Abstract
Theorisations of state violence under austerity have been criticised for their imprecision. In response, this article introduces the concept of institutional neglect: a specific modality of structural violence. We argue that institutional neglect occurs when state services deny care to eligible clients. This is a normative claim which locates an obligation to care in the body of the state. Through case studies of two local authority-run care services in the UK, we identify three banal, quotidian techniques of neglect: delay, deferral, and diversion. We emphasise that care is not necessarily an antidote to violence; instead, care and violence are increasingly entangled within state bureaucracies under austerity.
Introduction
Historically, neglect has been conceptualised as a form of interpersonal abuse. It is seen to comprise a deviation from a duty of care towards another; this duty is, the presumption continues, naturally located in the bodies of mother and family (cf. Garbarino, 1977; Steele, 1977; Trube Becker, 1977). From this perspective, neglect is a matter of individual (mis)conduct, where care systems play only interventionist roles (cf. Braye et al., 2011; Hague et al., 2011; Tanner and Turney, 2003). The state is thus depicted as a saviour while the neglectful role of care systems themselves is minimised (Jolly, 2018). In this article we expand beyond the limitations of such individualistic, biological- and gender-determinist definitions. We focus instead on the neglect of a collective ethics of care which we locate within the body of the state, conceptualised as a metaphorical parent (Wacquant, 2009: 289–290). Its caring functions are carried out by welfare institutions normatively oriented around – and therefore capable of deviation from – ideals of care (Tronto, 2010). Consequently, the state itself is capable of neglect (Bhattacharyya et al., 2021).
We define institutional neglect as welfare state inaction where institutions fail to recognise or respond to eligible demands for care. Institutional neglect therefore takes place not when needs are the subject of contestation (Tronto, 2010), but when institutions fail to provide for care needs which they have historically recognised as valid (albeit under different fiscal-political climates). We use this concept to extend and nuance theorisations of state violence under austerity (Cooper and Whyte, 2017) which have been criticised for being general and imprecise (Grover, 2019; Redman and Fletcher, 2022). Consequently, we theorise institutional neglect as a specific modality of structural violence and identify three banal, quotidian techniques through which it occurs. Operating in the face of extreme resource scarcity and insurmountable levels of demand, institutional actors delay access to their service, via waiting lists or through stonewalling. This not only preserves service capacity, but also increases the likelihood of eligible people withdrawing from services. They defer to additional conditionalities or procedures to prevent people from accessing a service on a technicality. This process is necessary because under the terms of a conventional assessment access would have to be granted. Finally, they divert clients using complex and opaque conditions of access. This works to minimise the number of cases entering a service. Crucially, these strategies are most effective at reducing demand among those least able to navigate service landscapes independently.
These techniques of institutional neglect are examples of the discretion used by street-level bureaucrats to manage workloads and keep services functioning when resources are profoundly limited (Lipsky, 2010). In the UK, such scarcity has intensified in recent years due to the austerity programme first introduced by the Conservative-led Coalition Government in 2010. While much academic attention has – justifiably – focussed on cuts to social security benefits and the sanctioning of claimants under austerity (Grover, 2019; Mills, 2018; Redman and Fletcher, 2022; Tyler, 2020), this literature tends to overlook services which provide care, a central pillar of the welfare state alongside direct cash transfers (Wacquant, 2009). Our aim is not to deny the disciplinarity of the austere state, but to foreground how it binds together care and control (Disney and Schliehe, 2019). The concept of institutional neglect therefore highlights tensions between, and the concomitant meshing of, state care and state violence at the point of need (Gill, 2016).
The article proceeds in four sections. We begin by offering an account of institutional neglect in relation to existing literatures on structural violence and bureaucratic care, before outlining our two case studies. Each is based on fieldwork in a different local authority-run service in the UK: a special educational needs and disabilities (SEND) service within a London borough, and a mental health service within a county council in the south of England. Through the case studies we give empirical examples of institutional neglect: practices of delay, deferral, and diversion. We conclude by advocating for accounts which foreground the entanglement of violence and care, rather than viewing the latter as an antidote to the former.
Institutional neglect as a modality of structural violence
In Galtung’s (1969: 168) foundational definition, ‘violence is present when human beings are being influenced so that their actual somatic and mental realizations are below their potential realizations.’ Galtung (1969: 170) goes on to distinguish between personal violence (committed by an actor) and structural violence (‘where there is no such actor’): his aim is to highlight violence which occurs in ostensibly peaceful situations. For instance, colonisation has historically relied not only on brutal physical repression but also the “peaceful” operation of juridical and bureaucratic systems; these have been used to appropriate land, impose unequal taxation regimes, cultivate indentured labour, and erase traditional knowledges (Kabwegyere, 1972). It is not that these systems are simply backed up by the threat of violence; rather, their operations are in themselves inherently violent.
Austerity can produce manifold harms without physical force; consequently, it is a form of structural violence (Grover, 2019; Redman and Fletcher, 2022). Since 2011, successive UK governments have pursued an austerity programme of welfare state retrenchment under the ‘smokescreen’ of reducing fiscal deficit (Wilkinson and Ortega–Alcázar, 2019: 156). Deep cuts to public spending have thrust those who rely on services into destitution and market dependency (Ryan, 2019), deepening the commodification of labour power (Grover, 2019). In parallel, quasi-market models of service operation and provisioning have proliferated (Redman and Fletcher, 2022), offering new opportunities for capital accumulation. The state has retreated from its role in processes of social reproduction, shifting the burden of care to women – in particular, working-class ethnic minority women (Bassel and Emejulu, 2018; Pearson, 2019). This is one of many ways in which austerity deepens intersecting inequalities of race (Bassel and Emejulu, 2018), gender (Pearson, 2019), class (Atkinson et al., 2013) and disability (Ryan, 2019).
The violence of austerity has been narrated as variously structural, symbolic, epistemic, physical, psychological and institutional (see Cooper and Whyte, 2017; Grover, 2019; Redman and Fletcher, 2022). Locating so diverse a range of violences within austerity can confuse or diminish understandings of the specificity of violence (Grover, 2019; Wright et al., 2020), resulting in preoccupation with austerity’s violent outcomes at the expense of its operative processes (Redman and Fletcher, 2022). Yet naming the distributed harms of austerity as (structural) violences renders them visible and comparable to more spectacular and immediate forms of violence (Nixon, 2011; Norberg, 2021). Consequently, more specific, nuanced and applied conceptualisations of the various modalities of structural violence are required (Redman and Fletcher, 2022).
Institutional neglect is distinctive not only because of its location (in health and care systems) and associated practices (delay, deferral and diversion); it also possesses a particular tempo. The violence of austerity has been described as slow because it is ‘incremental and accretive’ (Nixon, 2011: 2): harm is not immediately visible (Norberg, 2021), but instead distributed across the life course (Tyler, 2020) and folded into longer histories of dispossession (Pain, 2019). Taken individually each act of violence is barely considered harmful (Kiely, 2021; Wilkinson and Ortega–Alcázar, 2019) even as, through their systematic targeting of poor and marginalised bodies, they cause deaths by a thousand cuts. Yet even against this slowness, institutional neglect constitutes a still slower form of structural violence. Under austerity, violent acts of state withdrawal – for instance, the closure of service or the withdrawal of a benefit – are relatively fast, and thus relatively visible. In comparison, institutional neglect is one of the slowest and least visible forms of structural violence because it is passive: a refusal to intervene, rather than an active retraction of support.
Inasmuch as neglect always involves a deviation from expected standards of care, the concept of institutional neglect makes a normative claim about care at the level of the state. Here, we follow Tronto’s (2010) norms for good institutional care. For our purposes, three of Tronto’s ‘warning signs’ that an institution is ‘not caring well’ can be recognised within institutional neglect. If ‘[n]eeds are taken as given within the organization’ (2010: 163), cases which deviate slightly from institutional expectations can end up unjustly excluded from care. When ‘[c]are is considered a commodity, not a process’, institutions too quickly ‘slip into thinking of the concomitant notion of scarcity’ (2010: 164, original emphasis). This leads to restrictions on access to services. Finally, when ‘care is narrowed to care giving’, questions of need and responsibility for care are overlooked (2010: 165). In the process, institutions care only for those who gain access to their services, sidestepping wider responsibility for those who have been turned away. They thereby shift responsibility for recognising needs and providing care onto informal carers – particularly family members (Pearson, 2019). This displacement of responsibility is the consequence of a contradiction which emerges when an imperative to care is located within a bureaucratic system.
Bureaucratic care at a distance
Care is ‘a species activity that includes everything we do to maintain, continue and repair our “world” so that we can live in it as well as possible’ (Tronto and Fisher, 1990: 40). An ontology of care is broader than simply processes of social reproduction, but rather includes an ethical and political commitment to both human and more-than-human interdependencies (Puig de la Bellacasa, 2017). A feminist ethic of care thereby emphasises that mutuality and care for others is a moral issue (Tronto, 1993). State welfare institutions can therefore be conceived of as more-than-human entities that embody an ethic of care; indeed, there is a moral imperative for them to place such an ethic at the heart of their operations.
However, this jars with bureaucracy’s reliance on processes of categorisation, operationalisation and demarcation (Weber, 2013). Bureaucracies are structured by a dehumanising instrumentalism (Bauman, 1989). Historically, they have been utilised as a technology of population control by colonial states – for instance, overseeing the production of ‘a suitably fit yet docile, exclusively male labour force’ (Mama, 2001: 64) – and in postcolonial Britain. In the latter, state bureaucracies have targeted migrant populations with repressive measures ranging from virginity testing (Parmar, 1982) to racialised exclusions from services and deportations (Bhattacharyya et al., 2021). This points to the contradictory nature of caring bureaucracies: they embody both an expansive imperative to care and a restrictive impulse to demarcate and delimit eligibility. In the context of welfare states, this tension gives rise to both the rationing of care and the need to conceal this practice (Lipsky, 2010). Welfare state institutions therefore oscillate between caring and controlling processes (Wacquant, 2009), resulting in hybrid forms of care-control (Disney and Schliehe, 2019). Techniques of institutional neglect sit towards the controlling end of this spectrum, disciplining clients with promises of forthcoming care that are constantly deferred (Kiely, 2021).
As Lipsky (2010) suggests, it is most often frontline ‘street-level’ bureaucrats who are tasked with managing these paradoxical imperatives. Such bureaucrats are under considerable pressure to treat cases equally, but also lack the time and resources to do so. In these circumstances, objectivity, fairness and detachment (Weber, 2013) are impossible. Rather, discretion becomes central to managing workload (Lipsky, 2010). By making choices within such bounds, street-level bureaucrats walk a fine line between client needs and managerial demands (Durose, 2011). This does not necessitate the wholesale surrender of ideals of care (although these may be compromised); rather, professionals must strike a balance between caring about and for others, and surviving in the job (Lipsky, 2010).
In practice, street-level bureaucrats are forced to rely on a range of physical and moral distancing practices (Gill, 2016). Distanciation allows certain claimants’ credibility to be questioned, legitimising a bureaucrat’s decision to deny them care (Redman and Fletcher, 2022). This masks the rationing of service provision by sustaining the claim that all authentic needs are being met (Lipsky, 2010). Distancing is supported by ‘common-sense’ discourses which construct welfare recipients as undeserving (Jensen and Tyler, 2015), with distinctions in deservingness frequently drawn along racial lines (Shilliam, 2018). These discourses are linked to a wider process of responsibilisation which shifts ‘responsibility for social risks such as illness, unemployment, poverty’ from the state to the individual, transforming them ‘into a problem of “self-care”’ (Lemke, 2001: 201). This neoliberal mode of governance foregrounds notions of personal freedom (Rose, 1999), allowing state agents to withhold care based on the “irresponsible” choices of individual claimants (Rose, 2014).
At the same time, distanciation is always incomplete, with denials of care acting as a source of ethical conflict for staff (Lipsky, 2010). While backroom bureaucrats may avoid a sense of moral responsibility because they do not encounter the people whose cases they are processing (Bauman, 1989), street-level bureaucrats deal with proximate clients (Gill, 2016; Lipsky, 2010). This opens the possibility of staff using their discretion to provide care in contravention of rationing regulations (Durose, 2011), as they navigate contradictory yet intertwined personal desires and professional responsibilities (Gill, 2016). We emphasise that for those at street level, institutional neglect is not conscious or intentional: rather, it is subconscious and context specific. It emerges against a backdrop of fiscal pressures, conflicting moral imperatives and punishing workloads that compromise consistent, normative standards of care.
Background and methods
Local authorities (LAs) are a crucial site from which to consider institutional neglect in the context of UK austerity. These local government bureaucracies are responsible for a range of services including transport, planning, education, and social care, across discrete geographical areas. Since 2011, LAs have endured some of the deepest funding cuts of any branch of government (Zaranko, 2021), and this has disproportionately affected the poorest areas of the country (Phillips and Simpson, 2018). Real-terms funding for special educational needs and disabilities (SEND) support has declined by almost 20% since 2015 (Hunter, 2019) while by 2018–19, per capita council spending on social care was 9% lower in real terms than in 2009–10 (Phillips and Simpson, 2018). Simultaneously, LAs have been given additional statutory obligations under the Care Act 2014 and the Children and Families Act 2014. Many have subsequently struggled to balance their budgets, leaving them close to bankruptcy (de Freytas-Tamura, 2018). LA finances have been further undermined by the Covid-19 pandemic (Ogden and Phillips, 2021).
This article draws on empirical research from studies of two local authorities. The first study (conducted by RW) examines how parents of autistic children navigate and access SEND and social security services in a London borough (“Greenfields”). Fieldwork was conducted between November 2018 and July 2019, involving a four-month institutional ethnography with Greenfields’ SEND team, and in-depth repeat narrative interviews with 15 parents with autistic children living in the same borough. While parent participants received vouchers for their participation, SEND practitioners participating during work hours did not. This article is largely based on research with the SEND team (including 58 semi-structured interviews with LA, NHS and school SEND professionals), backed up with evidence from parents. The second (conducted by EK) examines how austerity pressures have affected the planning and delivery of mental health services in a county in the south of England (“Fenton”). Fieldwork was carried out between July 2019 and March 2020, including four months of research across several mental health services funded by Fenton County Council, and two months of participant observation within the council itself. This involved in-depth semi-structured interviews with 25 council staff, seven clients and 10 staff members from a range of services. No compensation was offered to staff participating during work hours. This article draws on analysis of council policy documents and interviews with the two council workers who held overall responsibility for “Thrive”, a ‘community wellbeing team’ established by Fenton County Council to meet new Care Act duties to prevent, reduce or delay mental health needs from arising.
Through a comparative study of these two services, we aim to demonstrate similar processes of institutional neglect in divergent contexts and settings, due to chronic understaffing relative to local needs for support. A longstanding issue within public-sector bureaucracies (Lipsky, 2010), this had intensified in both LAs due to austerity. At the time of research, Greenfields had around 2000 children with Education, Health and Care Plans (EHCPs), and about 200 EHC needs assessments in progress. All were overseen by a fluctuating team of around nine plan coordinators (PCs). In Fenton, the council estimated that tens of thousands of people could meet the diagnostic criteria for a ‘common mental disorder’ such as anxiety or depression, and thus be eligible for the Thrive service. The team comprised eleven staff members, including social workers and occupational therapists, meaning that it could safely carry a maximum caseload of around a hundred people. While staff did their best to care as much as they could, it was impossible for either service to meet these levels of demand. In attempting to negotiate this discrepancy while surviving themselves, practitioners engaged in three techniques of institutional neglect.
Delay: Stalling for time
Almost all the care provided by the two services was subject to delay. Both would postpone the point when clients could gain access to a service; delays bought more time to deal with or discharge existing cases. These delaying tactics could be formalised (as when cases moved through a regimented waiting list), but they were often informal. For instance, by failing to follow up on certain cases, staff made clients responsible for chasing their own care. If clients eventually got in touch after hearing nothing, then that was a useful pause for the service; if they did not, then they were de facto discharged, thus lightening caseloads. This constituted institutional neglect because these discharges took place irrespective of eligibility.
Case study one: Greenfields SEND service
Staff in Greenfields SEND service faced unworkable levels of demand for education, health and care (EHC) needs assessments. Extreme pressure (due to the emotional, practical and statutory demands of the work) resulted in high staff turnover: for example, four of the nine plan coordinators (PCs) left the service during the four months RW spent there. There were lengthy waiting lists for both non-statutory and statutory support and assessments, so delaying responses to parental enquiries – whether by stalling or stonewalling – was generally due to lack of capacity rather than deliberate avoidance. Staff members employed varying strategies for managing contact with parents to control their workload: I try not to give my email out to parents. Not because I […] want to be uncontactable but because you can’t manage the workflow if you give your email out. So a couple of parents I work with have my email address, either deliberately or accidentally, and, I mean, you have to respond to emails where there’s clearly quite a lot of anxiety in the email […] But the problem is, in the current climate […] we survive because we’re traded [contracted out to schools], and that, that work [supporting parents] isn’t funded. The authority don’t fund us to email parents and support parents in that capacity. Schools don’t. So it’s not a sustainable way of working (Educational Psychologist, LA SEND team)
While this Educational Psychologist (EP) avoided email contact, other SEND practitioners in the borough refused to take phone calls. Greenfields SEND service had a central phone line operated by administrators who fielded initial enquiries, transferred calls and dealt with upset parents who could not reach particular professionals. These administrators could do little about practitioners who ignored parents, besides using their discretion to disclose useful inside information. Parents who were unwilling or unable to be pushy could easily be forgotten. Such evasions were a source of incredible frustration for parents but were also a technique which allowed the continued operation of the service in times of extreme demand. Social and financial capital allowed some parents to overcome these delaying tactics; the consequence was a widening disparity in access along race and class lines: So you have the parents who are – I would say mainly middle class, mainly white, they live in specific areas of the borough […] They are better educated, they have better jobs, better income levels, so I find that they’re in a better position to access services, especially because they can pay for private reports rather than [wait for the LA/NHS to respond] (PC, LA SEND team)
Case study two: Thrive community wellbeing team, Fenton
Delays to access were also vital for Thrive. The service manager had introduced a formal waiting process which prospective clients had to complete before they could gain access: [After a referral] we send a letter out to say […] here’s two weeks, please contact us in two weeks. If not, you know […] we manage the time, when they should, the date that should be coming back to us. We ring them on that date […] And if there’s no response we shut [discharge] (Service manager, Thrive) People have to be […] in the right stage of their cycle of change in order for us to make any meaningful change, [to] support to them. Because, you know […] a lot of it I would have said is, motivation. […] we’ve had lots of cases that I’ve spoken to people about where it’s, yeah, I could do some really good work but they just don’t want to (Service manager) Q: So what proportion of people that come in, get referred, don’t engage would you say? That’s interesting, I should probably look into that. Um. I couldn’t, I couldn’t put a number on it, but I Q: Ballpark is fine Over half (Service manager)
Defer: Assessing before assessment
Where clients had navigated these delaying tactics, a second technique could come into play. Staff would introduce and then defer to additional conditionalities or procedures, blocking otherwise legitimate claims on a technicality. Often this involved the introduction of additional assessment processes with higher thresholds. Cases would then fail to pass these additional requirements, preventing them from reaching statutory assessments which were easier to pass, and led to expensive, longer-term care. This constitutes institutional neglect because claims that were otherwise eligible could be blocked based on new, arbitrary assessments.
Case study one: Greenfields
Access to SEND provision was shielded by multiple layers of prior assessment. To secure an EHCP from any LA entitling them to the highest level of SEND support, a child or young person must first undergo a statutory EHC needs assessment. To access a needs assessment, a parent or SEND practitioner must complete an application, documenting the measures already taken to support the child. This application therefore relies on evidence from specialists including speech and language therapists and EPs. However, a combination of austerity and academisation1 meant that the Greenfields SEND team was chronically under-resourced, so access to most of its non-statutory services was ‘traded’. While schools maintained by the LA could access the team for free, academies – a significant proportion of schools in the borough – could not. Instead, they could block-purchase a given number of days of each specialist’s time per year. This marketised approach led to high levels of rationing in academy schools, yet access to statutory EHCP assessments depended on these initial, non-statutory assessments. The number of children that each school would put forward for EHCP assessment was therefore determined not by levels of need, but by the limited budgets for, and availability of, non-statutory specialist time: The thing that I find the most frustrating is that you have to have an EP report for almost all of them [EHCP applications] and they can take ages Q: And is that through the EP time that you’ve bought in? Yeah. And because we’ve got a big waiting list of children, and because if you want a full EP report it's two days’ worth of work, so you know, most [secondary schools] buy in like 15, 20 days [per year], two days’ worth of work on one child is quite a lot of work […] Q: Okay, so do you find you kind of need to prioritise children or cases then, with the time that you have? Absolutely (SENCo, Academy school)
Just as access to SEND specialists was rationed, so too was special educational needs coordinators’ (SENCo) time for writing EHCP assessment applications. Like central LA SEND staff, SENCos also made discretionary judgements about how to allocate scarce resources. These were often influenced by professionals’ sexist, classist and ableist judgements of parents (see Angell and Solomon, 2014). As one autistic mother explained, the SENCo took their autistic daughter’s needs more seriously if her neurotypical husband accompanied her to meetings: The tone changes. He gets taken seriously. He’s not autistic, he’s a guy, he’s a [school] governor […] what he says is taken seriously. What I say is like ‘oh’, you know ‘mum’s a bit anxious, mum’s a bit over-protective’ [… T]he SENCo has, pretty much said that I’m projecting my own issues onto my child (Parent 1) There are certain types of evidence that the LA must look at when deciding whether or not to agree a request for an EHC needs assessment, and I think sometimes that evidence isn’t there when we receive a parental request, yeah Q: Okay. So […] if the evidence isn’t there, the child won’t get an assessment, will they? Well, but the Children and Families Act says if the child may have SEN or a disability then we should assess, so yeah – as I was saying, the bar [for an EHC needs assessment] is very low (PC, LA SEND team)
Case study two: Fenton
Access to Thrive was not governed by a statutory needs-assessment process. Staff claimed this made it easier for people to access the service, via: Any point of access that the individual so chooses, the individual can self-refer […] erm, maybe GP, maybe housing, you know as long as they’ve got the individual’s consent from, whichever referring agent Q: And there’s no diagnostic criteria or anything, or? No, er as long as, there’s a mental health condition, of some [kind] (Operations manager, Thrive) People […] that are sleeping in cars […] at that time, if you’ve still not got your basic, and your primary concern is your mental, your mental health is affected because of your housing situation, then the housing situation needs to be sorted [first] (Service manager)
These processes of prior assessment were encouraged by wider council policy. The service manager attributed Thrive’s approach to a programme titled “Healthy Lives, Healthy Conversations”, which had been rolled out across Fenton’s social care department. The programme’s documentation instructed council professionals on how to deliver three tiered conversations, named Offers A, B and C. These were initial assessments with prospective clients designed to limit the numbers of people receiving statutory eligibility assessments for social care, and therefore ongoing support. In council documents, only Offer C provided a pathway to an eligibility assessment. However, to reach this point, the first two ‘offers’ had to be exhausted. Cases assessed as requiring Offer A were given ‘help to help yourself’, with success defined as ‘enabling you to get on with your life’. While the documents suggested that Offer A ‘connects you to your whole community’, the service manager put it more bluntly: ‘Offer A is no further action’. Cases assessed as Offer A were discharged without even a referral to another service. The service manager described this in terms of personal freedom and responsibility: Q: [Following Offer A] would there be a re-referral? No, because […] people, people have capacity and consensual [sic] to our work. We would give them advice and information (Service manager)
Divert: Informational discretion and redirection
If the first two techniques put barriers in the way of prospective cases, the third was a diversionary tactic: professionals divert people to prevent them from entering a service in the first place. At its most simple, a case was marked as either unsuitable or resolved: it could then be referred to another service or discharged. Often this involved the active reframing of a case and its needs by staff. But it was not only cases that could be diverted: the energies of prospective clients were redirected too. Both services maintained a constructive opacity around eligibility requirements; claimants were forced to spend time piecing together the information required to prove they were eligible for care. This regulated the flow of cases into overstretched services and prevented clients from making requests on staff time.
Case study one: Greenfields
Professionals in Greenfields bounced cases between services and teams, reinterpreting the needs of clients in the process. One of the parents who had experienced this was dyslexic and spoke English as a second language. She struggled to access information unless she could speak to someone in person, yet she was often diverted from one busy service to another without services engaging with her son’s needs: I can’t get my OTs [occupational therapists] to stick with me. It’s so annoying! And then sometimes in the process, one of them leave, and then […] I have to meet the new one, and I have to go through [my son’s history], then after three months or two months or even a month, the OT will call me ‘oh yeah mum, I think we solved this issue […] so [son] is fine now so I think it’s time to discharge him’. […] Like [one issue] I brought first to the OT, and the OT [said] ‘oh this is more of a psychiatrist or clinical [psychologist], you know, area. I think you should go and talk to them.’ It’s not like ‘oh yeah, I will call my colleague’, or ‘I will refer you to it’ […] But most of the time, that’s what they do now, they just tell you to [go to a drop-in session], or give you the number, or the extension – they could be in the same office [laughs] but you still have to go through the process of the number, and to call, and book the appointment (Parent 2)
Case study two: Fenton
In Fenton, demands on the service were controlled via a careful rationing of information about the Thrive team. While both the service and operations managers described self-referral via the council website as a key route through which people entered the service, the contact details for the team were hidden within the website. The front page offered self-referral forms for safeguarding and for social care assessments, while a section on health and wellbeing redirected users to a consortium of community groups offering support outside of the council. Despite Thrive’s focus on ‘low-level’ difficulties, the team’s contact information was located in a website section titled ‘disabilities and health conditions’. This required users to click through three menus to find their details. Those who had taken the initiative and navigated this route were frequently judged too unwell to be taken on by the team. These more severe cases would then be diverted to other services (Kiely, 2021): We often get emails, phone calls from people saying I want to end my life. They’ve, they’ve plucked our number from the internet and they thought, Oh, well, I’ve tried the crisis line and I’ve not found that helpful so let’s ring these people […] So we might offer, would you like us to call your GP […] We might reiterate with them, look, you know, you’ve got the crisis line […] if we had that much concern we’d offer a police welfare check (Service manager)
This promotion among partner organisations was in direct contrast to the rationing of information noted elsewhere. But external organisations could also share the workload of providing care, thereby speeding up discharges and reducing the team’s workload: So we’ve currently got a case that’s been on our caseload for two years […] I think it has now come to a, a natural end, and I think we’ve done a last visit and we will be, closing [discharging] her […] she’s back at, going back to church and we have, um, connected her to a befriender. Er, and she stopped contacting [us] (Service manager)
Conclusion
In this article, we have introduced the concept of institutional neglect to make a normative claim about the conditions of care within the austere welfare state. Defining institutional neglect as welfare state inaction in the face of eligible demands for care – that is, demands that have historically been recognised and honoured – our article challenges the idea that neglect can only happen in the home or family. Rather, we argue that welfare state institutions can themselves be neglectful (Bhattacharyya et al., 2021). Framing institutional neglect as one of the slowest and subtlest modalities of structural violence, we extend and nuance theorisations of state violence under austerity which have been critiqued for their imprecision. Our analysis demonstrates how institutions limit access to care through banal, quotidian practices of delay, deferral and diversion. Our empirical examples – an adult community mental health service, and a SEND service – are rarely examined when considering the austere state. Yet both services reveal the subtle ways in which institutional neglect results in withdrawals of care, while also masking these. Framed by professionals as adherence to (discretionary) standards of access, institutional neglect constitutes a structural denial of care. Each act of institutional neglect – each avoided phone call or unfair discharge – might seem insignificant. But writ large across the declining institutions of the British welfare state, these instances combine to power a grinding down and wearing out of marginalised bodies which, with its gradual tempo, barely registers in a popular consciousness oriented towards the spectacular. This subtle, slow, structural violence bears down along intersecting axes of race, gender, disability and class. As institutional neglect facilitates the withdrawal of the state, bodies are forced into market dependence and care becomes privatised as a personal responsibility.
We conclude, then, by advocating for accounts which foreground the entangling of violence and care, rather than viewing the latter as an antidote to the former. Where accounts of state violence focus entirely on policing, bordering and more spectacular modes of welfare retrenchment, this implicitly frames health and care services as only ameliorative. Likewise, when demands are limited to funding increases to education, health and social care, this neglects institutional practices within these systems. While these are conditioned by funding, they also betray a keen ability to deny just as much as provide care. The centrality of the NHS in the Brexit campaign demonstrates the role health and care systems can play in racist, nationalist imaginaries (Fitzgerald et al., 2020), while policies requiring clinicians to check the immigration status of patients shows how these systems can serve punitive border control regimes (Yuval-Davis et al., 2018). In this context, it is imperative to account for the violence bound up in care systems as well as that which they can mitigate. Going forward, this requires more detailed accounts of subtle modalities of violence and neglect within caring bureaucracies, and more precise specifications of normative standards of care. Such normative frameworks are not mere policy tools but constitute a political demand against the violence of the state.
Footnotes
Acknowledgements
Thanks to the anonymous referees for their incisive and helpful comments, and to Arianna Silvestri for editorial guidance. We also wish to thank Mia Gray for detailed feedback on earlier drafts of this article, Matipa Mukondiwa for guidance on relevant literature, and, most of all, the participants in our projects for giving their time and sharing their stories.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Economic and Social Research Council (grant numbers ES/J500033/1 [EK] and ES/J500124/1 [RW]) and the QMUL Postgraduate Research Fund.