcomers by showing them how to do things. The pay has been steadily eroded by below-inflation increases in the last 11 years of austerity.”

The jobs can sort-of work if home life is straightforward, and light on obligations. Garland and his wife, for example, can both work night shifts, so put themselves at the top end of the pay scale at about £11 an hour. They can end up with a household income of £45,000 and, he explains, since their one son has grown up, they can now treat themselves to a nice holiday every three or four years. 

Even so, it is often as well not to look too far ahead. Pat’s particular concern is that her low pay—she’s on £8.90 an hour—will lead to serious poverty after she retires. She has about £200 in savings. She feels the pinch. Her 96 year-old father lives eight miles away but she can’t afford the petrol for the 16-mile round trip as often as she would like; she’d love to take her grandsons to the local nature reserve but the 22-mile trip is too expensive. She wants to get a better job for the last decade of her working life. 

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Gilda is happier now she has left the sector. Photography by Rob Lacey

Cut-price professionalism

None of these care workers had much faith in government initiatives to improve pay and conditions. But in some parts of the UK at least, there is growing interest in trying to alter the downward logic of outsourcing. The Welsh government has set up a Social Care Fair Work Forum committed to improving terms, and it has championed a Social Partnership agenda for employers; it echoes similar initiatives developed by the Scottish government and plans in Northern Ireland. 

One of the main ideas is to use large local government procurement budgets to drive up pay levels, so that contracts are only awarded to companies paying the independently-calculated Foundation Living Wage (currently £9.50 compared to a legal minimum for workers aged 23+ of £8.91, which the government insists on calling the “National Living Wage”). It sounds like the sort of thing that ought to make a difference, especially if combined with broader employment legislation to improve the reliability of shift work, but Mark Turner, the lead on social care in Wales for Unison is concerned that even this modest initiative could run into the sand after recent advice that it could be open to legal challenge. The presumption for treating this sort of labour as a commodity is almost hard-wired into our political economy. 

Nothing comparable has been even attempted by the Westminster government for English care workers like Gilda, despite the campaign of the Future Social Care Coalition which includes five former or current health ministers and dozens of organisations pressing for better pay and conditions.

One set of reforms that is in train promises “professionalism,” which sounds great if you’re not working in the sector, but has lost its lustre for those employed within it. In particular, a system of registration was brought in to prevent poor care workers moving from job to job and was sold in these terms, but is now charged with having become yet another weight on those at the sharp end. Pat Jones acknowledges that part of its function—weeding out bad care-workers—is important, but points out it has led to an annual £30 fee for all care workers—however good—plus a requirement to keep up with training (videos and manuals) in their own time. “It’s become another stick to beat the care-workers with,” comments Garland, adding that professionalisation has had no upside for the workers themselves, it has not been tied to better pay or more security. 

“Most of us are not care workers. But many of us will depend on social care at some point”

As to Susie and Gilda, they have both been determined to improve their harsh circumstances, and it’s telling that to do so, they have both moved out of care companies. Shortly before the pandemic—and shortly before Susie’s move to that local authority service—Gilda finally plucked up the courage and went for a job as a healthcare auxiliary in the NHS. 

Most of us are not care workers. But many of us will depend, or have relatives who will depend, on social care at some point, so the fact that such dedicated workers as Susie and Gilda are being driven out of the sector, really should give us collective pause for thought. Vacancies in the sector are running in excess of 100,000. There is an urgent need to improve pay and conditions. 

Despite finding herself quickly plunged into the maelstrom of a Covid-struck healthcare system, Gilda has no regrets: “I absolutely love the new job. I am learning so much—how to insert catheters and cannulas—and it’s blowing my mind. I never thought I would be able to do it.” 

In her view, the biggest difference is the quality of management and the teamwork—the pay is only slightly better, at £19,900 a year. The support of colleagues has helped to deal with such extremely trying challenges as Covid wards. “My confidence has grown so much. Even after a 14 hour-shift, I would get in my car and I would still be smiling. That never happened in the care homes.” 

Nor, one suspects, does it happen across swathes of the service sector and gig economy which don’t so much “manage” their workers, still less properly train them or build team relationships to sustain them through challenging tasks. On the contrary, people are deployed as a faceless commodity, and managed as atomised units of labour. Until we have regulations and laws that ensure these workers are treated as people, millions like Susie and Gilda will be condemned to punishing hours, interminable insecurity and a remorseless day-to-day struggle to ensure the money stretches to the end of the month.

Supported by the Joseph Rowntree Foundation