Work with people in need of care and help, whether as a job or in the private realm has many aspects. The English word care is now also used in German social science discourse to describe this work. On the one hand care describes nursing activities; but it also includes care in the sense of the aid and attentiveness between carers and those dependent on their help. This opens up a holistic approach to care. The word care is therefore broader than the German word Pflege (which refers only to nursing) and this is precisely the strength of this term.
The neglect with which the care economy has so far been treated in theoretical economic debates is due, at least where nursing is concerned, to the fact that most of this work is done by women. What is more, applying the concepts of economic analysis such as efficiency, inputs and outputs, production and productivity is difficult in care work. It is even difficult to find an appropriate way of quantifying quality, regardless of whether the quality of results, structures, or processes is being measured.
Florence Nightingale’s legacy of care
Nursing as a part of care has historically been dominated by women. Even today 88% of outpatient and 85% of inpatient nurses are women. In domestic care the figures are similar: 75% of those responsible for care work are women. Normally they are relatives of a person in need of care. More precisely that means they are wives, daughters, daughters-in-law or granddaughters. In many cases elderly spouses or partners care for their relatives.
Why nursing has not been able to free itself from these roles over the centuries is a valid question. Neither in the family nor in the professional sphere has there been any real change. A related question is why the care economy has not yet even been properly discussed. Furthermore, together with the growing number of people in need of care, there is also a rising need for nursing and care services. More than half of people aged over 50 have experienced care in their immediate social surroundings. The issue at least is now part of public debate. But it is a pity that the discussion about the value created by care – also discussed in Christa Wichterich’s article Care, the Market Economy, and Gender Equity – has only become a seriously issue due to the lack of nursing provision. A recent prognosis by Germany’s Federal Statistical Office (Statistisches Bundesamt) warned that by 2025 a total of 112,000 full-time trained and untrained nurses will be needed for the elderly, as hospital nurses, and nursing assistants. This clearly demonstrates there in recent years there has been a missed opportunity to make care work more attractive and ensure higher levels of public recognition for the work done in this sector. As is typical for so-called ‘women’s jobs’ this work is taken for granted and has remained invisible.
Through the introduction of compulsory care insurance (Pflegeversicherung) in 1995, an economic logic found its way into care. This marked the beginning of a wave of professionalization, and a quality offensive in nursing. Yet this has failed to include a broad discussion about the value of care and the economic framework within which this value should be created (for example in well-paid jobs). Furthermore, it would also be important to discuss the differences between professional and non-professional care. The differentiation between care provided by lay carers and professionals is fundamental and an important factor in Buhls’ criticism of using volunteers for care work. There are huge differences between care provided by professionals and lay carers and these include aspects such as knowledge, standards and the ability to follow care guidelines.
The care economy must emancipate itself
Care is feminine. It remains an occupational profile that seems to remain unattractive enough for an equal gender distribution to develop. Clearly there are men working in this sector, but most of them work in top management positions. When men decide to go into care, most of them stop working as direct carers very quickly. For men, the job of a carer is frequently only a short stop on the career ladder. Such patterns are not only frequent among carers, they are equally common in other sectors of the economy and it is still rare to find women in top management positions. This shows that as Greens our demand for a women’s quota especially in leading management positions is still justified. But at the lower end of the income scale a lot still remains to be done, for example, standards for agency work and minimum wages are absolutely necessary. Clearly we welcome the minimum wage for assistant carers that was put in place in 2010, but the difference minimum wages in eastern and western Germany (€7.50 are €8.50 repsectively) as well as the actual amount which is paid in itself, are extremely problematic. Furthermore thes minimum wage will only apply until 2014, when it will be assessed by the Federal Ministry of Economics and Technology. Female carers in particular are forced into precarious conditions through temporary contracts, part-time jobs and agency work. This alone shows how important it is to discuss and highlight the value created by the work done in this sector.
The economic aspects of care by relatives
The question of who will take over nursing duties cannot simply be left to nursing policy and this particularly applies to care provided by relatives. This question is intimately connected with policies concerning the labour market, women and the family. Currently most people in need of care are cared for by their relatives. Out of 2.34 million people in need of care 1.62 million are cared for at home. Out of these, more than one million receive a nursing allowance (according to the Federal Statistical Office in Wiesbaden). But this care has its limits and is dependent on certain basic conditions. Individual measures must be coupled with broad measures to help support family members who provide care. The German Green Party’s concept of time for family care (Familienpflegezeit) aims to provide support in such circumstances. Our plans for family care time will grant carers three months to provide care for relatives. During this time either further care can be organised or the time can be used for hospice care for close relatives. Care time is meant to protect carers from losing their jobs. Furthermore our concept of family care time envisages compensating individuals for their lost salary by providing them with up to 50% of their net income, or between €300 and €1,000, funded by taxes. At the same time the law regulating part-time work (TzBfG: Teilzeit- und Befristungsgesetz) will have to be refined, so that employees are guaranteed the possibility to return to their previous work after caring part-time for a relative.
Our model aims to ensure that care and work are compatible to the lives of both women and men. Men need strong incentives to take part in care work. But as long as women in the EU continue to earn on average 17.8% less than men (according to a recent statement by the EU Commission) we will not overcome the false incentives that mean women continue to take on the majority of care provided by families. If we want men to become more active in care, then this gender pay gap must be closed.
If we wish to achieve a ‘healthy’ care economy, it is just as important to change our perceptions of those in need of care and their relatives. Instead of viewing them as having a problem, we should also see them as customers or clients. We need to leave behind the predominantly supply-induced ‘motherly care’ form currently found in Germany. We need to expand free choice in the sense that we become more focussed on consumers of care. Everyone must be able to decide themselves which type of care is most appropriate to their needs. Consequently, we need an array of easily accessible offers, for example, in domestic services and related areas.
Similarly, the introduction of a personal care budget would be an important step in raising the options available to those in need of care, and would empower them to develop the type of care that is most suited to their needs. A care budget would then allow people in need of care to individually select and buy care services outside of the strict regulations of social insurance. This would raise individual influence on what is being offered on the care market and increase competition between care providers. This can only be of advantage to consumers, and a consumer driven market would provided more individualised and financially flexible services.
In spite of the demands for more options for those in need of care, people who are in a difficult and sensitive situation must never be left to themselves. Therefore new and independent counselling centres as well as professional case management structures in care work must be rapidly established. This would necessarily have to be a neutral, accompanying, and advisory entity which closely works together with clients (similar to the way solicitors do) in the selection, combination, and coordination of care. Only in this way can quality and consumer rights be guaranteed. Consequently, professional case management must aim at empowering those in need of care and their relatives and help them organise care for themselves for as long as possible.