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We all want increased choice in elder care – but neoliberal health policies make this difficult

We can all agree that older people should have the choice to stay at home, and be cared for there, if that is what they wish to do. But the push for choice in elder care comes at a time where many governments are disinvesting in home-care public services.

With the view of reducing healthcare costs – and under the pretext of increasing choice – the UK and Irish governments have outsourced a great proportion of their home care services to for-profit providers. This is having several implications: no meaningful choice, increased loneliness among older people, a dissatisfied and sometimes exploited care work force and poor quality care.

While governments pay lip service to the notion of choice, their disinvestment in public home care services means that older people and their families often have no choice but to “choose” for-profit home care providers, as these are becoming the norm for elder home care. In the past decade, there has been a change from government-operated public facilities into private, autonomous facilities and services, organised for profit.

And there are further problems with this situation, beyond transformation of care into a commodity. Home care is not a typical product on a supermarket shelf. Care is a complex bundle of activities, tasks and interactions. Home care is a high involvement purchase, which requires considerable time and emotional investment. But people in need of care might not have all the necessary information, skills or time required to navigate intricate care markets.

What does ‘choice’ actually mean?

In the course of our research into the needs of the growing ageing populations in Ireland, social workers admitted that clients have little information on home care agencies. The little information they have comes from marketing communication activities, not from an objective source. But this might not matter anyway, as participants told us that good care was down to the individual carer: “You couldn’t say one home care agency is better than the other, it’s all about the actual person” delivering the care.


The increased view of home care as a product has led to the reduction of care as a set of clearly defined units of work (such as showering, washing, dressing, toileting and cleaning) leaving little time for companionship and meaningful engagement with clients. In the UK between 2010 and 2013, more than half a million care slots lasted five minutes or less. In Ireland, participants told us that a 30-minute slot is now the norm. Carers spoke about the disappointment service users experienced as they hurried out the door to the next client.

Paradoxically, many home care agencies promote themselves on the emotional capacities of care workers and the potential friendships that can be formed. But older adults told us about feeling lonely and wishing that carers spent more time with them. The carer is the only person many clients see all day.

Loneliness is a major problem among older people that can lead to depression and can have a serious effect on health. Many participants agreed that providing “companionship time” should be part of the home care package, but this is not generally seen as a productive and efficient use of resources.

The carers

There is also a dark side to today’s market promotion of choice for care workers themselves. When profits and efficiency are prioritised, there is pressure to keep costs down.

Agency directors told us that unfortunately the tender process, whereby governments invite bids from home-care agencies, is a race to the bottom as price is an important criterion to secure a contract. Low costs have created a system characterised by casual and zero-hour contracts and low wages. The insecurity and low wages in the sector causes recruitment and retention problems.

What about the carers themselves? Kzenon/

Care managers complained about capacity problems and the difficulty in attracting people to the profession. Since care markets deliver efficiency at the expense of workers’ pay and conditions, care workers tend to be drawn from vulnerable groups in society: traditionally women and increasingly migrants, who have few job opportunities. Carers in our research told us they do not feel valued or trusted and wished for better working conditions and a better funded sector.

Questioning choice

So what can we do? We need to question the extent to which choice should be the most important characteristic of a care model. Not because choice isn’t intrinsically good, but because the current neoliberal environment, in which governments are seeking to disinvest themselves of care responsibilities, makes such an ideal unattainable.

In his well-known book Being Mortal: Medicine and What Matters in the End, the surgeon Atul Gawande asks us to think about what brings the most meaning and purpose to our lives and fill our days with those things, to the best of our ability, until we die. In principle, choice is a good thing, but it is only valid if we are able to choose among meaningful alternatives.

And maybe choice should not be the most important factor in elder care. Guaranteeing good quality care that includes companionship, independence and safety for all older people should be what matters the most. We need to think further about what we want good quality care to mean. Determining how people can be properly cared in a way that exploits no older person or carer is a profound challenge of our society.

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