Placing care in times of austerity

Abstract

The concept of care and its associated practices remain a key subject of debate in human geography, as they continue to evolve in response to changing norms and expections of who does and should provide care, how, and where care takes place. With the growing politics of austerity shaping welfare and support provision across the Global North, these norms and expectations are once again being reviewed and reconfigured. New spaces and relationships of care are unfolding, as austerity intensifies many debates over the role of the state vis-a-vis the private, informal and third sectors. This paper examines the changing geographies of care that are unfolding within this context of austerity and frames a collection of papers on this subject. It offers a short review of the concept of care in the discipline of geography before examining the shifting landscapes of care provision overtime. It considers where these new spaces of care are unfolding. After identifying the boundaries of this scholarship, it then outlines the key themes within and across the four papers in this special issue.

Résumé

Le concept des soins et des pratiques qui y sont associées restent un sujet clé de débat en géographie humaine, au fur et à mesure qu’ils continuent d’évoluer en réponse aux changements des normes et des attentes de qui fournit ou devrait fournir les soins, de comment et où se déroulent les soins. Dans un climat grandissant de politique d’austérité en ce qui concerne l’aide sociale et les apports de soins dans les pays du Nord, ces normes et attentes sont encore une fois en train d’être révisées et réaménagées. De nouveaux espaces et rapports de soins se développent, tandis que l’austérité intensifie beaucoup de débats sur le rôle de l’Etat vis-à-vis des secteurs privés, non-officiels et tertiaires. Cet article examine les géographies changeantes des soins qui se déroulent dans le contexte de l’austérité et réunit une collection d’articles sur le sujet. Il propose une courte revue du concept de soins dans la discipline de la géographie avant d’examiner les paysages changeants de l’apport de soins dans le temps. Il considère où ont lieu ces nouveaux espaces de soins. Après avoir identifié les limites de cette étude, il présente ensuite les grandes lignes des thèmes clés dans et à travers les quatre articles de ce numéro spécial.

Resumen

El concepto de cuidado y las prácticas asociadas al mismo siguen siendo un tema clave de debate en la geografía humana, ya que continúan evolucionando en respuesta a las cambiantes normas y expectativas de quién hace y debería proporcionar cuidado, y de cómo y dónde se lleva a cabo dicho cuidado. Con la creciente política de austeridad que moldea el bienestar y la provisión de apoyo en todo el Norte Global, estas normas y expectativas están nuevamente siendo revisadas y reconfiguradas. Se están desarrollando nuevos espacios y relaciones de cuidado, ya que la austeridad intensifica muchos debates sobre el papel del estado frente a los sectores privado, informal y de terceros. Este artículo examina las cambiantes geografías de cuidado que se desarrollan en este contexto de austeridad y enmarca una colección de artículos sobre este tema. Ofrece una revisión corta del concepto de cuidado en la disciplina de la geografía antes de examinar los paisajes cambiantes de la provisión de cuidado a través del tiempo. Considera dónde se desarrollan estos nuevos espacios de atención. Después de identificar los límites de esta área de estudio, describe los temas clave dentro y entre los cuatro documentos en este número especial.

Keywords:

• Care
• welfare
• austerity
• practices
• gender
• disability

Mots clés:

• Soins
• aide sociale
• austérité
• pratiques
• genre
• handicap

Palabras clave:

• Cuidado
• bienestar
• austeridad
• prácticas
• género
• discapacidad

Introduction

There has been a flourishing of geographical studies of care and caring in recent times. Drawing on a range of new theoretical insights, and driven by questions of who and where in the provision of care, geographers have critically examined the spaces, relations, emotions and politics of caring in contemporary society (Bowlby, 2012; Cox, 2013; Giesbrecht, Williams, Duggleby, Ploeg, & Markle-Reid, 2016; Juhila, Hall, & Raitakari, 2016; Lawson, 2007; Milligan & Wiles, 2010). The evolution of this body of work has shown how the landscape of care is being continually transformed.

Care has also been an ongoing theme explored in Social & Cultural Geography. Conradson (2003a) considered the practical and emotional aspects of caring, as part of a special issue that examined the spaces (including the home; Milligan, 2003), complex relations (e.g. giving and receiving mental health care in rural communities in Scotland; Parr & Philo, 2003) and local community contexts (the care and support found in a ‘drop-in’ centre in a deprived area; Conradson, 2003b) in which care is expressed. Atkinson, Lawson and Wiles(2011) further examined the distinctive geographies of care, emphasising both the range of scales where caring occurs and the place of care in society. The papers in that special issue examined the ways in which care is profoundly embodied, emotional and relational involving both providers and recipients (Wiles, 2011), and that it takes place within socio-political contexts that are increasingly characterised by individualism and commodification (Hall, 2011).

In recent times, the unfolding phenomenon of ‘austerity’ has once again begun to transform this landscape. The politics of austerity has been characterised by significant neoliberal reform of care provision in many countries, involving a programme of financial cutbacks and the adoption of private sector inspired management in public services (Clarke, 2012). This latest reform is an ideologically driven intensification of previous ‘roll-back’ strategies centred on a more wholesale withdrawal of the state. Support provision has also become more market-led and individually focused, where people access packages of care provided by a mix of public, private and third sector organisations. Such a change in state care provision has consequences for individuals, families and supporters, as well as for local organisations.

The focus of this special issue is to examine the spaces, places and relations of the care landscape in this context of austerity, where there is significant pressure on public sector finances and a concurrent political shift towards individualism. In doing so, it highlights some of the important theoretical, methodological and policy contributions that geographical scholarship can make to an understanding of care provision across different countries that have either explicitly or implicitly chartered policies of austerity. It builds on arguments developed in previous stand-alone papers and special issues that engage with care, both within Social & Cultural Geography and other journals (Atkinson, Lawson, & Wiles, 2011; Conradson, 2003a; Cox, 2013; Hall & McGarrol, 2013; Lawson, 2007; McEwan & Goodman, 2010; Milligan, 2000, 2003; Milligan & Wiles, 2010; Parr, 2003; Staeheli & Brown, 2003). This special issue derives from a session at the Royal Geographical Society Annual Conference 2013, which examined the reconfiguration of care within an era of austerity, in a range of contexts that included Switzerland, Sweden, England and Scotland.

This editorial frames the selection of papers, mapping the transforming geographies and relations of care in the context of welfare reform and ongoing austerity in the public sector. The special issue draws on diverse strands of social and cultural geography to explore emergent forms and spaces of care provision, and to describe how individuals, families and local community institutions are negotiating, and in some cases contesting, this new landscape. The papers engage with a range of scales of care, from the individual to the institutional, and with the broader politics of provision; in addition, they identify and examine new and potentially progressive forms of care that are emerging in the midst of funding cuts (resonating with new forms of ‘progressive localism’, as identified by Featherstone, Ince, Mackinnon, Strauss, and Cumbers (2012).

Further, this special issue highlights the increasingly complex landscape of care. State, private and voluntary organisations are all now involved in delivering and shaping new spaces of care, as public sector funding has been significantly reduced and other organisations seek to fill the gaps that emerge (albeit unevenly and unequally). The papers highlight a number of related themes: how the decentralisation of care is reshaping local places as sites of care (Hogstrom, this issue); how care and support is being relocated from formal care sites to mainstream community settings (Power and Bartlett, this issue); how the closure and constrained access to care services produces unexpected new sites of care, such as local museums (Morse and Munro, this issue); and how the steady withdrawal of publicly funded care is promoting an expanded role for the private sector (Schwiter et al., this issue).

More broadly, the special issue pays attention to how the current context of austerity is accelerating existing trends in the neoliberal ‘project’ of retrenchment of government spending as part of a broader (and long-standing) reduction in the role of government. In the field of care provision, austerity has established a well-defined context of sharp cuts in government spending, reduced entitlements, new assessments and stricter eligibility. Governments are also increasingly advocating policies of ‘personalisation’, ‘choice and control’ and independent living; localism; and ‘third way’ approaches to create a mixed economy of care provision. The austerity agenda has to varying extents taken centre stage across the U.S, Canada, Sweden and the U.K, as well as western Europe, particularly in countries that suffered from the post-2008 financial crises, including Ireland and Greece. That said, Switzerland, unlike its counterparts in the euro zone, has not advanced an explicit ‘age of austerity’ agenda, as Schwiter et al’s paper shows, having long adopted the principles of low taxes and a small state.

In order to place the papers in context, this introduction offers a short review of the concept of care in the discipline of geography. It then examines the shifting landscapes of care provision overtime, with a consideration of where new spaces of care are unfolding. After identifying the boundaries of this scholarship, it then outlines the key themes within and across the four papers.

Care in geography: a short review of an evolving theme

There has been an expansion of the boundaries of the study of care in geography, from the examination of formal sites and delivery of health and social care, to the relations and emotions, and ethics and politics of care and caring, in formal and informal spaces, at a range of scales, from the individual to the global (Atkinson et al., 2011; Cox, 2013). Feminist geographers have played a key role in this expansion, shifting the discourse of care beyond service provision and dependency, to the care relationship and the broader ‘acts of caring’ which occur in everyday spaces (Hall & McGarrol, 2013; Lawson, 2007). This contribution to the literature began in part as a response to the ways in which women were arguably confronted with a social and moral duty or obligation to provide care, referred to as ‘compulsory altruism’ (Land & Rose, 1985; Kittay, 1999; Schwiter et al., this issue). This assumed altruism often led women to become involved in different ‘caring cycles’ for young children (Busch, 2013; Schwiter, 2013), disabled or sick relatives, and elderly parents (Cox, 2013; England & Henry, 2013) at various stages of the life course.

Such work advanced the notion of an ‘ethics of care’ – a guiding principle that all relational practices should be done in a more care-full way – with an emphasis on interdependence and the values of caring (Green & Lawson, 2011; Hall & McGarrol, 2013; Lawson, 2007; Smith, 2005; Tronto, 1993). As such, for Atkinson et al. (2011), ‘care’ is about more than care, as it ‘affords geographers a richness of possibilities through which to engage critically with a range of politically charged discourses’ (p. 563), raising questions of choice, rights and responsibilities, relations and ethics. Cox’s (2013) special issue examined how care is understood and how it is valued within the context of a rapid expansion of paid-for care, an increasing role of private sector providers, and cuts to welfare state provision. She argues that these factors have made care a commodity, changing the ways in which it is given and received, and also where it takes place. Cox’s (2013) focus on commodification acts as a bridge to this present special issue; the rebalancing of state, private and third sector care, as welfare austerity continues, and increasing popular expectations of independence and ‘choice and control’, are raising important questions of the spaces, relations, experiences and values of care.

These considerations also build upon previous debates that framed earlier shifts in social care policy from the 1980s, in particular the erosion of state-run institutions of care (Park & Radford, 1997). This period saw the emergence of ‘community care’, which was welcomed by many proponents of social care reform, as it was envisaged that care recipients would take up more active and valued roles in their neighbourhoods. For many policy-makers though, it was understood that community care would mean care by the community, rather than in the community. As a result, many countries which had led the way with deinstitutionalisation, such as the U.S., Canada and the U.K., arguably failed to provide the range of formal services to make independent living in the community a real possibility (Milligan & Wiles, 2010). Local communities and homes/families were seen as ‘natural’ sources of care; in many cases, however, the care on offer did not live up to this expectation.

Given the gap between expectations and what the state chose to offer in the realm of community care, geographers began to trace the outcomes for former institutional service-users. Dear and Wolch (1987) chronicled the initial emergence of ‘service dependent ghettos’ and rising homelessness following the first wave of deinstitutionalisation in the 1980s and coined the term ‘landscapes of despair’ to illustrate the resulting urban geography. This work, particularly from the North American perspective, traced how these state and volunteer services were often located in inner-city metropolitan areas, which were often stigmatised places. Meanwhile, Wolch’s (1990) pivotal conceptualisation of the voluntary sector as a ‘shadow state’ raised attendant questions about its appropriateness, capacity and ability to deliver health and social care services. Specifically, the sector was seen as being co-opted by the state to provide essential care services, leading to more unequal and patchy provision.

There was particular concern within the early geography of care literature with the ‘patchwork quilt’ (that is, a piece of material consisting of many small pieces of fabric in different designs and colours sewn together) of community services that evolved throughout the 1980s and 1990s. The quilt metaphor is used to signal the diverse and uneven assemblages of providers involved in the ‘mixed economy’ of community care. This mixed economy includes formal sites provided by health services and local government (e.g. day centres and care homes), informal settings and services of voluntary organisations (e.g. local groups and activities), and private sector companies (e.g. assistance for people at home); as well as the non-funded ‘informal’ caring by family members and friends. Despite its patchwork nature, a discernible landscape of care nonetheless developed during this time in many countries for people with disabilities, mental health issues and older people, with designated day care centres, intermediate care facilities, shelters and residential care homes (‘group homes’) in mainstream neighbourhoods (e.g. Joseph & Philips, 1984).

Meanwhile, geographers were turning their attention to the home as a site of care, with studies exploring the complex and evolving socio-spatial relations between individuals and their homes. Milligan (2000) and Power (2008) have examined the changing meaning of the homespace for family caregivers, particularly for those caring for frail older people and people with learning disabilities. Care in the home has involved new care technologies, formal care workers and other professionals increasingly entering the private sphere, thus blurring the boundaries between public/institutional and private homespace, as part of what Milligan (2000) described as an ‘institutionalisation’ of the home. These physical and relational changes raise delicate moral and ethical questions for families, such as whether they want their home to become a locus of care, and losing autonomy over preferred routines and visitors within this space (Dyck, Kantos, Angus, & McKeever, 2005; Wiles, 2003).

Other geographic work has examined how care-giving operates across public space. Ryan (2005) considered how carers often have to cope with both the management of care-giving tasks (such as feeding a person) and the attitudes of some members of the public: for example some parents have to confront awkward and negative attitudes towards disabled children who may not be able to conform to ‘appropriate’ behaviours. Such cases reveal how care-giving is never really just a physically supportive act and involves complex relational practices and coping strategies, in particular sites.

Shifting landscapes of care provision

The following section examines how the landscape of care provision is shifting with austerity and considers the implications for how care is practiced and ultimately received. As we saw, there has always been a ‘mixed economy’ of social care for disabled and older people, as well as for migrants and refugees, those who are poor and those with mental ill-health. The ‘personalisation’ of social care funding and provision, now the dominant model in most welfare states (Power, Lord, & DeFranco, 2014), has further ‘stirred up’ this mixed economy, with traditional block-funding arrangements between local commissioners and providers increasingly ‘loosened’, and budgets devolved to individuals and families to organise and purchase care. Hall (2011) and others (Cox, 2013) have described this as the ‘commodification’ of care, in which a ‘marketplace’ is created where individuals exert ‘choice and control’ in their selection of ‘packages’ of care provision. Such ‘empowerment’ has been a long-term goal of the disability movement, and many disabled people and others have taken up the opportunity to, for example, employ a personal assistant. However, for others, such ‘powers’ are challenging to use and the closure of community-based facilities as personalisation expands negatively affects many (Hall, 2011).

Importantly, as national state policies of austerity ‘bite’, and funding in local areas is cut, in many countries around the world, such as the U.S, Canada and across Europe, fewer people will be deemed eligible to receive personal budgets to spend in the care marketplace (Green & Lawson, 2011; Hall, 2011). Those with severe disabilities will continue to receive funding, and those with other income will be able to purchase care from private companies. However, an increasing number of people will look to families and friends, and local voluntary organisations, to provide the care and support they need (Hall & McGarrol, 2013). Cox (2013) has raised the important question of what ‘care’ and, in particular, what ‘good care’ will become in an era of austerity. As noted above, the disability movement welcomes the ‘freeing’ of care from supposed structures of dependency, whilst others view any involvement of the private sector in provision of care as morally unacceptable. Cox (2013) argues that it is less the paying or not paying for care that is the issue, and more the contexts and places within which care takes place, and who is doing the caring.

More broadly, Green and Lawson (2011) highlight a global trend towards the commodification of care within market logics of choice and interrogate how care is being repositioned (read: displaced) within market relations of exchange. Meanwhile, building on the seminal work of Wolch (1990), Milligan (2001) and others have developed increasingly sophisticated theorisations of the role of voluntary organisations and volunteers in the provision of services, advocacy, self-help, and in some cases activism and resistance. The new boundaries which the sector increasingly occupies vis-à-vis the state give rise to wholly new geographies, where voluntary organisations are increasingly being recognised and co-opted, through different political governance models including neoliberal, third way or big society contexts.

The continued trend towards voluntarism and privatisation has been reinforced by a strong ‘localism’ agenda, which has unfolded in a range of countries, such as England and Australia. The U.K. Coalition Government’s 2010 flagship policy of the ‘Big Society’ powerfully articulated a ‘refreshed’ vision of previous governance models such as the ‘third way’, to shift the provision of public services from central government to a range of ‘local’ actors who, it was argued, were better placed to identify and find solutions to a range of ‘local’ social problems (Norman, 2010). These local actors included voluntary-run community organisations, private companies, professionals and social enterprises that were expected to provide for local people’s welfare needs. In Australia, a similar process of devolution of power and responsibility to local government and communities is seen as a possible solution to the challenges of service provision in sparsely populated regional and rural areas of the country; the emergence of ‘Local Area Co-ordinators’, who connect disabled and older people to care and mainstream community groups in rural Australia, is one example of such localism (Hall & McGarrol, 2013). The inevitable outcome is a more bespoke, yet precarious, community-led geographical patchwork of provision, raising questions of equality, sustainability, responsibility and where should care happen. More locally, this decentralisation process is cultivating an openness and engagement with local community spaces including gardens, libraries, and so on – a theme we turn to next. These new and emerging geographies stand out in contrast to the spatial ‘fix’ which emerged from the first wave of community care from the 1970s.

New spaces of care

In response to the social care reform agenda and broader climate of austerity, care is increasingly being found in new and undesignated spaces (Barnes, 2012; Hall, 2013; Munro, 2013). As day centres and care homes close in many areas, older and disabled people are encouraged to live independently in their own homes, and the private and voluntary sectors take a greater share of the caring burden, alongside families, supporters and friends. The landscape of care as a result becomes more and more difficult to map and interpret. This special issue is an initial attempt to do this.

The rapid take-up of personalised funding and choice and control has led to the opening up of new sites and relations of caring, in both expected (e.g. people’s homes and community centres) and unexpected (e.g. local museums and allotments) places. Support is thus being re-framed from ‘care’ in care settings towards enabling meaningful lives within local neighbourhoods and mainstream community settings. Geographers are becoming more attuned to the relations of care which are taking place within a growing myriad of ‘ordinary’ spaces of care including cafes (Warner, Talbot, & Bennison, 2013), parks (Laws, 2009), community gardens (Milligan, Gatrell, & Bingley, 2004) and arts spaces (Hall, 2013; Parr, 2008), where innovative and progressive forms of caring can emerge (Hall & McGarrol, 2013). Deverteuil (2016) argues that these innovative spaces and practices of care are a political and spatial form of resistance and creativity in the face of neoliberal driven gentrification and austerity.

A key concern here is how the social care sector responds to the challenges associated with the provision of care in a more diverse and fragmented environment, arguably exacerbated by the effects of welfare state restructuring on the ground, including cuts to transport services and geographically dispersed and uneven staffing levels. Meanwhile, service users, whilst having greater choice and control on the one hand, are having to navigate more complex systems and take on more personal responsibility in managing and paying for one’s own care on the other hand.

Geographic work has already begun to trace the outcomes of day care centre closures and greater expectations for former service-users to take up valued lives in the community and occupy positions in the open labour market. Power (2013) critically reflects on the emerging gap between the personalisation agenda’s desire to cultivate meaningful inclusion and ‘belonging’ for social care users on the one hand and the wholesale and rapid transformation towards individualised support on the other. The paper argues that the process of making ‘natural’ connections and support arrangements within the community will and should take time.

Placing care in times of austerity

The four papers in the special issue each examine care in times of austerity from a geographical perspective. In doing so, they highlight some of the important theoretical, methodological and policy contributions that geographical scholarship can make to an understanding of care provision in the contemporary moment.

The first paper, by Hogstrom, describes the deinstitutionalisation of mental health care in Sweden, documenting a transition from state-run hospitals to a diverse set of community and family-based spaces of care. This shift has been first driven by efforts to ‘humanise’ and normalise care, then by an agenda of promoting independence and choice, and most recently by austerity. In Sweden, austerity is part of a broader neoliberalisation of care, with an expanding ‘marketplace’ of care services as the ‘welfare state’ gives way to a ‘welfare society’. Hogstrom examines this emergent landscape of care through the notion of ‘multiscalarity’ and with reference to mental healthcare. She argues that in many cases, the delivery of services never quite fit together, as each service is always under review, expected to compete with each other, and subject to cuts. More positively, in this period of ‘spatial flux’, new (albeit often temporary) and hopeful spaces of care are opening care up, as part of what Hogstrom terms ‘interstitial urbanism’.

Power and Bartlett explore the ‘self-building practices’ of people with learning disabilities within the context of day care centre closures in the U.K. and the commitment to personalisation in adult social care. Drawing on participatory research, they identify new safe and relational spaces of care, which are each being uniquely negotiated, in places like allotments, marinas, bingo halls, and fish and chip shops. Underpinning these ordinary and unconventional spaces of care are delicate and precarious networks of support from advocates, community allies, volunteers and friends which seek to sustain the use of these spaces. These spaces of care are often negotiated to avoid experiences of harassment and isolation in local neighbourhoods, but also to meet people and seek ‘insider status’. In light of the findings, the paper argues that broadly based ethical relations and contexts of caring can emerge, in spite of, or perhaps even because of, the context of austerity.

Morse and Munro examine how care is becoming a newly embedded practice within the unexpected and undesignated spaces of museums in the U.K. Museums are increasingly expected to perform a social role, promoting the social inclusion and, more recently, health and wellbeing of marginalised groups through community engagement programmes. The significant cuts in both cultural and social care budgets and the localism agenda, which seeks to draw local voluntary and private organisations into community-based care, have generated new partnerships between some museums and social care services. Drawing on evidence from museums in north-east England and Scotland, Morse and Munro focus on the ‘ordinary everyday performances and practices’ of museum staff, such as building self-confidence, taking time to listen and talk to people, and using objects and activities to stimulate and calm, all within the safe space of the museum, which together constitute an ethics of care. Austerity is an ever-present threat to these activities, but there are some small examples of how museum staff engaging with communities develop projects that allow resistance to ‘austerity politics’ to be aired.

Finally, Schwiter et al. examine how Switzerland, although not experiencing austerity cut-backs of public spending to the same extent as other EU countries, has nevertheless undergone a profound transformation, with an ageing population, families unwilling/unable to care for relatives and no state aid for elderly care. As a result, Swiss households now increasingly purchase elderly care services in a privatised care market. This commodification has been accompanied by the recent emergence of numerous private suppliers of 24-h home care. As labour market intermediaries, these agencies hire migrant women from eastern European countries and sell packaged care services to the elderly and their families in Switzerland. In so doing, the agencies play a key role in configuring the commercialised care market. They shape the working conditions of the live-in migrant care workers and the definition of care itself as a marketable good. The paper analyses the strategies and practices of these new corporate intermediaries, illustrating how the current reconfiguration of elderly care transforms the home into a new space of commercialised care, with consequences for families, care workers, care recipients and the state. The authors conclude that this new emerging market ‘serves as a prime example of the consequences of austere neoliberal governance’.

Conclusion

There is an increasing need to apply geographical perspectives and approaches to the multidisciplinary challenge of understanding care in an era of personalisation, austerity, decentralisation localism and commoditisation. Importantly, care in the era of austerity is not a uniform tale of cutbacks and an erosion of caring. As Deverteuil (2016) argues, neoliberal reforms of care and ‘post-welfarism’ are not all encompassing; there is resistance, and creativity and innovation. New spaces, relations, networks and practices of care and caring are emerging in difficult times, in unexpected and unconventional places.

Disclosure statement

No potential conflict of interest was reported by the authors.

Acknowledgements

The authors would like to thank the editor David Conradson for his generous offer of time and patience to us and all the contributors to this Special Issue.