Ageing and the Crisis in Health and Social Care forms part of the Ageing in a Global Context series of books published by Policy Press in association with the British Society of Gerontology. The Introduction sets out the book's key themes: how neoliberal policies, austerity politics and ageism have impacted the quality of health and social care for older people, and the increased ‘precarity’ facing both older people and workers in the health and social care system. The author explains how the book is founded upon empirical studies into different areas of the health and community care system in the United Kingdom (UK) and, for comparative purposes, case studies of the Swedish and German health and social care systems. The Introduction then outlines the contents of the following six chapters, the latter ones inevitably reflecting the impact of the COVID-19 pandemic and, to a lesser extent, Brexit.
Chapter 2 sets out some of the main concepts informing the book. Biomedical discourse, social gerontological and successful/active ageing theories are critiqued. The author explains their conceptual and theoretical framework which includes Foucauldian ideas about discourse, governmentality and biopower; Bourdieu's concepts of habitus, field and capital, and feminist intersectional theory. A section is devoted to exploring the notion of ‘precarity’ and its application both to people in old age and the working conditions of those who care for them. These ideas are used to argue that the unequal possession of different forms of capital and the intersection of identities such as class, gender and ethnicity have cumulative effects on both ageing and on health outcomes. The consequence of the state shifting more responsibility to the individual means that those possessing the least capital experience the most precarity in the health and care system. A challenge with this chapter, and throughout the book, is the frequent reference to the ‘Global North’, a term which is not defined, but as the book focuses only on the UK, Germany and Sweden, could imply that these three countries alone constitute the ‘Global North’.
Chapter 3 outlines the political and economic context in which care occurs and explores the impact of neo-liberal policies both on older people and staff working within the care system. It begins by briefly discussing globalisation, neoliberalism and how both have contributed to the ‘financialization’ of health and social care services. Using the typology developed by Esping-Andersen (Reference Esping-Andersen1990), Simmonds discusses in turn, the UK, Swedish and German systems of health and social care, and concludes that all three systems are converging in terms of the marketisation, privatisation and consumerisation of services. This, it is argued, not only contributes to health inequalities but is also damaging to staff working in these sectors. Given its centrality to the book, the discussion of neoliberalism could have been expanded to better contextualise and explain why and how this political ideology has become so dominant. This would necessarily include discussing the breakdown in the post-war social-democratic settlement and the perceived failures of Keynesian economics. To provide a fuller context, this chapter would have benefited from providing statistical data in respect of ageing populations globally and in terms of comparative per capita spend on health and social care as a percentage of Gross Domestic Product globally and nationally.
The Chapter 4 focus returns to the UK in discussing ‘failing health and social care in the UK’ from 2007–2008 onwards following the fallout from the ‘global economic crisis’. Given that this crisis left governments globally with levels of national debt not seen since the Second World War, this major economic shock required a fuller discussion to place it and its consequences into a proper context. The chapter begins by briefly discussing austerity policies in the UK and, specifically, the Health and Social Care Act 2012 and the Care Act 2014. The latter subjects exemplify an Anglo-centric bias to the coverage of policy developments in the UK. Scotland's position on both health and social care policy, for example, has varied significantly from that in England, but this is not discussed. The chapter then proceeds to focus on the negative impact of neoliberalism, privatisation and marketisation on the care home system and the domiciliary care sector, noting the precarious status of adult social care and health-care workers. The chapter concludes with discussion of the ‘dementia tax’, the 2017 election and, more briefly, a section on ‘Brexit and Boris’. Trying to encompass numerous subjects whilst trying to remain current, unfortunately results in this chapter lacking a coherent narrative thread.
Chapter 5 aims to link the themes discussed in previous chapters to empirical data collected by the author in three small-scale, UK-based case studies: a study into experiences of physical activity in later life; a study into the responses by paramedics when people fall or are at risk of falling, and a study examining end-of-life conversations and services. Simmonds uses the case studies to argue that cuts in services, ageism, intersectionality and differentials in capital possessed by older people impact negatively on access to and quality of services, especially in navigating a health and social care system made increasingly complex by marketisation and privatisation. These case studies are possibly the most interesting aspect of the book, but could be improved by providing better policy context globally, and nationally. The three case studies provide interesting insights at the micro/local level into the lived experiences of older people and the people providing services. However, whether they can be said to provide sufficient or appropriate evidence of the impact of neoliberalism on health and social care services (a key theme of earlier chapters) is questionable.
Chapter 6 looks primarily at the impact of the COVID-19 pandemic on older people's care. There is some comparison with how the UK, Sweden and Germany handled the crisis and a brief discussion about what the combined impact of COVID-19 and Brexit might mean for older people in the UK. It is stressed that both endemic ageism and the differential possession of capital play a part in shaping outcomes for different groups. Including this chapter on the COVID-19 pandemic is timely, but it is almost certainly too early to draw any firm conclusions as both the pandemic and its impact is ongoing and will be for some time.
Arguing that the pandemic could provide an opportunity for innovation and cultural change, in the final chapter, Simmonds briefly describes four developments that she proposes could provide lessons for alternative models of care and support for older people. They are Homeshare, based on the principle of intergenerational support; therapeutic nursing homes, another intergenerational initiative; age-friendly cities; and relational/asset-based approaches. Simmonds argues that the examples discussed demonstrate the direction in which the necessary cultural change in care should go. These suggestions include a focus on holistic and reciprocal relationships informed by taking collective responsibility, acknowledging the universality of precarity and accepting the principle of precarious interdependence rather than in terms of dependency relationships.
The book highlights the precarious plight of both older people reliant on health and social care services, and of the precarious employment position of many who work in the social care system. This book is possibly too ambitious in all that it wants to say in the space available. Focusing on fewer subjects and using fewer analytical concepts would have helped with depth, clarity and coherence.
