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  • Author or Editor: Bethany Simmonds x
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Global and National Perspectives

Neoliberal political discourses have normalised the belief in northern European countries that individuals are responsible for their health and wellbeing, regardless of social class, gender or ethnic background.

Drawing on examples from Germany, Sweden and the UK, Simmonds critically examines how the neoliberalisation and marketisation of health and social care have created an adverse environment for older people, who lack social and cultural capital to access the care they need. This crucial analysis scrutinises provision for ageing populations on an individual, national and global level.

Challenging current political and social policy approaches, this rigorous text discusses innovative solutions to contemporary challenges in a complex care system.

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Neoliberal political discourses have become inculcated in British and other northern European cultures, to the extent that it is normal to assume that individuals are responsible for their health and wellbeing, regardless of the inequalities they may have faced based on their social class, gender or ethnic background. However, this ignores how structural advantages and disadvantages accumulate across the lifecourse, producing contrasting experiences in later life, including in relation to health outcomes and life expectancy (Van de Mheen et al, 1998). Healthism is a political response often used at times of crisis when governments wish to deflect blame onto individuals (Crawford, 1980). This is illustrated in the UK government’s response to COVID-19, which has generally ignored the structural inequalities faced by older people (ageism), people from minority ethnic backgrounds (racism), people with ‘dis’abilities (disablism) and people from working-class backgrounds (classism), and how these put them at greater risk of contracting and dying from the virus. Older people’s lives have been systematically neglected in residential, domiciliary and hospital care (Horton, 2020; Calvert and Arbuthnott, 2021). Furthermore, people from minority ethnic and working-class backgrounds have also been systemically disadvantaged and discriminated against in their workplaces and everyday lives (Lawrence, 2020). The intersectionality of inequalities has been demonstrated in the high death rates within these groups during the pandemic.

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Chapter 2 reviewed a number of theoretical perspectives that provided critical lenses through which to frame the book’s themes, including the impact of global and national developments on health and social care. This and the following chapters use theoretical perspectives to examine the key global challenges that face health and social care provision for older people. Globalisation and neoliberalism have significantly shaped and moulded welfare state systems in the Global North on a national level, including health and social care services. This is the case for all the various archetypal welfare state systems: the neoliberal/Anglo-Saxon model, the social-democratic/Scandinavian model, and the corporatist/continental European model (Esping-Andersen, 1990). The United Kingdom, Germany and Sweden are used to demonstrate how three archetypal welfare state systems have been affected by neoliberalisation, and the resulting privatisation of health and social care services. The shift in responsibility for health and social care from the state to the individual has re-established the very class inequalities which the welfare state was originally constructed to eradicate. This regressive reassertion of class inequalities impacts health and social policy, and exacerbates the precariousness of the most vulnerable. This is especially true for older women with low levels of capital. Neoliberalisation and privatisation have made health and social care systems vulnerable to any pressures exerted on them, for instance, austerity measures or a pandemic.

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Historically, the UK, Germany and Sweden have been understood as the archetypes of three contrasting welfare state models. The structural convergences of all three countries’ welfare systems have been driven by efficiency-motivated state interventions, market competition and customer choice, leading to growing disparities in access. This chapter will discuss the impact of these changes in more detail on a national policy level. The discussion will focus on the UK, setting the context for examining the individual experiences of older people and health care staff in Chapter 5. The chapter starts with a discussion of contemporary health and social care policy, including austerity policies. Following this, austerity measures will be considered in terms of the impact they had on the Health and Social Care Act 2012 and the Care Act 2014. The subsequent sections examine the privatisation of health and social care, focusing on the failure of two of the biggest privately run care conglomerates: Southern Cross and Four Seasons. Then the neoliberalisation of the home care sector will be considered, followed by a discussion of adult social and health care workers’ precarity. Finally, the chapter will discuss the ‘dementia tax’ proposed by Theresa May’s Conservative government, Brexit, as well as some of the initial health and social care policies under Boris Johnson’s prime ministership.

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Previous chapters have outlined the theoretical and conceptual frameworks underpinning this book. Chapter 2 laid out the theoretical groundwork, examining how neoliberal discourse has shaped global and national health and social care policies. A shift in health responsibilities, driven by the rhetoric of choice, has paved the way for the marketisation of health and social care systems in most countries in the Global North. The dominant discourses of ageing – biomedical, social-gerontological and the idea of ‘successful ageing’ – were subsequently discussed. The chapter went on to review concepts of capital and field as developed by Bourdieu, making the point that higher levels of capital can protect against precariousness in the field of health and social care. Following this, I discussed feminist intersectional analysis, together with the importance of how different identities related to gender, social class and ethnicity can produce inequalities that compound along the years of a person’s lifecourse. Finally, the shift in ageing paradigms from welfare to active ageing to precarious ageing was discussed (Grenier et al, 2020).

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As Chapters 3 and 4 have argued, the challenges facing health and social care are the result of discursive and structural changes at the global and national level, namely globalisation, neoliberalisation and austerity. A shift from active to precarious ageing, alongside growing fragmentation, complexity, marketisation and intersecting inequalities, is illustrated in the empirical data in Chapter 5. The health and social care system have been in ‘crisis’ for many years; thus, the COVID-19 pandemic did not cause the ‘crisis’ in health and social care, but rather exacerbated it. Nevertheless, since COVID-19 hit in March 2020, the NHS has gone through the most challenging set of circumstances since its inception in 1948. Furthermore, it occurred at a time when health and social care institutions were underfunded, understaffed, fragmented and poorly coordinated with each other. The result of the pandemic was devastating for older people in the UK (particularly the tragedy of numerous deaths in care and residential homes) and this chapter provides an initial discussion of what went wrong. What follows is a comparative analysis of the respective COVID-19 health and social care policies of Sweden and Germany. Here, I revisit the two case studies detailed in Chapter 3, where Germany’s and Sweden’s health and social care systems were summarised. Finally, I discuss the impact of the COVID-19 and Brexit nexus on health and social care, and the ways forward the government is indicating it might take. Some of the policies offered by the Conservative government since taking power and securing a majority in 2015 related to integrating health and social care. These will also be critically examined considering the UK government’s handling of the COVID-19 pandemic.

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Throughout our lives, we all want to give and receive care, particularly at the beginning and the end. The expectation that there will be someone to care for us in later life is almost universal. Women were, and still are, usually tasked with this role, due to what is viewed as their ‘naturally’ existing caring nature (Hayes, 2017: 80–1). The daily activities of cleaning, cooking, washing and feeding have often been taken for granted and rendered invisible within social structures. Little value has been placed on these life-sustaining tasks (The Care Collective, 2020). Waves of feminism have highlighted the injustices of care work being feminised, devalued and not recognised as ‘work’ (Hayes, 2017). Yet, women are still providing most of the care for relatives in the family as well as in outside agencies, being paid to provide care services in either domiciliary settings or within residential institutions (Bunting, 2020). Thus, the historical connotations of care work being of low value and feminised have continued. Both formally and informally, women are overwhelmingly those still doing health and social care work with older people (Bunting, 2020). This, coupled with endemic ageism in society (Ayalon and Tesch-Romer, 2018), is arguably how neoliberal governments have successfully justified the low value and pay associated with health and care work, and the low political priority given to the care of older people.

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This chapter outlines the theoretical lenses used to frame and discuss the book’s themes. Framing discussion using theory is important because it lifts analysis beyond a descriptive account to a more critical examination of how societal structures and discursive developments have impacted institutions. For example, neoliberal and austerity discourse has shaped health and social care structures and institutions, such as the NHS, which have changed the experiences of individuals, such as older people and health or social care workers. Furthermore, it is important to discuss theoretical concepts such as neoliberalism, capital and precarity, in order to illustrate how broad discursive and structural change has influenced levels of security and stability for older people and staff in health and social care. For example, neoliberal discourse, which supports austerity measures and public funding cuts, impacts the resources or capital available to service users and those working in the public sector by making their lives more precarious. The extent to which older people are affected relates to their level of capital (economic, physical, social and cultural [Bourdieu, 1984; Dumas and Turner, 2006]); for example, being more educated or wealthy mediates an older person’s access to health and social care systems. Family and friends (social and cultural capital) are particularly important in helping older people traverse and negotiate the complexities of fragmented health and social care services. However, class is not the only identity that can impact older people’s access to health care resources.

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