MacDonald advances several claims. First, the ‘gig economy’ and ‘cash-for-care’ marketisation of social care and health support work come with major pitfalls: These are explored with reference to specific cases in Australia and England. Second, processes that underlie the individualisation of care need to be identified and critically evaluated. For when risk and responsibility are shifted onto individual workers, what we can expect to see, given the evidence, is a marked decrease in the quality of care that the elderly and people with disability receive. Indeed, there is already an employment crisis with respect to social care and health support work in many countries. Typically, the work is poorly paid, precarious, and socially stigmatised. To pre-empt the positive view: MacDonald advocates for a collective, organisation-based approach to person-centred support work.

The Australian National Disability Insurance Scheme (NDIS) is MacDonald’s primary stalking horse. Several chapters are dedicated to its analysis. Individualised care exists internationally, but the novelty of the Australian scheme is that ‘all public funding for care and support for people with disability is now allocated on an individual basis and, in a very short period of time, an entirely new, and largely unregulated, publicly funded market has been created for people to purchase their care and support by the hour’ (2). This market has had significant consequences. Those receiving care have become de facto ‘clients’, and care work has shifted from more secure employment in the public and not-for-profit domains to an on-demand gig economy propped up by unregulated service providers and private, for-profit enterprises, mediated by the digital app consumer environment. Now, it would hardly be controversial to say that when the NDIS was implemented, it took over from an unsatisfactory system. Support for people with disability had been comparatively narrow in scope, underfunded, fragmented, overly bureaucratic, and opaque (see 66–67). However, it seems one extreme replaced another.

Many OECD countries have long established market-driven publicly funded care. Since the 1980s the neoliberal premise that competition is the most efficient means to produce the best services for the best price, and more recently, an ethical premise concerning human rights, that people with disability ought to be empowered through enabling them to purchase their own support, has given rise to market mechanisms in the provision of care. MacDonald’s argument does not amount to the claim that these premises are wrong, or that individualisation, marketisation, or digitisation per se are intrinsically bad. Individualised funding for social care has been strongly advocated by people with disability, and for good reason (see 25–26). Of course, there are drawbacks to the marketisation of publicly funded services: ‘[according to the critics, markets] promote individualism over community collective action; bolster private interests while undermining public ownership, space and capacity; weaken public accountability and privatise citizenship … Evidence exists that markets can cement inequities, with disadvantaged groups having poor outcomes’ (24–25). However, what this shows is that there are better and worse ways for marketisation of care to play out. MacDonald understandably adopts an ecumenical approach. Drawing on labour market segmentation theory, she undermines the neoclassical economic idea that the labour market is a single competitive market. Drawing on feminist socio-economic theory, she emphasises power relations and the inequalities that can arise and persist as a result of the socially constructed nature of a plurality of regulatory mechanisms, from labour laws to local social norms about work and employment. Particularly, MacDonald’s analysis emphasises the cost reduction and consumer choice narratives of the NDIS that underpin marketisation (see 78, 85).

A natural objection at this point: There has long been marketisation of social care services. Even in Australia, the NDIS did not herald this. It has been emerging there over several decades. So, critique of NDIS-sanctioned individualisation of care and support work is misplaced insofar as that critique focuses on marketisation, a separate issue. MacDonald would reply,

the social care system for people with disability established under Australia’s NDIS represents a more radical marketisation and individualisation. The NDIS is radical for its rapid and wholesale transformation to a new market-based [sic] and for its very lightly regulated, individualised system. The NDIS establishes a market for supports for people with a disability that is fully open to businesses from the private for-profit sector for the first time. All funding is individualised and, unlike the English system, there is no role for local authorities to act as commissioning bodies. (68)

MacDonald considers this in combination with current Australian labour law. Most self-employed care workers are not protected by minimum wage standards, and their “price’ often does not include provision for the on-costs and overheads associated with employment security, other employment protections and benefits, training, or access to supervision and support’ (80). And this is described as ‘efficient’ in a government-commissioned report! Those employed on a part-time or casual basis by multiple organisations are likely to receive no employer superannuation contributions (see 98–99); digital platforms serve as a go-between, but are not themselves employers of care workers, so avoid those costs of employment. Given that the majority of the workforce in the care and support industry are women, MacDonald argues that the situation in sum reinforces gendered inequalities.

Building on the personalised risk framework of Christensen and Manthorpe (2016), MacDonald emphasises a concept of individualised risk to characterise the kinds of ways in which the new environment of social care and support work—digitised, marketised, individualised—creates and maintains distinctive risks for the care workers under NDIS. That is, ‘individualised risk as (i) risks of reinforcing gendered undervaluation; (ii) risks of isolating and individualising workers; and (iii) risks of fragmenting work, working time and working lives’ (138). Chapter 7 focuses on the first of these, and Chapter 8 on the latter two.

Relaying first-hand accounts of social care and support work acquired via a series of interviews with workers under NDIS, MacDonald paints a picture of their vulnerability and working conditions. In addition to issues of pay, care workers were dissuaded from undertaking potentially valuable training; told to abandon safety procedures and to accept that rostered hours may change, frequently, without notice; and, in some cases, were publicly paraded by their clients as if they were escorts or girlfriends, and in one case MacDonald reports, sexually harassed. Of course, such deplorable experiences are not necessarily or exclusively due to the digitisation, marketisation and individualisation of the care and support work. But MacDonald makes a strong case that the new environment of the work exacerbates things.

Rather than a hands-off, free market approach to care services, MacDonald suggests systems such as NDIS would be improved by implementing some sort of official or regulated space for the rights and working conditions of the workers to be considered and acted upon if found unacceptable. Coalitions of workers, people with disability, family members, etc. might also facilitate action for both better quality care and better quality jobs in the care and support sector. This has seen success in the US (Cranford 2020), and in the Netherlands (see 194). Although the NDIS was supposed to include mechanisms for collectivism and advocacy, apparently these were ‘largely lost in implementation’ (195).

MacDonald argues that policy must place greater value on social care and health support workers:

gender equality, decent work and quality care are all undermined as market-based individualised funding drives shifts to work in more informalised, lower-skilled, insecure employment where workers have little access to training and development or career opportunities … Identification of workforce capabilities by social care quality and safeguarding bodies must be accompanied by the establishment of system requirements and mechanisms for workers to be skilled and trained, and by investment to achieve this. (192)

Lack of a skill baseline (for lack of training) is worrying. Platforms for support and care work are for facilitating services for a vulnerable slice of the community. MacDonald says, based on first-person reports, that workers would welcome proper training and opportunities for skills development. And MacDonald approvingly cites the proposal of Ryan and Stanford (2018) for training entitlements linked to hours worked. Regardless, skills-based pathways for worker progression would benefit a system that sorely needs highly skilled and experienced workers to assist individuals, many with complex needs, some requiring intensive support.

In short, MacDonald’s analysis is sobering, and her criticisms make good sense. The development of more specific normative claims for influencing policy, however, is traded for a more general petition (see 200). The former, I presume, is a priority for future research.