When I was a child, I would watch my mother getting ready for her night shifts. During the day, she wore trainers and baggy clothes, but for work, she dressed impeccably, as if preparing for inspection. Standing in front of the mirror in the kitchen, the cat next to her on the countertop, she would coil her shiny blonde hair into a chignon and apply her make-up, listening to Neil Young, The Chieftains, Eva Cassidy, on repeat.
Her dark-blue uniform was boiled and freshly ironed. Her left breast pocket sparkled with the tip of her scissors and a pinned-on silver watch that, to me, was a totem of her two selves — a day-mother, late for everything, and a night-mother suddenly instructed by ticking time.
Nursing and, in particular, care for the dying defined my mother’s identity for most of her life. She retired recently after 45 years across 10 nursing homes. They varied in standard. In the best, management created a joyful and supportive environment. In the worst, conditions were so terrible she feared for her life. She can still recount the names of many patients, their ailments, mannerisms, even the drugs they took; precise details about the lives of people who have long since died.
As she tells me their stories, she feels the tug of fabric in her hands, smoothing down beds, squeezing out fluffy terry towels to clean delicate old skin. Smells jump out at her. She sees her colleagues, those she battled with over poor work or abusive behaviour and those she treasured, on the same mission as her. Her retirement came before the strikes that have erupted across the UK’s healthcare sector since late last year. Nursing was a calling that became increasingly untenable, her experience mapping the path we have taken as a country over several decades, emerging into the crisis we face today.
My mother was born in the Republic of Ireland in a house her father built, at the foot of the Cooley Mountains. She was the second child and second daughter. Two years later, the family moved to Manchester, intent on securing a more prosperous existence. Even as a child, my mother was acutely aware of death. Her younger brother had cystic fibrosis. One of her sisters died at three months old. At 15, my mother was sent to work. During the summer holidays, she earned £3 a week at a nursing home near Altrincham, which, at the time, was run by nuns. It was live-in. My mother and 11 other girls cared for the patients, brought them meals on trays and scrubbed the floors. At the end of their nine-hour shifts, they slept in dormitories side-by-side.
“There was a clever little lady with multiple sclerosis,” she tells me, “a woman in a hammock with bed sores so bad I could see her bones, an ex-teacher who spoke to imaginary children at the bottom of her bed.” Then there was the elderly priest who weighed about 15 stone and who groped the girls when they put him on the commode. “You couldn’t say anything,” my mother says. She wanted to know everything about the patients’ diseases and backgrounds. “It was traumatic. I was just a child. But this place prepared me for nursing. This is where I knew I wanted to be perfect at giving care.” She kept that desire her entire career.
At 20, she started her training. They learnt on the job in those days, deployed in different departments, with a couple of weeks’ theory in-between. Caring for the elderly was never the plan. Nobody wanted to do it. But her supervisors sent her to Barnes Hospital, an NHS geriatric facility near Manchester. It was a big, dark Victorian building with turrets. When she first saw it, she almost heard the crack of thunder.
One of my mother’s first tasks was to bathe everyone in a 15-patient ward on her own. In those days, there were no curtains or cubicles to protect people’s privacy. She felt it was wrong. There was a tiny old man who was incontinent and dehydrated. He would defecate on the floor, small Malteser-like droplets. One evening she came off shift to see a trail of droplets illuminated by a triangle of fluorescent light coming from the corridor. The man was cowering in bed with the sheets pulled up to his mouth. He was terrified. My mother grabbed his poo-covered hands. “Don’t worry, it’s OK,” she said. “I’ll clean it up. I’ll be back tomorrow.” She realised it was a vicious cycle. He was defecating on the floor because he was scared, and his fear made it more likely to happen again. She never forgot his vulnerability. “I left that day and said to myself, ‘I will never let these people down.’”
After I left school at 16, I started working as a care assistant in the same nursing home in which my mother worked in Shropshire. I didn’t want to become a nurse, but found I was drawn to the work. The nursing home was somehow secret, like a burrow, away from the world and yet deeper into it. I suddenly saw my mother in her other role. She seemed to speak another language to her patients. Her words were only one part of a more sensory dialogue that involved intricate knowledge of a person’s gestures, noises, skin texture, smell, bodily functions and history. She used touch and the tone of her voice to put them at ease.
“This is Mrs M,” she told me.
I looked down and saw a thin woman in a bed, curled around a radio like a crescent moon. Mrs M had been wailing at the top of her lungs. I couldn’t connect the wail that filled the corridors to the frail woman before me.
“This is my daughter.” My mother spoke in a friendly voice. Mrs M couldn’t speak, she couldn’t move except to raise her thumb. She was fed through a tube going into her stomach. But her body somehow smiled. Or maybe it relaxed.
“Now, what is it you need, Mrs M?”
The woman’s body tensed slightly — she was responding in her head to the question. My mother knew what Mrs M needed already but the conversation was part of her care. The radio had lost its station. My mother tuned the dial and the crackling stopped. But she sensed something else.
“Do you need the toilet?” Mrs M liked to get up for the toilet, and my mother wouldn’t leave her lying in an incontinence pad. She encouraged any independence, because it mattered, so profoundly, to the person. Mrs M raised her thumb.
I don’t know how my mother showed me this. That a person born and in the world is unfathomably present, sometimes even more so, without verbal language. It passed over me in silence. As I looked at Mrs M I could see her; there was something about her that I knew. It was the essence of a person. And it struck me that my mother had known about this magic since she was a child, that it was her gift. Afterwards, I saw it with each patient. I saw it in a man who was dying of throat cancer. I couldn’t see him for bandages and still, somehow, as he lay in bed, he radiated urbane humour. And then, one night, I saw who he was leave his body as he died.
Early in her career, my mother moved a lot with my father’s work: to London, Leeds, Surrey, Shropshire. She always worked in private nursing homes — that way she could work nights and look after her children during the day. After her training, while pregnant with her first child, she worked in a nursing home in London. One day she was asked to give one-to-one care to a man. She overheard her manager talking about him, describing how he had been verbally abusive to the other nurses. She asked why she was being sent in to care for such a patient when she was pregnant. She was told she had no choice.
He was, as predicted, hostile and misogynistic. Each day she went in. She learnt what he needed, the way he wanted to be dressed and bathed and assisted on the toilet. Soon, he softened. Before she left for Leeds, he gave her a gift, a box of perfume. “I should never have accepted it, but at the time I was overjoyed,” she says. “It smelled beautiful.” She felt it was a sign she had succeeded at winning over the most difficult of patients.
My brother and I, the youngest of four children, often spent time in the nursing homes after school. Around the time our parents were divorcing, we occasionally even slept there. One day after school, I went to the nursing home to wait for my mother to finish her shift. She was running even later than usual. I walked down the corridor and found her in a room with a few other people. The room was calm. Summer light from the garden outside filtered through the curtains and enveloped it in a peach glow. She asked me to leave and shut the door. Later she told me it had been a beautiful death.
“When all the stars come together, and there are enough staff,” she says now, “when they have no pain and they’re ready to go, you can get it right.” Sometimes, patients would die alone because there weren’t enough staff. Sometimes people would get panicky and didn’t feel ready. “You’re not used to the sensations of death, it’s your body shutting down,” she says, “so there can be a certain amount of fear. It was about being a part of it. Each one is different.”
There was one home that showed her how nursing homes could be run differently, run well, a family business in the Shropshire countryside. She found it in the middle of her career, when she was 46 years old. She walked in on November 5 2002. The residents were lined up in the living room, a row of women with lacquered hair-dos and nylon outfits, each holding a sparkler. She gasped. It was reckless and beautiful, and she came to understand that it was the ethos of the home in action: the residents must have a good life.
It wasn’t just an empty idea. There were activities on offer every day and good food. Musicians came to play. Every holiday, big and small, was celebrated, with decorations and a special meal. The owners helped manage the place and came in every day. They spent time trying to find out about the lives of the patients.
There was a sweet little lady with dementia who used to hang about the manager’s office, next to the entrance. One day, my mother saw one of the owners speaking with her. “Come on,” he said to the lady, “I need your help.” He took her to pick up some things for the nursing home. “She was over the moon,” says my mother. And they listened to the nurses. There were still challenging patients, and staff, but “we felt empowered by the management to do a good job”. There was more time for each patient. It was the best place she’d ever worked.
Then the home was taken over by a chain. My mother left not long after. She hated the new owners, the new uniforms. The standard of care dropped. Jam sandwiches replaced proper evening meals. The paperwork increased. It was the same thing she’d seen in previous nursing homes. “We felt we couldn’t give the care that we were employed to give.”
Before the 1980s, 80 per cent of residential care for the elderly in the UK was provided by the public sector. Margaret Thatcher changed that with her privatisation drive, forcing local authorities to put social care provision out to tender. By 2020, 85 per cent of elderly care home beds were provided by for-profit companies, with large chains accounting for more than a quarter of the market. Private equity groups today finance about 10 per cent of England’s care home beds. Many entered the market by buying the debt of struggling care homes, like the one my mother loved. Their complex financing model and opaque structure — often involving offshore subsidiaries — have been accompanied in many instances by cost-cutting and outsize executive pay.
“What we have is the financialisation of the care home sector,” an insolvency specialist told the FT in 2017, “where some of its biggest managers are operating on the private equity model and expecting returns of 12 or 14 per cent . . . [but] they can’t possibly make that kind of money.”
In a study that same year comparing 15,000 nursing homes across the UK, for-profit homes scored lower on care quality than not-for-profit or public sector ones. A 2022 study looking at the effects of chain ownership found that private-equity-backed providers scored lower on “safety, effectiveness and responsiveness” than other for-profit homes when inspected by the Care Quality Commission (CQC), which the authors suggested could be due to cost-cutting practices such as reducing staffing levels and maximising bed occupancy. All for-profit ownership types had lower average overall ratings than not-for-profit.
“I could never do half a job,” my mother says. “I was passionate about what I was doing. A lot of managers were only interested in saving money on wages. They didn’t care about the quality of care.” Once she heard a nurse slapping a patient. My mother reported her, but the nurse wasn’t fired because she’d been working at the home for a long time. Another time, she saw staff had left puréed food on a trolley instead of feeding it to patients who required assisted eating. Afterwards, she laid out charts showing the patients’ descending weights in front of the manager. The manager made excuses.
I ask about the CQC. Don’t they monitor the standard of care? She laughs. “Oh, yeah,” she says. “The CQC comes round and there are activities, everyone is doing a great job.” At one home she worked at that was owned by a chain, a carer who was under 18 earned £4 an hour, then the minimum wage for her age. She was supposed to be in training, but the manager used her in place of a fully trained member of staff. My mother complained, accusing the manager of skimping to line the pockets of investors. “This is business,” they replied scathingly. “Don’t tell me you wouldn’t want a big house with a swimming pool one day.”
In 2009, while working for a company called Barchester Healthcare, she received an award: “Barchester Nurse of the Year”. She’d been nominated by her boss, the patients and their families. Her picture was in the local paper, holding the award, arm-in-arm with a famous TV presenter. That same year Barchester made pre-tax profits of £27mn. She was earning about £12 an hour.
A few years later, her job had irrevocably changed. She was working elsewhere in a locked dementia ward, in a job nobody wanted. It was the worst place she’d ever worked. As a geriatric nurse, it had been normal for her to work 12-hour shifts, to receive bites and scratches from patients. But in this place she wondered if she might die. There were 33 patients, all mobile, all incontinent, many violent, most much bigger and stronger than her. She worried for the other patients. There were just one or two carers to help her, and they were often from an agency and didn’t know the patients.
She couldn’t be everywhere, nor see everyone. The ward was badly designed. There was a circular route around a courtyard garden. Some of the patients used to walk in a loop, around and around. One night, a patient, a big former police officer, was threatening to kill the two care workers on duty for a crime he believed they’d committed. He held an industrial laundry container above their heads. They were petrified and managed to escape. My mother talked him round.
I remind her of an incident that she’s since forgotten: I was at her house one morning when she came home looking broken. A patient had beaten her around the head with a Zimmer frame. There was no security. She had begged for more staff and been ignored.
I had always seen this urge in her to give so much of herself that her needs were erased. The job that she loved had become overwhelming, unmanageable, traumatic. The neglect of patients and staff perpetrated by her employers verged on abuse. Behind it all was the imperative to cut back, to run everything on tighter margins, to pay dividends to shareholders and increasingly high salaries to the most senior executives, which meant fewer care staff, worse conditions. It threatened to erase my mother completely. She stayed for two years. Afterwards, something changed in her approach to the work. Everything appeared the same but I could detect a hardening. A barrier put up to cope with what she had seen. She still experiences flashbacks. She cries, revisiting these memories.
My children and their grandmother videocall most days; they chat and sing songs. Now, she talks on my screen about her career and, for the first time, I write it all down, to pull together one story out of a million possible renderings from the fragments of her past. It is not easy revisiting her life’s work in one sweep. We spread it over a few days. She’s been working since she was 15, barely stopping to have children. Covid-19 hit when she was employed in a nursing home in Gloucestershire, in the same village as her sister. Close to retirement and with a smoker’s cough, she was caught in the panic that hit the care sector in 2020. There were no masks or gloves, no new hygiene regulations, no visiting restrictions. I begged her to find a solution, to ask to be put on furlough or leave. Initially, she wouldn’t. But after a lot of pressure from me and my brothers, she agreed. She took a short break and then returned to nursing — this time caring for one woman in her home.
“I worked in a bank briefly,” she says, “before starting my nurse training. I should have stayed there. I was good at it.” She corrects herself. “No, I should have become a doctor.” I think that the regret she feels is about the material comfort she could have worked towards if she hadn’t chosen nursing. Care work takes an enormous mental and physical toll.
She is still nimble. Her blonde hair is still pinned up. When I visit her in Gloucestershire, she often resumes a pose I remember from quiet moments of my childhood: leaning on the window ledge, looking out. Now, she has a garden where she grows vegetables and roses. I can feel the vastness of her memory. Inside are the corridors of those homes and the people long since gone, some of whom she couldn’t save from dying alone and those she helped let go. We plant three Photinia trees, which she hopes will knit together into a wall of glowing red leaves. I watch her hands, once perpetually scrubbed or gloved, now slightly twisted, dig the soil, and I see her history in them.
Imogen Savage is a writer based in Berlin
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