From necropolitics to necrocapitalism

Necrocapitalism emerges from Achille Mbembe’s (Reference Mbembe2019) writings on ‘necropolitics’, a retheorisation of Foucault’s biopolitics, highlighting the capacity of sovereign power to take away life. During political life, decisions and events render groups vulnerable to death whilst the life of others is sustained and supported through investment and state intervention. For Mbembe, this is a primary dynamic of the imperialist global order, as whole regions of the world, isolated from participation in production or consumption, are rendered superfluous. This flips Foucault’s biopolitics on its head, as not only does modern state power have pastoral qualities securing population health, they also perpetrate violence by rendering certain groups as marginal to primary social objectives. Mbembe’s thinking sheds light on the ways power institutionally protects and nurtures certain populations, whilst other groups are put at risk of extermination, marginalisation and slow injury. The deployment of necro-power is concerned with the creation of boundaries and categories, such as those pertaining to nationality, class, ‘race’, ability, gender or age, in determining social protection.

The question of valuing and devaluing groups is always connected to economics – who is seen as contributing to ‘productive’ aspects of economic activity and who is envisioned as tertiary to the production of profit fashions the nature of coercive state power (Banerjee, Reference Banerjee2008; Morris, Reference Morris2023; Singh, Reference Singh2017).

The term necrocapitalism has been deployed to refer to forms of capital accumulation which are ‘linked to and dependent directly or indirectly on death and the profits accruing from it’ (Singh, Reference Singh2017). Or as Banerjee states, ‘necrocapitalism’ is ‘defined as contemporary forms of organisational accumulation that involve…the subjugation of life to the power of death’ (Reference Banerjee2008: 1541). Whilst necropolitics describes the power of state institutions to take away life, necrocapitalism seeks to understand specific modes of accumulation producing mortality directly, or profit circuitously from death. Morris (Reference Morris2023) argues, for example, that state sanctioned racialised management of immigrants in Australia underpins corporate accumulation as private sector companies such as Serco provide security, document checks or dormitory services. In this sense, such populations are not easily understood as disposable surplus populations, but rather become a source of economic value directly through the matrix of insitutions and governance practices rendering them as othered and excluded groups.

Whilst a definitional separation between necropolitics, who’s life becomes valued and devalued according to the rights they can claim, and the more specific issue of necrocapitalism, the direct profiting from death, is useful, a neat separation is difficult to sustain. Maintaining a distinction between the state and the economy, reflected in a false distinction between necropolitics and necrocapitalism, would assert an idea that politics and economics exist in different spheres. The state frequently sanctions forms of profit to be made directly from death and injury – by contracting out, for instance, prison or military services. Groups who are outside the ‘community of value’ – excluded or ‘failed’ citizens (Anderson, Reference Anderson2015) – are subjected to degraded privatised, profit-generating services which ‘expose people to the potential to death’ but also offer the opportunity for accumulation (Morris, 2023).

The ageist necropolitical dynamics of COVID-19 have already been noted, for instance Pitimson (Reference Pitimson, Coleclough, Michael-Fox and Visser2023), showing that political decisions favoured the working age whilst disvaluing older populations. Pandemic policies also protected the autonomy of the corporate form whilst shaping necropolitical patterns of risk (Knox and Whyte, Reference Knox and Whyte2023). The pandemic ‘vaccinated’ capital from the worst effects of a potential economic slowdown, where unaccountable corporate loans and bailouts, lax regulations around keeping employees safe and a fraudulent system of procurement for various medical supplies, reveal that the government legislation sustained the generation of surplus value. As they argue, the very pandemic responses themselves, firmly propped up value extraction while delivering limited forms of protection against the virus (Knox and Whyte, Reference Knox and Whyte2023), and, as is argued here, this was also true in older people’s social care.

The necrocapitalist fashioning of older people’s care provision connects to the wider organisation of social reproduction in contemporary societies. As Jaffe (202) argues, oppressive social relations place certain groups’ existence in relative esteem while denigrating others. The structural imposition of poverty in later life and socio-cultural exclusion through inadequate assistance (Phillipson, Reference Phillipson1982; Walker, Reference Walker2005) emerge from the status of older people as non-labouring, ‘dependent’ groups. Whilst some older people are empowered as consumers or continue to play important roles in child-rearing, their positionality within the overall social organisation moves to one of increasing ‘unproductiveness’ in terms of capitalist conceptions of value (Jaffe, Reference Jaffe2020). The wider marginalisation of older-aged people in modern societies has broadly exposed people to substandard care, but in recent times social policies have sought to turn the treatment of older people into a source of accumulation. ‘Active ageing’ policies have operated to undermine robust collectivised pensions whilst legitimising extended labour market participation and an emphasis on self-planning for retirement (Walker, Reference Walker and Walker2014). This neoliberalisation of ageing (Macnicol, Reference Macnicol2015) involves the commodification of services, centring market-led provision through private sector pensions and care provision. Whilst what Brogden (Reference Brogden2001) has described as geronticide – a form of death-hastening by means of the bureaucratic control of older bodies – was previously largely associated with underfunded welfare provision, originating in the workhouses of the 1800s, now the logics of letting die in the sequestered spaces of older people’s residential care homes is done for profit: a necrocapitalist dynamic frequently subduing life yet consolidating accumulation. This paper argues that the state-supported projects of neo-liberal privatisation, such as the constructing of social care defined by significant degrees of unmet need, were a pre-existing set of arrangements which more intensively jeopardised the health and life of older people during the pandemic. Critically, the way in which value is extracted through social care by means of funding, de-regulation, financialisation and monopolisation exposed older residential care users to the risk of mortality.

Older people’s residential care: Another failure of the ‘regulative state’?

The disastrous outcomes of COVID-19 in the UK emerges from broader shifts in the transformation of state organised institutional power from direct provision and control toward a ‘regulative’ role. This has entailed the erosion and hollowing out of organisational capacities to respond to crises. With the movement from post-war Keynesian settlement to neoliberalism, state power transformed from ‘government’ to ‘governance’ (emphasis in original, Jones and Hamieri, Reference Jones and Hameiri2021: 3). Government refers to the state’s purposive capacity to directly intervene to achieve objectives, mobilising organisational, technological and human powers to quash catastrophes or overcome emergent challenges. Governance, on the other hand, is when ‘resources, authority and responsibility are dispersed to diverse public and private actors’ (Jones and Hamieri, Reference Jones and Hameiri2021: 3). State agencies assume regulatory stances over direct control: orchestrating and directing organisations whilst removing responsibilities from core state apparatuses. Governance has resulted in four dysfunctionalities of the UK state (Hameiri and Jones, Reference Jones and Hameiri2021): decreasing expectations in the capabilities of institutions amongst publics; re-orientation of responsibility over important command capacities to non-state actors; associated deterioration of accountability and control; and, finally, a shift to corporate involvement in previously state organised functions. These trends are fundamentally knotted with the changing terrain of British capitalism as differing accumulation strategies have emerged amidst crisis tendencies. Various privatisation policies have created platforms for capital accumulation where previously services were delivered by government agencies and funded through taxes. This outsourcing diverts authority and accountability from central state organs, insulating political classes from the social failures emerging from de-regulation and the installing of market principles.

The social care sector epitomises regulative, governance-orientated state transformation which has undergone intensive re-regulation and privatisation (Lavalette and Ferguson, Reference Ferguson and Lavalette2013). Essential long-term support for chronically sick, disabled, mentally distressed and older people has increasingly shifted from centrally co-ordinated delivery to a ‘mixed’ economy of care (Beresford, Reference Beresford2005). Initially it was argued that creating a market in social care would secure efficiency gains as a range of actors, namely state, charity/third sector and private, compete to provide services. Local authorities remain as funders, purchasing the best value-for-money services. This would, it was asserted, promote innovation in the sector leading to gains for service users and overall improvements in the quality of care. This is bound up with wider neoliberal legitimations that promote market principles as deliverers of freedoms and efficiency, laying the ground for the involvement of corporations across multiple contexts of policy (Harvey, Reference Harvey2005: 65).

The creation of the mixed economy of social care resulted in widespread privatisation, declining standards and deregulation. The argument presented here is that the established form in which accumulation takes place in social care – exemplified by the residential sector for older people – secures corporate profiteering amidst a generalised system of unmet need. The failures of the care system, and especially those services directed toward residential care in later life, has its basis in the existing mode of privatisation.

Configuring neglect through privatisation in older persons care homes

The deaths relating to COVID-19 in care homes in the UK, were ‘structurally curated’ (Fletcher and McGowan, Reference Fletcher and McGowan2023) – not simply explainable with reference to COVID pathogens but rather events which occurred in existing socio-political arrangements. This section argues that prior to the pandemic, older people’s residential care had been assembled in a way that configured endemic neglect, setting the potential for living and dying in these spaces. The instigation of the ‘mixed economy’ transformed the sphere of older person’s care into a sphere for the expropriation of wealth by small businesses and large multinational, financialised corporations. Specificities around the extraction of value from residential social care are analysed here, including the compulsion for providers to follow certain strategies in securing profit and the role of regulation in seeking to reproduce legitimacy in the sector. This neoliberal configuration of UK social care undermines the potentiality for supporting ‘personhood’ for workers and care recipients alike.

Primarily the industry remains funded through Local Authorities and prices are constrained due to the architecture of the market. Self-funding clients can expect to pay in the region of 42 per cent more than those who are being paid by local councils. Funding given by councils is known to be strained as ‘government austerity, increasing costs and static fees…continue to erode private sector earnings’ (Grant Thornton, 2014: 5). There is also increasing regional variation as wealthier areas which have higher numbers of self-paying users or can draw on bigger council tax bases are not faced with the same shortfalls (Curry and Oung, Reference Curry and Oung2021). The funding arrangements put serious constraints on service improvement as council fees are essentially limited and, for most homes, government funding is the primary source of income, accounting for 83 per cent of revenue for private sector care homes.

A previous covert ethnography by the author uncovered how the dynamics of regulation and profit-making in the industry undermine care quality (Greener, Reference Greener, Wolkowitz, Cohen and Sanders2013, Reference Greener2015, Reference Greener2019). Day-to-day practices are driven by ‘performative compliance’ where bureaucratic mechanisms documented the appearance of care quality in a contrary context of staff shortages and intensive cost-saving (Greener, Reference Greener2019). Because profit-rates are primarily determined by fees paid from Local Authorities with costs of service operation ‘subtracted’, cost-cutting becomes the core strategy for reproducing profitability. As well as influencing the availability of ‘extras’ – such as better quality of food or beneficial therapies – the tendency to achieve success through decreasing costs puts a strong compulsion on providers to minimise staff-to-resident ratios. Basic needs around toileting, bed care, feeding and moving were unmet due to inadequate manpower (Greener, Reference Greener2019: 660–4). Given the fixed rates of income and the inherently labour-intensive nature of caring, achieving gains in surplus value rests on decreasing spending and not according to logics which might dominate in other markets – for instance, increasing efficiency through technology or simply providing a higher quality of service.

As Cohen (Reference Cohen2011) argues, efficiency gains through rationalisation and re-organisation are severely constrained in labour processes which centre on bodies. Bodies are unavoidably labour intensive – they have obdurate requirements that must be attended to, at least if a certain degree of dignity is to be maintained. Technical revolution and innovation through machinery and management systems, which advocates argue are the benefits of marketisation, are severely constrained by the very nature of care as embodied and body-focused practice. Intensifying profit from care tends to take the form of gains in ‘absolute’ rather than ‘relative’ surplus value, in Marxian terms: ‘To cut costs, or increase profits, either the body must receive less attention…or a division of labour introduced, with parts of the labour process assigned to lower-skilled, or at least lower-paid, workers’ (Cohen, Reference Cohen2011: 193). Seeking racialised workers, rendered precarious through immigration stipulations, has been the central strategy in maintaining low-cost care home staffing over the last decades (Cangiano et al., Reference Cangiano, Shutes, Spencer and Leeson2009). Migrant workers, frequently experiencing lower degrees of freedom in the labour market with visa’s stipulating requirements to work within specific sectors and employers, provide a labour force experiencing a further set of coercive pressures to accept the conditions of employment. Migrant workers are frequently limited in their ability to change employer, cannot access out-of-work benefits available to citizens, or are supporting extended family networks in poorer nations they originated from, meaning their capacity to leave more exploitative and demanding labour conditions is highly restricted (Greener, Reference Greener, Wolkowitz, Cohen and Sanders2013).

Residential care for older people is also emblematic of the hollowing out of state capacity. As directly delivered and funded care services were closed-down, legitimacy for the new system has been sought through the instigation of regulatory bodies to manage the market. The Care Quality Commission (CQC) is the current regulator charged with monitoring the sector by providing ratings and managing registration. Although it has a range of powers that can be used against homes deemed to be failing, the CQC’s approach is largely one of persuading compliance by disseminating the appropriate values on which care should be based. The concept of client, for instance, ‘choice’ has become central in defining official understandings of quality care. To what extent the regulatory apparatus around care is geared toward impacting on the nature of services delivered is highly questionable. Inspection of care homes is largely a bureaucratic endeavour involving auditing documentation without more intensive checks on care delivery and quality (Greener, Reference Greener2019). Regulation projects the desire for dignified and compassionate care, but without securing the neccesary factors in the political economy (such as better career strucutures, upskilling, removal of profit motives or more intensive regulation) that would shift the materiality of caring relationships (Bolton and Wibberley, Reference Bolton and Wibberley2014).

This political construction of the social care market has resulted in commercial strategies around monopolisation and financialisation in the sector, resulting in instability and home closures. This has been particularly true in the residential care market which has been plagued by crises, epitomised when Southern Cross went bankrupt (Scourfield, Reference Scourfield2012). Achieving value gains through financial trickery such as ‘op-co/prop-co’, attempting to increase the scale of operations through buying up smaller competitors, and creating regional monopolies are macro market-level strategies seeking to overcome the constraints of insufficient revenue (Scourfield, Reference Scourfield2012; Greener, Reference Greener2019). Such dealings in the industry have allowed certain individuals to accrue personal wealth. The board of Southern Cross received high salaries and bonuses in lieu of implementing their opco-propco model two years before the company’s total collapse. Corlet Walker et al. (Reference Corlet Walker, Kotecha, Druckman and Jackson2022) examined the impacts in care homes during and in the aftermath of being taken over by investment firms. These firms deployed ‘financial engineering’ (Corlet Walker et al., Reference Corlet Walker, Kotecha, Druckman and Jackson2022: 2) tactics by accruing one-off large payments, extracting cashflow from ongoing operations and temporarily increasing the value of the business shortly before a sell off. Most critically, they were able to demonstrate that homes taken over by large investment firms usually experience severe degradation in service quality. This includes increasing exploitation of staff through understaffing as well as a host of other cost saving strategies around food, medical supplies, end-of-life care and activities.

The mass failure to meet basic physical and social needs for residents in private-sector care homes emerged at the intersection of state policies and corporate objectives – a form of state-corporate harm structured through a political economy of privatisation and a façade of regulatory compliance. The task of turning austerity Local Authority funding into profit necessitates low-cost provision. Nonetheless, surplus is generated with as much as 10 per cent contributing to profit, shareholder dividends, senior management pay and rents (Kotecha, Reference Kotecha2019).

Understanding death as politically produced, opens the door for a necrocapitalist examination of privatised care homes. Examining the particularities of the revaluing of care for profit reveals the how the construction of the industry undermines the supposed benefits of privatisation. Existing arrangements structure widespread neglect. Funding systems depart from the basic principles driving certain capitalist markets – there is a very limited sense in which there is competition over of efficiency, technological innovation or quality of service. Squeezing value out of the meagre Local Authority funding rests largely on rationalising around absolute surplus value – securing cheap, highly exploitable workers and constraining other expenses.

The COVID crisis and older people’s residential care

On March 3, 2020, the UK Government published the Coronavirus action plan claiming that the country is ‘well prepared for disease outbreaks, having responded to a wide range of infectious disease outbreaks in the recent past, and having undertaken significant preparedness work for an influenza pandemic for well over one decade’ (Department of Health and Social Care, 2020). The government claimed to have capacity to ‘deliver a co-ordinated multi-agency response to minimise wider societal impact’. Early in the pandemic the government was committed to a ‘phased’ response involving little intervention but stating the ability to do more, if needed. From late March 2020 the government’s position shifted with various guidelines published and new legislations. The initial relaxed policy response proved to be disastrous for many vulnerable older people. As Daly (Reference Daly2020: 988) recounts, the government’s response toward the care sector in the first two to four months after early March was dire, and especially residential care for older people. The Coronavirus Act 2020, enacted on 25 March, reduced Local Authority’s responsibilities to meet needs, transforming ‘duties’ into ‘powers’ and effectively eroding the central set of responsibilities dictating needs assessments and care packages. Government actions encouraged a sequestration of older people within care homes, siphoning off the group most vulnerable to death from COVID-19 into inadequately resourced institutions.

An Action Plan for the social care sector was not announced until 15 April 2020 (Department of Health and Social Care and CARE, 2020). Prior to this thousands of people were discharged from hospital to care homes without systematic measures determining isolation, ensuring worker safety or measures to prevent contamination between homes. The Commons Select Committee (House of Commons & Public Accounts Committee, 2020) noted that the NHS had declared level 4 emergency in late January and began making various plans such as readying beds through February, but the Department of Health and Social Care did not publish plans for social care until mid-April. As the COVID-19 epidemic gathered pace across the UK, it quickly became apparent that those living in care facilities, and especially older individuals, were at a much greater risk of death. Officially, between 2 March and 12 June 2020, 29 per cent of all virus deaths occurred in care homes (Office for National Statistics, 2020). It is evident that the numbers of deaths during this period in 2020 are significantly higher as compared to the same period in 2019. It seemed the pandemic had caused in the region of 30,000 ‘excess deaths’. Care home residents accounted for 55 per cent of England’s total excess deaths from 28 December 2019 to 1 May 2020 (Comas-Herrera and Fernandez, Reference Comas-Herrera and Fernández2020). In the region of 25,000 patients were discharged to care homes in England from the beginning of the outbreak until the Action Plan was published (National Audit Office, 2020). The British Medical Journal (BMJ, 2020) reported on 13 May 2020 that the excess death rate attributable to COVID-19 was concealed as pandemic-related mortalities were not recorded. From five weeks before 12 May there had been some 30,000 excess deaths in social care facilities and only 10,000 had any reference to COVID-19 on the certificates. Shifting older vulnerable people (with considerable underlying conditions such as cancer or serious respiratory and heart conditions) to care homes subjected them to poorer quality care and denied intensive medical support available in hospitals. This initial crisis arguably set the conditions for many more outbreaks in the month after the Action Plan’s publication. The Commons Select Committee (House of Commons & Public Accounts Committee, 2020: 6) showed that the number of outbreaks in homes peaked in early April, with thousands more until 17 May with a total of 38 per cent of care homes in England reporting at least one outbreak.

During the pandemic the older people’s care home sector was thrust into a deep crisis (Fotaki et al., Reference Fotaki, Horton, Rowland, Ozdemir Kaya and Gain2023). Whilst it was expected that a pandemic could seriously impact on the financial health of the sector, there were no pre-existing plans to inject public monies. Between March 2020 and February 2022 1,290 social care workers died from COVID-19. Of the care home workers surveyed in Fotaki et al.’s (Reference Fotaki, Horton, Rowland, Ozdemir Kaya and Gain2023: 6) study, 80 per cent reported working longer hours and 50 per cent reported that their capacity to meet residents’ needs had decreased. By the end of the pandemic the government had delivered £2.1 billion in extra funding to the sector allowing it to narrowly avoid financial collapse. The findings of this report showed across the residential sector cost-savings were implemented and staff-resident ratios fell (Fotaki et al., Reference Fotaki, Horton, Rowland, Ozdemir Kaya and Gain2023: 7), a key indicater that care quality fell significantly.

The Action Plan announced strategic re-regulation in four areas of service delivery including stopping the spread of infection, supporting workers, guaranteeing the rights of service users, and helping providers and Local Authorities. Despite these commitments to improving care and support in homes grave problems persisted. One of the clearest examples of failure emerging from the historical erosion of state capacity from early in the pandemic was the lack of access to personal protective equipment (PPE). As Jones and Hamieri (Reference Jones and Hameiri2021) recount, the National Health Service (NHS) supply chain was privatised in 2010 with guidance by consulting corporation Deloitte. Various contracts outsourced this important function to Supply Chain Coordination Ltd, which operates on a ‘just-in-time’ basis leaving it exposed in times of crisis. In the early phase of the pandemic at least 30 per cent of ‘care workers, doctors and nurses reported having insufficient PPE, even in high-risk settings’ (House of Commons & Public Accounts Committee, 2021: 6). Central government was distributing unusable PPE and from its helpline referring operators to suppliers who had no stock. There were also huge avoidable expenses (in the region of £10 billion) because of the shortage of supply (House of Commons & Public Accounts Committee, 2021).

The biggest failings in PPE distribution were experienced in the social care sector, exactly where the most vulnerable cases were placed. From March to July 2020, NHS trusts were provided with 1.9 billion items of PPE, 80 per cent of assessed requirement, but the adult social care sector received 331 million items, only 10 per cent of its needed supply (House of Commons & Public Accounts Committee, 2021: 8). What panned out was hugely incongruent with statements made in the UK Influenza Pandemic Preparedness Strategy 2011. This document states that ‘provision of personal protective equipment for front-line health and social care staff’ will prevent spread of potential viruses (Department of Health, 2011: 34) and ensures that the ‘government already has in place stockpiles of facemasks and respirators for health and social care workers’ (Department of Health, 2011: 37). Thousands of frontline social care workers, including those in care homes, were left without PPE. It was reported that workers’ exposure to COVID-19 in care homes has been formally connected to 8,152 cases and 126 deaths (National Audit Office, 2020 a: 10–11).

The significant absence of testing also contributed to the initial failures and ongoing difficulties in the social care sector. The 2011 Strategy promised to deliver ‘[D]detection, diagnosis and reporting of early cases through testing and contact tracing’ (2011: 21) in the event of a pandemic. The reality was that the UK had capacity to test around five people per day (Donnelly and Morgan, Reference Donnelly and Morgan2020). Similarly, reporting on the NHS Track and Trace Scheme has revealed it completely failed to disrupt the progression of infections or tangibly mitigate against the need for more restrictive measures, such as lockdowns or school closures (BMJ, 2021).

The Action Plan sets out the intention to grow the social care workforce across all care facilities. This is an important dimension of the crisis. Firstly, care work is incredibly skilled and demanding labour which, if organised effectively, requires work systems based on tacit and explicit capacities of employees, including medical knowledge, sensitivity to people with complex sets of vulnerabilities and stringent coordination through co-working. The UK’s care sector has long-term high turnover rates and low staff-to-client ratios. However, rather than seeking a recruitment strategy based on a commitment to standards of care quality through training, the government set about heavily deregulating recruitment, including training requirements, during the pandemic. Primarily this included the provision of fast-track scheme allowing people to complete the Care Certificate online.

The role of the CQC during the pandemic is a further clear example of the failures assoaicted with the shift toward ‘regulative’ governance and state power (Jones and Hameiri, Reference Jones and Hameiri2021). Control in social care took an advisory and discursive form, essentially distant and weak. Early in the outbreak, the CQC (2020a) announced the development of an Emergency Support Framework, yet these measures were not rolled out until 4 May 2020. These measures were stated to include: ‘Using and sharing information to target support where it’s needed most’, ‘Having open and honest conversations with providers, health and care staff, partners and wider stakeholders’, ‘Taking action to keep people safe and to protect people’s human rights’ and ‘Capturing and sharing what we do and how we do it’ (CQC, 2020a). Nonetheless, the CQC’s activities around the pandemic are further suggestive of its legitimising role in rubber stamping practice even in the face of failings (Greener, Reference Greener2015, Reference Greener2019). This is exemplified in the publication of the CQC’s (2020b) report, How care homes manage infection prevention and control during the coronavirus pandemic 2020. Published in November 2020 the report claimed to be an impartial assessment of the capacity of care homes to implement infection control procedures including interrogating practices around visitors, admission, isolation and distancing. Incredibly, out of the 440 cases examined in the report, 301 were selected because it was believed they were already implementing procedures effectively. The other 139, selected on more objective criteria, were assessed between 1 August and 4 September. The general claim of this report is that there is a high level of compliance (or what they term ‘assurance’) in all eight identified areas of infection prevention and control. This report did not present an objective analysis of care quality for two major reasons. Firstly, previously detected examples of quality compliance made up most of the sample and, secondly, the report did not scrutinise activity and policies in care homes during the crisis period from March to June. The report scrutinised protocols and management procedures rather than on-the-floor activity. Other than opening a channel for receiving feedback about care concerns and managing some of the procedures around staff testing, it seems that it is not possible to identify any capacity in which the CQC could have effectively assisted in ensuring standards of care . In the main, intensive auditing and criticism concerning pandemic residential care has tended to come from the media or Parliamentary Select Committees and not from the CQC.

Despite the falling standards of service provision and the increasing pressure placed onto staff, care home profits rose. Although profitability increased by 3 per cent in the first year of the pandemic, some providers increased dividends to shareholders by sizable amounts. A quarter of the 460 companies analysed by Fotaki et al. paid out dividends worth £120 million at the end of the first financial year of the pandemic, an 11 per cent rise on the previous year (Reference Fotaki, Horton, Rowland, Ozdemir Kaya and Gain2023: 6).

Poor care as a cause of death in the COVID-19 care homes crisis

A report by Collateral Global assessed deaths in care homes across twenty-five countries, including the UK, concluded that that majority of deaths are attributable to established poor conditions of care:

Whilst data does clearly indicate a much greater chance of dying in a care home than any other social space, they also note that statistical correlations do not elucidate the exact relationship between mortality and care home habitation. For example, a case may be recorded as a COVID-19 death because the individual patient tests positive but the underlying cause can still be attributable to poor care. To complicate the matter further, deaths may also be attributable to poor care of the symptoms of COVID-19. A person’s decline may have been preventable if the patient remained in hospital with more specialist interventions. In other words, a range of situations may lead to recording deaths as COVID-19, but insufficient and neglectful care may still be a primary contextual factor or direct cause.

Heneghan et al. (Reference Heneghan, Dietrich, Brassey and Jefferson2021: 21) also suggest that occupation rate, the quality of care, staffing levels, regulatory compliance and ownership are all implicated in shaping the numbers of COVID-19 deaths in care homes. Ibrahim et al.’s (Reference Ibrahim, Li, McKee, Eren, Brown, Aitken and Pham2021) study in Australia revealed that homes owned by large care provider chains have more COVID-19 outbreaks and increased mortality rates. A study by Stall et al. (Reference Stall, Jones, Brown, Rochon and Costa2020) in Canada revealed that for-profit care homes, as opposed to those operated municipally or by charities, had higher mortality rates in the event of a COVID-19 outbreak. All these studies highlight that the virus itself is not the sole predictor of mortality even when we consider it at the institutional level of a given care home.

Briggs et al. (Reference Briggs, Telford, Lloyd, Ellis and Kotze2021) comprehensively analysed the harms relating to COVID-19 arguing that it was not inevitable that measures taken by governments to control the pandemic, primarily lockdown orientated policies, were the best choice. They document that a range of social groups were severely detrimentally impacted by lockdown policies. The extent of domestic and child abuse rose, the risk of contracting the virus was disproportionately borne by working class people, while support and screening for a range of other illnesses, including cancers, declined significantly. For older and disabled populations there were a range of harms related to lockdown policies including deteriorating mental distress. Evidence that the excess death in older people’s care homes is related to declining standards in care is uncovered by Briggs et al. (Reference Briggs, Telford, Lloyd, Ellis and Kotze2021) through interviews with frontline health and social care workers. Their respondents describe the use of Do Not Resuscitate orders (DNRs) being placed on patient files without evidence of consent. It was suspected DNRs helped to divert cases from hospitals to care home settings, as residential care facilities are considered suitably equipped for end-of-life care. They also highlighted that COVID measures may often be responsible for deaths rather the virus itself. Poorer quality care, distress related to isolation measures and restricted visitations contribute to rapid deterioration. Briggs et al. (Reference Briggs, Telford, Lloyd, Ellis and Kotze2021) also found reports where, as staff began contracting COVID-19, staffing levels dropped to extreme low levels.

Many of the deaths, both those listed as COVID-19 deaths and those not listed but identifiable as ‘excess’ mortalities when compared to other years, were clearly avertable. It needs to be stated, however, that this was not only dependent on the failure to execute measures stopping the spread of the virus (and reducing the cases of older people contracting COVID-19). The prevailing pre-pandemic conditions of care, which further deteriorated as the pandemic took hold, led to thousands of individuals with high levels of need being ‘triaged’ to ill-prepared facilities. Critically, the true number of avoidable deaths in care home settings during the pandemic period – those relating to both poor care due to deteriorating standards and the residents suffering from the virus but denied better healthcare – cannot be accurately determined.

Conclusion: Older people’s residential care as a necrocapitalist enterprise

Viewing the COVID-19 pandemic through a necrocapitalist lens connects risk of dying to dynamics of accumulation. The central argument here is that the specific institutionalisation of private sector care fashions endemic neglect and mistreatment in the sector with care homes sites of misery before and during the pandemic. Due to the central fact that seeking declines in service standard are central to the possibility of profit in older person’s residential care, means there is an identifiable connection between the increased risk of dying and its commodified nature. There are perhaps three main axes through which poor care and structural market conditions are interrelated. Firstly, the inherently bodily intensive nature of caring leads to driving down wage and labour costs and avoiding professionalisation of the precarious racialised and feminised workforce as systemically paramount strategies for maintaining profitability. Secondly, appropriating this necrotic form of value is supported via a lax system of regulation geared to maintaining a modicum of legitimacy whilst reproducing the conditions for accumulation. Long-term conditions of crisis arise partially from inadequacies associated with regulative modalities of control ‘at-a-distance’, rather than by commitments to improving service provision. State apparatuses do not function as watchmen, protecting publics from the most harmful aspects of corporate activity. In fact, governance practices bring into being and reproduce the conditions needed for accumulation (Tombs and Whyte, Reference Tombs, Whyte, Coleman, Sim, Tombs and Whyte2010). This is the foundation of the regulative state: state agencies primarily act to legitimate business practices and institutionalise markets, whilst authoritative command in protecting the welfare of the public is eroded (Jones and Hameiri, Reference Jones and Hameiri2021). And lastly, there is a tendency to seek short-term gains through temporarily generating fictitious, financialised capital.

Under capitalist societies ‘value’ is primarily seen in terms of economic growth and thus profitability. Political decisions about where to direct resources, about who’s life and dignity is worth preserving, and who’s can be imperilled, are shaped by the position of different actors in circuits of value and ideals of liberal citizenship. By orientating care around profit, residential care services have been regeared as enterprises with necrocapitalist tendencies. Developing a necrocapitalist lens on privatised welfare also sheds light on the structural hurdles faced in delivering better services. It seems clear that a system of social care based in alternative values – such as a feminist ethics of care positing attentiveness, responsibility, dependency and so forth (Tronto, Reference Tronto1993) – are continually undermined in the poorly funded profit-seeking system.