Polly Morland’s A Fortunate Woman: A Country Doctor’s Story – an ethnography of a GP living and working in the rural Midlands – is a readable, lyrical work of great depth. Morland and the doctor live in the same valley that was home to ‘Dr John Sassall’, the subject of John Berger and photographer Jean Mohr’s revered A Fortunate Man. When Morland came across Berger’s book, it dawned on her that her home for the last decade had been the place where, in 1966, Berger and Mohr had spent six weeks documenting Sassall’s life. Morland made her discovery in the summer of 2020 and, drawing inspiration from Berger’s book, she – alongside photographer Richard Baker – started to chronicle the life of a current GP.
Thinking with Berger and ‘Sassall’
Morland revisits Sassall’s life and work as she unfolds observations of his modern-day counterpart’s situation. This learning prompts considerations of the future of general practice. Key to her argument – which she builds through stories in a persuasive, non-didactic way – is care continuity once again being central to the shaping of GP services and work. Reading the book prompted me to think further about the care work that I have encountered, both on the front line and as a researcher: that of paid adult social care (ASC) work. Much of the book’s content chimes with my experience and knowledge, and with wider narratives about and understanding of paid ASC work. However, there are some key differences, and these shed light on hierarchies between health and social care.
Morland composes a picture where time, in the everyday and over seasons, years and generations, enhances relationships, and thus the quality of the doctor’s care and work:
Being there, available most days for your patients, is one of the key elements in building relationships, and strong, rooted relationships don’t just help the patients. They also help the doctor.
Time allows for learning and creates space for the doctor to see and to know. When this happens repeatedly over time, the doctor benefits from the ‘accumulated knowledge’ (a concept Berger employs) derived from continuity. This accumulation is the layered understanding the doctor gains of individual patients through repeated consultation. Towards the end of the book, Morland refers to a burgeoning academic literature on the multilayered benefits of care continuity, both to individual doctors and patients, and to the wider health system. With time, this accumulated knowledge can also be holistic in nature, and expose doctors to valuable and useful information about patients’ lives that is not obviously or narrowly ‘medical’. In the ASC context, this carries echoes of insights from perspectives on disability rights, and of the importance of understanding the person rather than focusing narrowly on any condition they may have.
Time is created for stories, and trust paves the way for them to be told and heard. This listening – and observation – is central to work across health and social care, including for paid ASC workers. Morland’s stories are deftly curated: free from repetition, they are consistently involving and fascinating, and convey the variety of the doctor’s lifeworld. The sadness of profound emotional loneliness comes through in the account of an older woman who had never before been asked about the effect a serious accident sustained in her youth had had on her, until the doctor thought to delve a little. This sharing of stories has the potential to prompt preventative intervention, including alleviating loneliness.
The practices of paid adult social care work
Companionship and ‘being there’ are part of the support that paid ASC workers offer, and they often take on responsibilities identified by doctors or other health workers (and those in other occupations such as social work). Paid ASC workers’ skilled, complex work can include supporting people with taking medication, helping to implement dietary changes, or assisting with physio routines. Despite working conditions that are among the worst in the labour market, ASC employees identify strongly with their work, and hold attachment to it and particularly to the people they support.
Morland implants her case for care continuity within the debate on the future of GP services. However, in ASC, despite inadequate solutions to a persistent labour shortage and sustainability challenge, much of the debate focuses on numbers or sectoral or care provider concerns with recruitment and retention. This is at the expense of arguments that foreground care continuity and its benefits for supported people, and for the relationships that matter to workers and enrich the quality of their work. The negativity around ASC – the constant talk of ‘crisis’– is palpable in discussions on its future, yet set against this context of scarcity, unmet need and declining care quality and coverage, Morland offers a positive account of good care and its life-affirming qualities. Social care has the potential to offer the same on a more consistent basis, and continuity ought to be at the heart of the case for life-enhancing, sustainable care supported by a stable, valued and more appropriately rewarded workforce.
Debates continue over the ‘professionalisation’ of ASC work, yet such efforts to enhance status, valorisation and desirability are stymied by inadequate progression routes and the lack of a binding, national (in England) long-term workforce strategy. This is before we mention the endemic and normalised very low pay in ASC. Morland does not mention pay: it is axiomatic that this is a financially secure position for the doctor. Clearly there is a vertical distinction between GPs and frontline ASC workers and what their job requires, but this plays out horizontally too. For example, healthcare assistants in the NHS earn more than ASC workers, who do similar roles. The former have access to a wide range of occupational welfare (including pensions), pay banding and career progression routes, and benefit from higher levels of unionisation and collective voice. Despite ASC’s ubiquity and the growing need for it, the rewards do not encourage or incentivise staying on: increases for length of service, qualifications or promotions are often piecemeal. Health Foundation research estimates that one in five residential care workers lives in poverty.
The state and paid adult social care’s political traction
The state plays a defining role in setting working condition standards in ASC, despite the dominance of outsourced – via majority private providers – delivery of care. The cost of care, which shapes rates of pay, is largely set by local authority commissioning. The Department for Health and Social Care has responsibility for workforce development, and the Care Quality Commission has regulatory powers over care standards. Other areas of policy, such as migration, have profoundly shaped ASC services, particularly in the last decade. I would argue that the state has, in recent years, actively and directly undermined workforce – and thus care – continuity in ASC. Examples include mandating COVID-19 vaccines in ASC settings before any others, and the frequent, and largely harsh and restrictive, Health and Social Care visa reforms. The latter have culminated in the government’s May 2025 announcement that workers will no longer be able to come from abroad to take up employment in ASC. The politicised, short-term reforms to migration for ASC employment have been antithetical to stability and continuity. Paid ASC workers do stand to benefit from changes through the Employment Rights Bill, but questions remain over the viability of implementation when the government’s ASC review does not report until 2028.
Class is arguably an important factor here. A few years ago, I asked a social science professor and care expert why she thought the political leverage of social care differed from the NHS so much, and she proposed class as a crucial element. She pointed out that the NHS workforce is more middle class than working-class-dominated paid ASC work. She also said that the middle class benefits more from NHS services than from ASC. ASC is means tested, and state-funded services overwhelmingly cater for people with lower levels of income and wealth. Proposing the introduction of means testing in the NHS, for example, would be highly contentious politically. This relates to what ASC commentator Richard Humphries terms the ‘different political or moral calculus’ between the NHS and ASC. This has relevance in the context of recent industrial action: contrast the unified, collective actions across different areas of the NHS with the dispersed pockets of paid ASC worker organising, symptomatic of a fragmented workforce lacking collective voice or instrument.
Workers across health and social care have faced degradations to their pay, conditions and working environments in recent times, but the severity of cuts to ASC budgets and lack of long-term planning mean it has suffered more heavily. New pressures caused by the pandemic have exacerbated these, and Morland’s book provides an additional function as an important human document of that time alongside the likes of Stu Hennigan’s blistering Ghost Signs. ASC services continue to be the junior partner to the NHS in many senses. Many of the arguments Morland makes about care continuity in this affecting book apply in ASC settings too, and they should be at the forefront of attempts to improve ASC provision and employment. ASC suffers in terms of perceived importance relevant to healthcare, and when compared with other public and health policy priorities. We need stories about how care continuity, based on ‘accumulated knowledge’, can be life-affirming for supported people, and transformative for social care and paid ASC workers.
Duncan U. Fisher is a researcher at the ESRC Centre for Care at the University of Sheffield, UK. His research focuses on paid care work within adult social care, with his current project a study of organising, activism and trade union activity among paid care workers in England. He wrote this article about the depiction of paid care work in Ken Loach’s film Sorry We Missed You for a previous issue of Futures of Work.
Image credit: Centre for Ageing Better via Unsplash