Care markets and choice for users

Different dimensions of the marketisation of care have emerged across western welfare states (Daly and Lewis, Reference Daly and Lewis2000). These processes include, first, reforms to the public provision of care services, including the contracting out of services to private and non-profit providers (Glendinning, Reference Glendinning, Dannefer and Phillipson2010). The private sector now accounts for the majority of residential and home care providers in England (Eborall et al., Reference Eborall, Fenton and Woodrow2010: 18). Second, the use of cash-for-care services has shifted public responsibilities for the purchasing of services to individuals and their families (Ungerson and Yeandle, Reference Ungerson and Yeandle2007). There has been a rapid increase in older people (sixty-five and over) in England receiving direct payments, though the numbers still remain relatively low as a proportion of older people receiving publicly subsidised provision (Eborall et al., Reference Eborall, Fenton and Woodrow2010: 27). A third dimension of the privatisation of long-term care concerns the private funding of care by older people and their families. Public funding is currently estimated to contribute around half of total long-term care expenditure in England, while the share of private funding is associated with increasing selectivity in eligibility for publicly funded care, including charges paid by individuals receiving public provision, extra support purchased by individuals in addition to public provision and support that is entirely privately funded (Forder and Fernández, Reference Forder and Fernández2010).

These developments across European countries have taken place in the context of ongoing demands faced by welfare states in negotiating growing needs for and the costs of long-term care, which have been heightened by cuts in public expenditure. At the same time, greater choice for users has been a central aim for improving the quality of care provision (Timonen et al., Reference Timonen, Convery and Cahill2006). Underlying policy aims are contrasting discourses of choice, which reflect different political and theoretical critiques of the welfare state (see Glendinning, Reference Glendinning2008). Choice of providers and services is conceived as a means to promoting competition. ‘Passive recipients’ of care are re-positioned as ‘active consumers’ whose power of ‘exit’ within the market – the ability to leave one provider for another – exerts competitive pressures on providers to be responsive to individual needs and preferences (Le Grand and Bartlett, Reference Le Grand, Bartlett, Le Grand and Bartlett1993). The power of exit is conceived as potentially facilitating the power of ‘voice’ for users (Hirschman, Reference Hirschman1970) by exerting pressure on providers to listen to the demands of users where users have control over the purchasing of provision (Le Grand, Reference Le Grand2007). The exercising of choice and control over care provision is also conceived as an end in itself, as integral to achieving full citizenship and independence for disabled and older people in need of care (Morris, Reference Morris, Glendinning and Kemp2006).

There remain important debates concerning the implications of the marketisation of care for users, whose ability to exercise choice as individual consumers is, not least, highly constrained by the limits of their purchasing power (Arksey and Kemp, Reference Arksey and Kemp2008; Glendinning, Reference Glendinning2008; Newman et al., Reference Newman, Glendinning and Hughes2008). However, missing from the debates on choice is attention to the social relations in which care is embedded. As underlined by Daly (Reference Daly2002), care is a policy good with two sets of interests: those of the person experiencing care needs and those of the actors who provide it. Choice in relation to care, therefore, concerns not only choice over how care needs are met, but choice over whether to provide care and the conditions under which caring is carried out (Daly, Reference Daly2002).

Care labour markets, immigration controls and choice for migrant workers

The concept of choice for users in welfare markets can be extended to labour markets to consider choice for care workers regarding their employment. Individual workers are, according to liberal economic theory, able to exercise choice and control through the freedom to sell their labour to the employer of their preference, encouraging the worker to act as a ‘consumer’ of workplaces (Smith, Reference Smith2006). The power of exit for workers – the threat of leaving an employer – may exert competitive pressures on employers to develop strategies to retain workers. It may also enable the individual, or collective workers, to voice complaints and to re-negotiate terms and conditions within employment, such as improvements to wages (Smith, Reference Smith2006). The exercising of choice and control by workers can thus be conceived in terms of their labour mobility. The autonomy of workers to enter and exit employment relations is of intrinsic value to workers in so far as, at the opposite end of the spectrum, coercive practices of recruitment and employment, or ‘forced labour’, are used to exercise control by employers over workers and to derive unfair advantage from their labour exploitation (Anderson and Rogaly, Reference Anderson and Rogaly2005).

Just as the literature on user choice has emphasised the social context and institutional setting in which individual choice is framed (Taylor-Gooby, Reference Taylor-Gooby2008), so too has the literature on care, labour markets and migration emphasised the social and institutional context which shapes labour migration (Anderson, Reference Anderson2010; Williams, Reference Williams, Dahl and Kovalainen2011b). Decision-making over transnational migration reflects not simply rational choices of individuals, but the collective strategies of families and communities located within the structural conditions of global market economies (Castles and Miller, Reference Castles and Miller2003). At the same time, state policies on migration frame the exercising of choice not only concerning the mobility of migrant workers across national borders but within labour markets (Anderson, Reference Anderson2010). Immigration controls are highly significant in constructing particular categories of ‘non-citizens’ – e.g. labour migrants, asylum seekers, students – who are accorded different rights and entitlements in relation to work and welfare (Spencer, Reference Spencer2011). Both the construction of ‘illegal’ status and the terms and conditions attached to legal status must, therefore, be considered when examining how the labour mobility of migrants is conditioned by immigration controls (Anderson, Reference Anderson2010).

First, immigration controls shape choice regarding rights of entry to the labour market. The lack of entitlement to work may leave few options for ‘irregular’ migrants but to enter irregular types of work that offer low wages and poor working conditions. Likewise, the entitlement to work, e.g. for work permit holders, may be tied to particular sectors of work and to particular occupations. Second, immigration controls shape choice by limiting the ability of migrant workers to leave or to exit an employer. Fear and insecurity concerning immigration status – both for irregular migrants and those with temporary rights to work and temporary rights of residence – can severely limit the ability of migrant workers to exercise powers of exit. For irregular migrants, fear of being reported to immigration authorities and of deportation has been found to contribute to experiences of forced labour, whereby employers are able to use the threat of denouncing a worker's irregular status to not only retain the worker but to force compliance with poor working conditions, including excessive hours of work, payment of low wages (below the national minimum wage) and delayed or non-payment of wages (Anderson and Rogaly, Reference Anderson and Rogaly2005). Power of exit is also restricted by the terms and conditions of legal status, which may tie the worker to an employer. This is the case for migrant workers who hold temporary work permits and are dependent on their employer to obtain and renew their work permit (Anderson, Reference Anderson2010). Work permit holders may be less likely to leave an employer on whom they are dependent for their right to work and remain in a country, and, ultimately, for an income. As such, immigration controls may limit both the power of exit of migrant workers from poor working conditions and the ability to voice individual or collective complaint over working conditions. The ‘institutionalised uncertainty’ of temporary as well as illegal immigration status thus serves to construct workers over whom employers have greater control (Anderson, Reference Anderson2010).

There has been increasing diversity of immigration statuses accorded to different groups in the UK, reflecting an increasing stratification of rights and entitlements between UK and non-UK citizens and among particular categories of ‘non-citizens’ (see Spencer, Reference Spencer2011). Policy towards labour migration in the UK over the past decade has been relatively liberal towards skilled and higher skilled workers, and restrictive towards workers in low-waged jobs (Ruhs and Anderson, Reference Ruhs and Anderson2010). Prior to the introduction of the points-based immigration system in 2008, work permits could be obtained for workers from outside the European Economic Area (EEA). These included work permits for occupations in health and social care that were conceived as ‘skilled’ according to national qualifications criteria, including nurses and senior care workers. The enlargement of the European Union in 2004 also facilitated the employment of workers from the eight accession (A8) countries, predominantly in low-waged sectors of the labour market. Likewise, a range of other types of visas have allowed for the employment of migrants in the UK, including students, working holidaymakers and those entering through family reunion (Ruhs and Anderson, Reference Ruhs and Anderson2010). At the same time, particular categories of migrants, such as asylum seekers, have faced increasing restrictions on their rights and entitlements, including the right to work and to welfare provision. Moreover, rights of settlement for non-EEA nationals have become increasingly restrictive regarding the eligibility criteria for obtaining permanent residency and UK citizenship.

These divisions of citizenship and immigration status are evident among foreign-born workers employed in long-term care in the UK (Cangiano et al., Reference Cangiano, Shutes, Spencer and Leeson2009). Just over a quarter (28 per cent) of foreign-born care workers are UK citizens. Among non-UK citizens, around a quarter (26 per cent) are EEA nationals. The majority (74 per cent) are non-EEA nationals who are subject to immigration controls, the main nationalities including the Philippines, India, Nigeria, Zimbabwe and South Africa (Skills for Care, 2011). Non-EEA nationals include work permit holders, but a range of other categories of migrants are also working in care, including domestic workers, students, asylum seekers and refugees, and ‘irregular’ migrants who are not legally entitled to work or reside in the UK, as discussed below.

Data and methods

In-depth interviews were carried out with fifty-six migrant care workers in 2007 as part of a broader study in the UK (see Cangiano et al., Reference Cangiano, Shutes, Spencer and Leeson2009). Interviewees were selected to include: those working in direct care-providing jobs employed by residential care homes, home care agencies and by older people/their families; the main nationalities among foreign nationals working in care; and those who held different immigration statuses in order to explore the influence of immigration controls on workers’ experiences. Interviewees were recruited through residential care homes and home care agencies, migrant community organisations, faith-based groups, trade unions and snowball sampling. Issues of non-response bias that affected who was willing to participate and what was discussed in interviews include concerns surrounding immigration status (particularly for those not entitled to work) and the limited time available to some care workers (particularly those employed as live-in care workers in older people's homes). Potential interviewees were given written and verbal information on the research and on confidentiality and anonymity. Interviews were carried out in the first language of care workers who were not proficient in English (who were given translated information). Interviewees who needed advice and guidance on issues relating to their employment rights and immigration status were referred to relevant organisations for assistance. The names of interviewees cited in this article have been changed.

Interviewees were all foreign nationals, whose nationalities reflected the principal countries of origin of foreign nationals working in the care sector in the UK, including Zimbabwe, the Philippines, India and Poland, and other African, South and South-East Asian and Eastern European countries. Almost all interviewees had arrived in the UK between 1998 and 2007. The majority were women (forty-nine were female and seven male). They were employed as care assistants, senior care workers or nurses by private residential and nursing care homes or home care agencies (except one local authority employee), or directly by older people or the families of older people. Interviewees were working in England, mainly in London and the South EastFootnote ⁶ and also the South West, Yorkshire and The Humber, and North West (see Cangiano et al., Reference Cangiano, Shutes, Spencer and Leeson2009: 201−7 for further details).

Interviewees included the following groups according to their immigration status at the time of interview:

• • First, those with unrestricted rights to work in the UK (e.g. EEA nationals from A8 countries, refugees with indefinite leave to remain, others who had obtained permanent residency since coming to the UK);

• • Second, those whose right to work in the UK was restricted to care-related work (e.g. those holding work permits for senior care workers or domestic worker visas) and who were dependent on their employer (who was responsible for obtaining and renewing their work permit or visa), or were restricted in other ways (e.g. students who were entitled to work a limited number of hours);

• • Third, those without permission to work in the UK (e.g. those who had overstayed entry visas to the UK).

However, the rights of migrant care workers were not static and changed according to changes in their immigration status since entering the UK – for example, those who had entered the UK as asylum seekers without permission to work who had subsequently been granted refugee status with permanent residency and full rights to work, and those who had entered on student visas and had been unable to renew their visa and were subsequently not legally entitled to work.

The following sections of this article explore how immigration controls shaped the exercising of choice and control by migrant care workers regarding, first, entry to particular types of care work, second, exit within work and, third, voice regarding the terms and conditions of care work.

Choice and entry to care work

Reasons for entering work in long-term care were partly shaped by restricted rights to work in the UK. Respondents who entered the UK as asylum seekers were not entitled to work according to their immigration status. Likewise, those who overstayed their entry visas were not entitled to work. These care workers generally did not have a background in care-related work – previous employment before coming to the UK included teaching, the civil service and administrative work. However, they indicated that finding work within the UK was mainly confined to jobs in long-term care (and a narrow range of other low-paid sectors of the labour market, including cleaning and factory and catering work) where demand for care workers was such that residential care homes and home care agencies were willing to overlook restrictions on their right to work. Entering care work was, therefore, defined not as a ‘choice’ but rather as a ‘need’, being a source of work and income for those with restricted access to the labour market and to welfare provision.

The terms and conditions of legal access to the labour market likewise shaped entry to care work, and to particular types of work. Restrictions on recruitment to the National Health Service that were implemented since the mid 2000s in the UK made entry to the public sector, including nursing occupations, more limited for non-EEA workers. These restrictions were reflected in subsequent reforms to the admission of overseas nurses to nursing adaptation programmes (Bach, Reference Bach2007). Non-EEA nationals with backgrounds in nursing included those who had entered the UK on student visas with a view to becoming a registered nurse in the UK. Carol had come to the UK by applying to a private care agency, through which she worked while enrolled on a nursing adaptation programme. At the end of the programme, she was unable to enter nursing work due to restrictions on the issuing of work permits for nurses. As a student, her employment was limited to part-time, temporary work.

Her status as a student thus placed her in agency work under worse terms and conditions.

Others with nursing backgrounds had come to the UK through work permit channels of entry for senior care workers within private residential care homes. Therefore, the work permits by which they entered the UK likewise positioned these workers within ‘privatised’ care work in the private sector on temporary contracts.

Similarly, the terms and conditions attached to domestic worker visas positioned domestic workers in other forms of privatised care within the homes of older people and their families. Domestic workers had come to the UK on visas that had been obtained by their employers (individuals by whom they were employed in private households). These workers had subsequently found work caring for older people in other households, through informal networks or agencies for domestic staff. While they were entitled, in principle, to change employers, this was restricted to employment within private households, in which the boundaries of their responsibilities as domestic/care workers were blurred.

Exit within care work

Lack of legal rights of residence and employment as well as the temporariness of those rights, determined by ‘non-citizen’ status, placed migrant care workers in highly unequal relationships with employers regarding their power of exit. Work permit holders were dependent on their employer (private residential care homes) for their temporary work permit, though they were, in principle, entitled to change employer. Insecurity surrounding immigration status was compounded by changes made by the UK government to the regulation of work permits for senior care workers, involving greater restrictions on the issuing and renewal of these work permits in the period prior to (and since) the introduction of the points-based system in 2008.Footnote ⁷ Within this context, the power to exit an employer was limited by migrant workers’ concerns that leaving an employer before the end of an employment contract would be considered unfavourably by immigration authorities and potential future employers, and might therefore jeopardise the renewal of a work permit or application for permanent leave to remain or for citizenship in the UK.

The uncertainty of temporary legal status was reinforced as legislation on obtaining permanent residency in the UK likewise became increasingly restrictive during this period, including the lengthening of the required period of stay in the UK (from four to five years) to be eligible to apply. This limiting of access to full rights to work in the UK inhibited opportunities for mobility from lower paid care assistant occupations within the private sector to nursing occupations within the public sector (with better pay and employment-related benefits). Sophia had come to the UK on a work permit as a senior care worker, employed by a residential home. At subsequent intervals since coming to the UK, changes in immigration legislation prevented her from applying for permanent residency, until after five years she was finally able to do so with the intention of leaving her employer and re-entering nursing.

While other factors clearly limit the power of exit for workers who are not subject to immigration controls, the differential rights of non-EEA nationals shaped perceptions of their potential to change employer. Work permit holders contrasted their position to that of UK and EEA nationals who could more easily change jobs if they wanted, given their citizenship rights.

EEA nationals included both those with previous experience in nursing and care-related work, who had applied for positions in residential care homes before coming to the UK, as well as those without previous experience in care-related work (including students) who had found work in long-term care after coming to the UK. Among the latter, entry to ‘easy-to-find’ jobs in residential and home care services reflected the quickest route into the UK labour market. However, these respondents emphasised intentions to move on to better jobs, with better pay and hours of work, unrestricted by immigration controls since gaining the rights of EU citizenship.

By restricting not only entry to the labour market but the power of exit – from one employer to another, from the private to the public sector, from employment within private households to institutional care – immigration controls therefore shaped the exercising of choice and control by migrant care workers over their labour, while structuring their position as providers of care under particular terms and conditions.

Voice and working conditions

Restrictions on the mobility of migrant care workers also shaped power of voice in negotiating the terms and conditions under which care labour was provided. Among ‘irregular’ migrants who were not entitled to work, fear and insecurity concerning irregularity limited the ability to voice complaints over experiences of exploitation of working in residential care homes. These experiences included the withholding or underpayment of wages by employers.

Unfavourable working conditions reported by respondents also included hours of work. According to LFS data, over 30 per cent of foreign-born care workers work more than 40 hours a week, compared with 18 per cent of UK-born care workers. Higher proportions of foreign-born care workers (74 per cent) also do shift-work compared with UK-born care workers (60 per cent) (Cangiano et al., Reference Cangiano, Shutes, Spencer and Leeson2009: 81). Migrant care workers interviewed in the research who were employed in residential homes indicated that their managers relied on them to work overtime and to work less favourable shifts in order to address staffing gaps.

EEA nationals who were not subject to immigration controls were able, in principle, to move into other jobs, as the above respondent eventually did, finding work in an NHS hospital where she received double the wages she had been paid in the private care home where she had been working. However, work permit holders from countries such as the Philippines were less able to negotiate the terms and conditions of their employment through the option of exit. Moreover, work permit holders subject to immigration controls were not entitled to tax subsidies for low-waged work (working tax credit), which in effect necessitated longer hours of work to achieve equivalent wages.

The positioning of those who held domestic worker visas in relationships of dependency on employers for their immigration status, but also in less regulated types of care work in private households, likewise limited their power of voice regarding their working conditions. The isolation of care workers in private households (particularly those co-residing with the older person as a live-in carer) from other workers and from organisational sources of support – including information and advice on employment rights – also served to limit their collective voice. The working conditions referred to by these workers included long hours of work, sometimes with no contractual agreement on their hours.

With regard to weekly wages, given the long hours of live-in care, hourly rates of pay in some cases fell below the national minimum wage when accounting for the actual number of hours worked each week. Working overtime was sometimes not paid, and care users or their relatives sometimes forgot or, in one case, openly refused to pay weekly wages. The latter concerned the experiences of Maria, a live-in care worker who had come to the UK on a domestic worker visa. In her previous job she had been working on the basis of a verbal agreement regarding her wages. After trying to negotiate her wages, she eventually was dismissed by her employer with wages of several months still owed to her.

Irregular employment practices also involved the avoidance of employer contributions to tax and national insurance payments, sometimes by employing migrant care workers on a ‘self-employed’ basis (despite self-employment being prohibited for those holding domestic worker visas). While the irregular employment of migrant care workers in private households provided a means of cutting the costs of care, thereby facilitating choices for users for home-based provision, it had clear implications for the exercising of choice by migrant care workers beyond their current conditions of work. Irregular employment not only prevented migrant care workers from applying for permanent residency in the long term (as they would not have met the criteria of continual legal employment in the UK to be eligible to apply), and therefore from full rights of access to the labour market, it also limited their access to welfare rights, including pension rights, with implications for their own future care provision.

This paper has focused, specifically, on the ways in which divisions of citizenship and immigration status frame choice over the provision of paid care labour. However, those divisions intersect with gender, race/ethnicity and class, and are located within broader inequalities between countries in the global North and South. Likewise, the mobility of individual workers in care labour markets connects paid and unpaid care. The gendered allocation of care to the private sphere of the household provided (albeit restricted) opportunities for employment for migrant women as domestic workers, who referred to their caring responsibilities for their own families in countries of origin, such as India, Sri Lanka and the Philippines, as shaping their migration trajectories in transnational markets of home-based work. Likewise, while the individual preferences of some women and men working as senior care workers in residential care homes may have been to pursue other types of work or education, opportunities for working in the care markets of the global North were a means to providing remittances to families in the South.

At the same time, entering care work was also perceived as providing opportunities for more rewarding employment compared with other low-paid jobs that migrant women had been able to access within a gendered and racially segmented labour market – despite obtaining permanent residency and unrestricted employment rights in the UK. Similarly, caring responsibilities for families within the UK also shaped the decision to stay in care-related jobs. By contrast, EEA nationals, who were White and, overall, comparatively young women without children, had greater capacity to frame their decision-making regarding their labour mobility in terms of individual choice.