Bureaucratized management
of paid care-work

A high demand by families for home-based elderly care services and the predominance of the traditional household-based private employment in the care sector are the main features of the arrangement for reproductive labour in contemporary Italy.[1] However in some contexts  this resilient familism of the Italian welfare system includes the participation by local authorities and not-for-profit organizations in the provision of elderly care services. Such ‘welfare mix’ is also expressed by the latest reforms in the delivery of health and social services and in the administration of public funds based on laws No. 328 of 2000 and No. 42 of 2009. Together, these laws require regions and municipalities to take responsibility for the provision of social and health services. In this policy shift, the not-for-profit sector has acquired a crucial role, with social cooperatives becoming in many cases the local institutions’ partners par excellence.[2] 

The number of Italian households relying on home-based care provided through social cooperatives is growing. After a reform of the sector in 1991, social cooperatives can be active also in the provision of home-based and residential care. They are entitled to provide these services on behalf of the municipalities – thus at no cost for low-income care-recipients – after a tender selection, and on the condition of certifying that they meet certain standards in terms of quality and availability of the service. 

Through the example of the management practices in place in some cooperatives we examine the impact of cost-effective and business-like approaches to home-care provision, albeit organized by public and not-for-profit actors, and the impact of the economic crisis on the organisation of work. This can be observed in the homogenization of tasks, divided and organized into fixed units of measurement (that we have defined as ‘care interventions’) and performed by rotating teams of workers. This is necessary to organize the work in a Taylorist sequence of regular well-structured identifiable tasks, in which each worker can potentially be replaced by another. At the backbone of this bureaucratic scheduling of the care provision is the function of local authorities as the ‘buyers’ of these services, being also those that can define the contents and conditions of this care service that, as commodities, are provided in this sui generis ‘quasi-market’. The documentation produced by the cooperatives on the performance on the job is also the basis to document the outcomes of the public sponsorship, in line with new output-oriented approaches in public governance.

The research

In this light, this article elaborates on in-depth interviews with managers and team-coordinators of not-for-profit organizations that provide domiciliary elderly care services sponsored by the local authorities. The interviews have involved a small-size social cooperative for home-based elderly care in Milan, and a large-size cooperative in Reggio Emilia, which provide residential and home-based care for children, elders and disabled. 

The two social cooperatives which we studied are examples of the case of such local contexts, where the actions of public authorities and private actors combine to create new forms of organizing, delivering and accounting for care services for the elderly and of managing employment in paid care work. 

In each of the two cooperatives, ten interviews with both workers and managers were conducted in collaboration with the administration of the cooperative under study. Workers in the two cooperatives were usually employed on a permanent part-time or full-time contract, although the actual amount and the distribution of their work hours varied as they were negotiated each week. While the fieldwork in Milan was carried out in 2016, the data concerning Reggio Emilia were gathered in 2012-2013.

Lombardy and Emilia Romagna share similarities which are significant from the point of view of the development of the not-for-profit social and health care sectors. Both are characterized by a high degree of implementation of the model of local multi-stakeholder administration promoted by the new Italian laws on public services mentioned above. Emilia Romagna is the historical cradle of social cooperatives and Lombardy has been an area of intense development for them. 

Results

Cooperatives like the one we studied in Reggio Emilia are adopting all kinds of tools in order to adjust to the requests of marketized home-care (partially) funded by public authorities. We have noted that the cooperative had to adjust to the requests of local authorities in order to keep up with the demands of not-for-profit marketized elderly care.  From the interviews conducted, the following examples emerge as some of their strategies to accomplish this goal.

1. Ill and disabled people are approached as if they were the objects of a ‘project’, in which their individual cases are seen within the logic of economic cost-benefit calculations. Not for nothing, personal care provision is called, in these organisations, "care plan". This plan consists of a list of goals drawn up on the basis of an analytical assessment of the situation of each care-receiver and relative objectives for the future. The care plan is jointly prepared by a manager of the cooperative, a social worker (on behalf of the local authority) and the care-receiver with his/her family. In practice, a care plan sets out the treatment that is needed for each elder person, together with its duration and frequency. From the point of view of the local authority, it is important to minimize costs and identify the kinds of task which are ‘really necessary’ in each case. From the point of view of the managers, it is important to consider whether the social cooperative is in a situation to be able to provide the treatments requested, especially in terms of organizing their resources and workforce availability. 

2. Local authorities demanded social cooperatives to schedule the provision of their services on the basis of 30-minute care-interventions, meaning that the provision of care treatment ideally should last 30 minutes or multiples of 30 minutes. This means that each task accomplished by the worker is quantified on the basis of its duration: so many minutes for giving medicines, so many minutes for a body-wash, so many minutes for serving food, so many for lifting the person out of bed and taking her to the bathroom, etc. A full bath for a person, for example, has to last exactly 30 minutes. Giving medicines needs to last 8 minutes. Basically, in this system, the care provision entails a series of carefully planned ‘interventions’ consisting in several tasks which, all together, should result in a job with a minimum of 30-minutes’ duration. 

3. Local authorities also set the pricing of these interventions, which is fixed at 18 euros for each 30-minute intervention. This price is subdivided on a 13-point scale which is used to calculate how much is to be paid by the care-receiver and how much by the local authority, depending on the local authority’s assessment of the care-receiver’s finances and health conditions. In the case of care-receivers with lower incomes, the service is paid for in full by the local authority. The opposite can also happen: local authorities can assess that persons are not in need of financial support from public funds and so they have to fully pay for the services themselves. This assessment is not only based on the income level of the care-receivers but also on their physical and health conditions as verified by social workers during a preliminary meeting, which is described below. 

4. Local authorities also determine the quality of the service by specifying that the sponsored cooperatives need to meet a certain standard in terms of the professional qualifications of their personnel. All the caregivers have to possess a Socio-Sanitary Operator (OSS) diploma, and, as the cooperative managers related, in order to participate in the selection for the sponsorship, the cooperative had to undertake a process of professionalization of their employees. This often means that cooperatives provide free training programmes for their employees who are at lower professional levels, supporting them in upgrading their professional (and employment) status. 

5. In order to facilitate the (quite complex) process of payment for the care-interventions described above, the caregiver uses an electronic tablet with a catalogue of all the tasks that can possibly be performed in care-intervention. After their accomplishment, tasks are systematically ticked off on a tablet-screen, thus caregivers can automatically produce a complete calculation of the time they have worked and therefore a receipt for the payments. When in the care-receiver’s house, caregivers also have to sign a traditional paper-register, writing down their times of arrival and departure. At the end of the month, this can be used by the care-receivers to check that the working-times accounted for in the receipts are correct. 

6. Caregivers use a special type of electric car to move between their destinations and which is equipped to transport disabled or elderly people if necessary. One can see this car in some ways as the actual ‘workplace’ of the caregivers. In fact, caregivers’ working-time is calculated not on the basis of the duration of the care-interventions that they provide, but starting from the moment they pick up the car in the morning. Their working-time ends when they bring the car back to the parking lot at the end of the day. This car is also the place where they carry the tools for their job: care-equipments, their patients’ house keys, the documentation regarding each patient and, most importantly, the tablet. It therefore goes without saying that all the workers in the cooperative need to be able to drive these vehicles safely, and this is an additional working skill attached to their profile.

While the data on the Reggio Emilia authorities show how the non-profit care providers responded to the local authorities requesting a ‘bureaucratised’ service, those on the Milan cooperative allow for appreciating some implications of the economic crisis for the sector. Indeed while in the 2000s there was a certain increase of the public spending devoted to elderly care at national, regional and local level, the economic crisis has involved a reduction of this expense in Italy in more recent years.

In this new context, the Milan cooperative has diversified its activities, participating in a local project initiated by the Municipality in 2015, creating the figure of the ‘apartment building caregiver’ (badante di condominio), inspired to the ‘sharing economy’ model. In this experimental project, a caregiver is employed by a temp agency to provide care and domestic work to several elderly or disabled people living in the same apartment building or block of buildings; each client can benefit from a few hour work provided by the ‘apartment building care giver’. The Municipality funds the entire cost of the service and the care receivers do not pay anything for it. For the Municipality, this is cheaper than funding the same service provided by the cooperative. The temp agency in fact hires the caregiver based on the national agreement of the domestic workers’ private employment: compared with the cooperatives’ care workers’ agreement, the former involves lower salaries. The cooperatives’ role in this arrangement is to deliver a bureaucratic management of the care provision: processing the administrative practices needed for hiring the care worker, supervising the care giver’s work and reporting to the Municipality on the hours worked and the tasks performed.

According to our data, this arrangement can however prove problematic because of the unclear nature of the roles of the different actors involved. The managers say that it is not easy to assess to what extent the indications which they give on how the care tasks should be performed are followed; the cooperatives were in the awkward position of filling the role of controlling the care workers without being their employers, as would happen if the care service was provided by one of the cooperative’s employees. In fact, the ‘apartment building care worker’ is employed by the temp agency and is supervised by one of the cooperative’s managers. Moreover, as different workers are involved (the Municipality social worker is in charge of the clients, a cooperative’s care worker and the ‘apartment building caregiver’), some tensions emerged between co-workers about who should be in charge of which role and task. Further, some of the care-receivers were confused about who they should consider responsible for the different tasks. Indeed the ‘apartment building caregiver’ is responsible for cleaning and shopping tasks and can’t take up any personal care task; she liaises with a skilled care worker employed by the cooperative, who is a professional ASA or OSS, and is in charge of personal care and hygiene, one the one hand, and, on the other, with the Municipality social worker whose role is to monitor the social and psychological well-being and health of the elderly clients. 

Despite the difficulties experienced in ensuring the quality of the service and of the work relations, the interviewed managers considered that the ‘apartment building caregiver’ arrangement has benefits compared with the traditional household-based paid care work in private employment, both from the point of view of the care workers and of the care receivers: it breaks the isolation which is typical of care giving jobs based on one-to-one work relations between a private employer and an employee; and it may help to create social networks among the elderly clients living in the same building. Further, this new arrangement avoids the need for the care worker to move between different clients’ homes in the city using public transport. 

Conclusion

In the context of the restructuring of welfare state systems in Europe, the ‘quasi-markets’ for care involve a combination of industry-like criteria and market principles with public regulation, and have become an important aspect of the commodification of care. All these elements together lead us to a portrait of a bureaucratized management of home-care that, as it is sponsored by public authorities, involves the limitations, requests and obligations set by them since they will pay for the service, at the condition of keeping public expenditure low. In this example, we see how it is the public authority that encourages the cooperative towards more business-like behaviour in the management of their workforce.

Further, in order to respond to the economic crisis, the cooperatives can diversify their activity and participate in innovative forms of ‘second welfare’ based on local-level partnerships with the public sector as well as with private for-profit actors. The cooperatives’ role in this arrangement is to deliver a service of bureaucratic management and organisation of the care provision rather than providing a care service, as in their original social vocation and mission. While the new care provision arrangement is overall beneficial to the care receivers and is cheaper for the Municipality, it also raises issues related to the management of care work which remain to date unresolved.

Notes

[1] Home-based care is the main response to the 2.3 million Italians older than 65 who have different degrees of dependency (Pasquinelli and Rusmini, 2013). Individual care workers directly hired by Italian households represent 90% of the 830,000 caregivers; migrant women are overrepresented among them (Pasquinelli 2013).

[2] Social cooperatives account for 7% of the Italian GDP and employ more than one million workers (Fabbri, 2011).

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