When Betty’s husband died most people in the village suspected that she would struggle. They had moved to live by the seaside when Bill retired fifteen years earlier. Their children lived far away and had demanding jobs, and even more demanding young families. It was difficult for them to keep an eye on how mum was coping, let alone be involved in caring for her in any significant way.
The first person to see that things weren’t going well was Sandra, the landlady of the village pub. A week or so after the funeral Betty started coming into the pub several times a day asking had anyone seen Bill. A few weeks later the story changed. She told Sandra that Bill had run off with a ‘floozy’ he’d been carrying on with. The house was full of strangers who’d thrown her out and locked the door. Sandra took her back to the empty house and tried ever so gently to remind Betty that Bill had died, but she wouldn’t have it and became irritable. Steve, who ran the Post Office cum village stores, was also worried. After the funeral the family had arranged for Betty to visit the shop every week to order her groceries and collect her pension. This worked for a month or so, but her attendance became erratic, and then she stopped coming.
No one in the village knew how to contact the family to express their concerns. That changed when her son came over a couple of months or so after the funeral to see how Betty was getting on. He was shocked at the state she was in. It was summer, and the house was filthy. Flies ruled the kitchen, which stank of decaying food. The toilet hadn’t been flushed for several days because the cistern was broken. Betty had lost weight and was in a dreadful condition. She once took pride in her appearance, was smartly dressed in fashionable clothes. She took great care over her hair, and her make-up; her fingernails were once immaculately manicured. Now, her clothes were filthy, stained with food and worse, her white hair a tangled and unruly crown, her nails talons beneath which filth and grime had accumulated.
Betty’s son spoke to her family doctor, and the next day the wheels of health and social care were set in motion. She had a brief admission to hospital where her physical and mental state were thoroughly assessed, and the diagnosis of Alzheimer’s disease confirmed. She was assessed at home by a social worker and occupational therapist, and a social care package put together. Betty required a lot of support. She was unable to budget because Bill had always looked after the money. It was clear that before he died, he had taken over responsibility for the domestic chores as Betty’s dementia rendered her incapable of them. She was unable to prepare simple meals, or simple tasks like cleaning and ironing.
Betty’s family doctor and social worker felt that she really needed supported accommodation, somewhere where she could live semi-independently, but with 24 hour care and support available at the push of a button. Betty didn’t want that. Despite her problems she remained a strong-willed lady who valued her independence. Besides, her family had other reasons for not wanting her to move into supported accommodation. Such care is means-tested, and as Betty owned the house she lived in the family would have to sell it in order to pay for their mother’s care.
Until twenty years ago the responsibility for providing the sort of care in the community that Betty required fell on the shoulders of primary care services and the local authority. District nurses working closely with Betty’s family doctor would have monitored her physical and mental state, and checked that she was taking her medication correctly. However, since the recession cuts in government spending have resulted in an acute shortage of district nurses. The Royal College of Nursing in Britain reported in 2014 that over the previous decade the number of qualified district nurses in England had almost halved,1 and this at a time when the numbers of infirm older people being cared for at home was increasing rapidly. NHS community staff are pushed to breaking point, with 80% reporting they have to work unpaid extra hours at the end of their shifts.
The assessment made by the social worker and occupational therapist indicated that Betty required intensive practical help. Her care package involved a team of support workers making three visits a day, to prepare her meals, ensure that she had taken her medication correctly, clean the house, and make sure that her little terrier had been exercised and fed.
District nurses may be an imperilled and pressurised group, but the situation as far as local authority community care is concerned is much, much worse. In fact, it really no longer exists. In 1990 the NHS and Community Care Act changed local authorities’ role from one of providing community care, to commissioning it. In 1992, immediately before the act became law, the independent/private sector provided only 2% of state funded home care; by 2008 that had risen to over 80.2 The support workers involved in Betty’s care were employed by a company called MiHomecare. They had been awarded the contract for home care support by the local authority in whose area Betty lived.
At first these arrangements seemed to work well. The visits went ahead with metronomic regularity. Initially Betty was very mistrustful of her carers. They were mostly young women; she didn’t know who they were, nor did she understand their role in her life. To begin with she thought they were Bill’s ‘floozies.’ But the carers did a wonderful job. They spent time with Betty, patiently getting to know her, and building a relationship with her. They took her and her dog for walks down to the beach. They took her to the village pub for a glass of merlot (in truth, blackcurrant juice) and a sandwich. Gradually they won her trust, and although Betty still didn’t really understand who they were, she grew to like them and to accept their presence in her life.
The situation remained stable for a couple of years, until gradually things started to change. Betty’s favourite carer, a woman called Tracy was a few years older than the others. Betty was very upset one day when she realised that Tracy had stopped coming to see her. No one was able to explain to her what had happened or why this was. Tracy was a very kind-hearted person, who identified strongly with Betty. She reminded her of her own mother who’d died a few years earlier of dementia. Tracy was deeply upset about the uncaring way her mother had been treated in a local authority old people’s home. She was determined that she would never treat any of her clients the way her mother had been treated. If Betty was short of food or other necessities she always made sure she got them, even if it meant paying out of her own pocket with no prospect of claiming the money back from either the family or the company she worked for.
Tracy worked for MiHomecare, a subsidiary of Mitie, a major British outsourcing company founded in the 1980s. In 2014 Mitie announced that its homecare arm, MiHomecare, was less profitable than expected, and that it was finding it difficult to recruit and retain care staff 3 Around this time Tracy’s company changed their policies for home visits. When Tracy started to work with Betty, the time allocated for her visits in the diary excluded travelling time between visits. In other words she was paid by the company when she travelled between clients. In England there is a legal duty on employers to pay employees for their time spent travelling or on sleepover duties.4 But a leaked internal MiHomecare document indicates that home care workers in two of the company’s Welsh branches were no longer paid for their travel time. The 44 workers involved were estimated to be owed in excess of £80,000 over a three-year period. The organisation Corporate Watch points out that scheduling home visits with no time allocated for travel, a practice known as ‘clipping’, has two consequences. Either it means that workers end up being paid less than the minimum wage, or that the duration of agreed visits is reduced. The leaked document notes that the company has no safeguards in place to ensure that its 6,000 employees in its 57 branches receive the basic minimum wage 5
Tracy couldn’t ‘clip’ the duration of her visits. How could she possibly when she arrived at Betty’s one morning to find her distraught because she was covered in faeces? Betty had become severely constipated and developed overflow incontinence as a result. It took Tracy over an hour and a half to bathe her, clean up the mess in the bedroom, wash the bedclothes with detergents she had to buy out of her own pocket at the post office because there was none in the house, then prepare Betty’s breakfast and take her dog for a walk as she usually did. She worked the extra time at the end of her shift and of course wasn’t paid for it, placing her earnings that day below the minimum wage.
That incident was the last straw for Tracy, for whom the cumulative stresses were too much. She had had enough of the changes in the company’s policy, which forced her to cut her visits short, or to work unpaid hours at the end of her shift to make up the travel time she was no longer permitted. She went off sick with stress and anxiety. She was unable to return to a job that she once really enjoyed, which gave her great satisfaction, and in which she genuinely cared for the people she worked with. In effect she ended up as ‘collateral damage’, a victim of the company’s practice of ‘clipping’ visits.
Tracy and Betty, and goodness knows how many others like them, have become ‘collateral damage’ in a neo-liberal campaign to slash costs in order to maximise profit. And that reminds me; there is a telling footnote to this sad tale. Shortly after Tracy stopped visiting Betty, Mitie announced a 6% increase in its profits for the financial year ending April 2014. The chief executive received a salary of £526,000. This rose to £1,447,266 once benefits, annual bonus and pension contributions were included 6
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1 RCN warns that district nurses face ‘extinction’ in 2025, accessed 24th March 2014
2 Quality versus cost: A brief history of outsourcing in adult social care, accessed 24th March 2014
3 NHS Trust Financing Woes expected to boost private sector openings. Financial Times. 24 November 2014.
4 National Minimum Wage compliance: ‘sleepover’ shifts and travel time, accessed 24th March 2014
5 Revealed: major homecare company paying staff below minimum wage, accessed 24th March 2014