Long-term care in the gig economy

4 May 2022

In the immediate onset of the Covid-19 pandemic, two groups of essential workers came to the fore of public attention.

Firstly, care workers, in medical, nursing and direct care roles were recognised for their service, commitment and care in the face of threats posed by the virus. The second group were those in the gig economy (e.g., delivery drivers), for whom precarity and lower access to benefits was highlighted in comparison to individuals in standard employment.

A cohort of workers who straddle both of these groups are care workers in the platform economy, working in long term care delivery, particularly in private home settings. Advances in digital technologies have led to the development of a flourishing platform economy in the provision of long-term personal care at home. This shift towards a freelance, task-based model of personal care, while on the one hand affording greater choice to those in need of care, also heightens many of the challenges that exist in the system such as already tightly monitored time frames for care delivery. The gender division in platform work is stark, with women representing a large majority (64 per cent). According to the European Trade Union Institute, this category is dominated by young women performing care services.

This blog asks how the nature of care work is altered by the platform economy, how women in particular are affected by this, and how inequalities might be overcome in the future?

The commodification of care

Long-term care (LTC) involves help with the basic activities of daily living and personal care over an extended period. While LTC encompasses a variety of roles across health and social care, personal/direct care workers account for 70 per cent of the LTC workforce. At the same time, LTC work has long been undervalued, partly due to its vocational nature, and partly due to the characteristics of its workforce, who are largely female and immigrant workers.

New public sector management principles have also intensified the marketisation of care, with an increasingly dominant role played by private sector agencies acting as intermediaries employing care workers in home and residential settings. Work in the sector is characterised by low pay, tight control and management of working hours, precarious contracts, and limited opportunities for development or advancement.

Advancements in digital technology (e.g., the rise of platform-based organising) have allowed a gig economy in care to flourish, but for workers and those receiving care, what is the impact?

Task-based or person-centred care?

The concept of choice is commonly discussed within LTC, that those requiring care should have a say in by whom and how that care is provided. Platforms and their “freelance” approach to workers epitomise the ideology of choice, allowing clients to match their needs to a carer based on a targeted presentation of profiles, ratings, and location details provided to them by the platform.

However, while clients have access to a significant amount of information, workers may still have limited information and/or choice on which work to accept. While the element of choice that platforms provide for those requiring care may be perceived as positive, it also increases short-termism.  This can be destructive to the development of caring relationships that demand an atmosphere of trust which tends to develop over time during a caregiving relationship.

Person-centred care is considered a key indicator of quality care. The concept is underpinned by mutual respect and understanding. However, the fungibility of care workers (a pre-eminent feature of the gig economy model)  can undermine this principle as the marketized arrangement emphasises the transactionality of care delivery.

The platform model may well therefore reinforce task-oriented care practices, through an emphasis on checklists and task completion within designated and monitored time frames.

Structural conditions are critical to providing effective person centred care in the home setting. In a task-based approach, the tasks allocated take precedence over the  psychological and social needs of the client, while such individualised working arrangements do little to enhance wellbeing and social support for the care worker either. A relational (rather than task) based approach is needed if care is to become truly person centred, but this is starkly at odds with what platforms in other sectors have been modelled on to date, where replaceability and fungibility of workers is inherent.

Recent research has found that rather than having a protective role, digital platforms in the sector can increase risks for workers in individualised care relationships. This is particularly problematic for workers with limited social support structures in their non work domain, such as migrants women who form a disproportionately high percentage of care sector workers, often due to the need to fit work around their family needs or due to qualifications or work permit restrictions. Given the lack of social and welfare protections available to platform workers, this can also impact workers’ ability to turn work down, even where that work may place them at risk, for example in caring for clients exhibiting challenging behaviours.

Alternative futures for care work

Research shows that even when platform workers are highly educated, they nevertheless conduct low-qualified tasks, and low skills are perceived to be required for on location work. This further fuels the perception that care work is unskilled.  The perception of care as low skilled is flawed, yet the lack of recognition afforded to direct care within health and social care regulation does little to counteract that perception. I suggest 2 ways to address this.

  1. Firstly, changes in regulation in regard to the certification of care workers could potentially address the fungibility of workers and supply of labour to platforms. Occupational licensing has increased dramatically in the health sector, with a plethora of roles added to those holding professional or protected title status. While there is a lack of consensus on whether or not this actually results in improved care outcomes, the outcomes for workers can be significant (not just in substantive terms relating to pay and conditions) but in elevating perceptions of the value of their work.
  2. Secondly, the same technologies that have afforded platforms an opportunity for growth in the care sector could be leveraged in ways that would support the development of locally based care provision, for example through worker cooperatives. Though small in scale, relative to some of the established care platforms, examples of care cooperatives are growing and provide potential new ways to improve job quality in the sector, if sufficiently supported to do so.

The reality is that supporting new models like this requires a change in the tendering, commissioning and regulatory processes relating to care provision, particularly in home care where the emphasis on short term costs needs to be replaced with an ethos of quality care and quality jobs.

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