‘Paid or unpaid’ – a challenge for care policy

old women try a second pair of glasses

Care is everywhere, even in the economy

A central claim in the introduction to this dossier is that ‘care is everywhere, even in the economy’. Yet for many areas of care work this no longer holds true. New concepts such as that of the ‘care economy’ attempt to highlight this fact by pointing to the overlap between care and efficiency, use, process maximisation and productivity. At least since the introduction of compulsory health insurance which was specifically aimed at organising care along the lines of economic criteria, certain areas of care have moved from the domestic sphere (or that of human relations) where they remained unmeasured, into the economic sphere. Yet once care is organised along the lines of a business, profit maximisation is the next logical step.

This shift in care services also plays a role in general services and health care as well as in education. The privatisation of hospitals, for example, has already led to the implementation of numerous business practices and concepts. The decision to enable private companies to run health care services and provide care was taken several years ago. Following this decision many facilities were privatised and public sector services were reduced. Education is also currently undergoing a process of privatisation, albeit to a lesser degree.

Aspects of competition between paid and unpaid work

Work which is not yet covered by the concept of care economy includes work undertaken in households and done by volunteers. Care work in this category often consists of work that is difficult to rationalise according to step-by-step procedures, and also includes the provision of personal care and attention to those in need. This results in well known problems such as care by the minute, unpaid work by home care nurses – especially when there is no (longer a) family to provide care – and the unavoidable ‘volunteer’ work undertaken in institutions. Another result of this division is that some aspects of care work come to be seen as both unaffordable and invaluable. This reduces the value of care work and means only work viewed as economically quantifiable is paid for.

Although it has always been argued that the wishes of elderly people in need of care remain the priority (and consequently the preference of care in their own homes) care policies have also been decisive in establishing this preference. In this sense current care policy represents both meanings implied by the principle of ‘private care instead of care in an institution’. It is then dedicated to ‘strengthening home care’. In the reality of care for the elderly, this principle moves the focus from in-patient care to care provided free of charge by relatives or privately in the home.

Such a model of the care economy only takes salaried care into account. The daughter, wife and neighbour engaged in free care work (which of course could also be paid for) are not part of the calculation. But even if carers are paid through care allowances this does not increase GDP. Instead care allowances are treated like social benefits and as part of public consumption they actually lower GDP. Salaried care services on the other hand raise GDP and are treated as part of the national income.

As a result, an expansion in salaried care work would lead to economic growth. It would bolster internal demand and improve employment options for women. This is the case, as on the one hand it would create additional jobs for women and on the other, it would lessen women’s burden of care in the home. Ver.di Frauen argue that this should be taken seriously by the government as an approach in care policy. Politicians must then also be involved in the decision as to how much care provision should remain part of the care economy.

Yet the German family ideal is still centred around (at least) one person whose economic and social needs are taken ‘care’ of and who in turn provides free care work to the family when they are young, sick or in need, whether in their own family or through voluntary work outside of the home. Legally this family form is supported by tax breaks for couples, social insurance for family members and the widow’s pension.

At the same time, people in need of care cannot afford to pay for care because social insurance only covers part of the costs. Some people are not prepared to pay for care as they have a daughter who can do it for free, so why pay? These are all parts of the reality of care in Germany today and result from the idea that care at home is preferable to care in an institution. Importantly, this leads to a family policy framework which places responsibility for care onto the family and to female family members in particular.

Due to financial problems, funding for care was reformed in 2005. The underlying idea was to ‘strengthen home care’ by raising the amount of unpaid care work undertaken. This was to be compensated for by slightly increasing care allowances and reductions in benefit payments to carers in employment. Due to the justified objections of women’s and social welfare organisations (amongst others) social insurance contributions were raised to secure the financial basis for the coming years and expand the care economy. As statistics on care from 2007 show, rising costs at the time were mainly due to the rising number of people in need of care.

For a long time now, social welfare organisations and the unions have been striving to improve the image of social work and other work based around people. Yet it is precisely because professional carers compete with unpaid care work regarding salaries, working conditions and social security that it is so difficult to do so. Recently support has also come from the government on this and politics and public debate have generally focussed on increasing the ‘social recognition’ of the types of care work which can be done without pay. This of course is certainly not enough.

Salaried care work is also faced with difficulties. Social insurance providers expect competitive prices and there is also competition with unpaid care work taken on by families. Naturally this puts pressure on prices and salaries. This is helpful to insurance providers as it helps to drive down costs. But for carers it results in low levels of pay which in no way reflect the work they do. It then pushes back the chances of achieving higher levels of pay for carers or raising their social recognition. As the recently agreed minimum wage for carers shows, this problem is an undesired side-effect.

If we are to raise the social recognition of carers, it is simply not enough to aim for a higher social recognition for this type of work. Salaries in this sector must also be increased and this can only happen through dialogue and negotiation. The responsibility therefore lies with the ministries that decide how much care workers should be paid; as well as employer associations and the unions which negotiate hourly rates and working conditions. It also lies with individual employers due to the way they classify specific types of work and associated working practices. Last but not least, families too are responsible as they help determine the price of privately financed care which is not covered by social insurance.

The market for care is special because patients and their families need care. Along with the concerns of social insurers and care providers to cut budgets and costs, this has led to a certain amount of state regulation. But I believe decision makers consciously use the idea that home care is ‘invaluable’ and ‘unaffordable’ to ensure care rates and salaries remain low. Nonetheless, the fact that this is based on the gendered division of labour should provide additional policy arguments to raise the proportion of care work that is remunerated.

The important question: when does work become ‘voluntary’?

Care work is considered voluntary when it is neither remunerated nor provided by a close relative. During the 2005 social insurance reforms there was much talk about expanding the engagement of civil society. There were even regulations aimed at promoting care work by volunteers in certain areas of care.

In many care institutions and out-patient services, work by volunteers is welcomed. Care has now been so rationalised that today’s carers have very little time to provide personal attention to patients; even standard benefits can only be provided if they fit into the timetable. The special wishes of those in need of care therefore frequently remain unfulfilled. Who then can take care of these needs? It is in such cases that volunteers actually help carers and are certainly not viewed as a problem. Yet it is difficult to draw the line between care work that is paid for and care work that is done free of charge: what is viewed as an extra? Which type of work needs special training? Which services should be considered standard? Can a person who comes to read a book to a person in need of care, also serve them something to eat and drink or accompany them to the toilet? The general rule is not to define these roles so tightly and this leads the borders between them to become blurred.

From the point of view of the unions, voluntary work becomes problematic when it means jobs are lost, salaries are paid, or services are charged although they have not been provided professionally. When welfare organisations visiting patients (free of charge) find out, for example, that patients are not receiving enough to drink, or adult nappies are being allowed to ‘fill up’ (as they call it in the advert) they sometimes talk of a ‘gold mine’.

A clear line between salaried and voluntary care is sometimes not even drawn for salaries. Some employers avoid paying social insurance by contracting carers with so-called €400 ‘mini jobs’. They then pay employees extra for what is set out on the pay sheet as ‘voluntary work’ or listed as a payment for ‘running a workshop’. In this way carers can earn up to €575, but are not provided with social insurance. This model is then also based on the assumption that these employees will be taken ‘care’ of by their families.

How can we increase the provision (and amount) of paid care work?

In future, policy aimed at service provision must also be linked to women’s policy and equality policy. As described above, one possible approach would be to change the legal framework (in this case the definitions of social insurance) and ensure family policy focuses on women’s independence. Most importantly the specific employment practices occurring in the care sector must be examined. This could also help improve the quality of care. Concerning the division of labour, a new definition drawing the line between work done by volunteers and work done by families must be found. Which work should be done by families? What should be done by volunteers? What should be remunerated? Where should the line be drawn? To ensure quality, we also need a professional definition of care. A political solution would be to ensure that some areas currently relying on free care provision move towards public or commercial service provision. This would create growth incentives, considerably improve quality standards and the infrastructure available to families, as well as new employment opportunities. At the same time there would be more salaried employment for women and it would be more compatible to the lives of men and women alike. The well known successes of Scandinavian countries could serve as an example. But such an ‘investment in the future’ comes at a cost: it would need both economic investment and the political will to stimulate economic growth and growth in GDP through targeted changes to existing laws.