Postscript

Summary

The Welfare Workforce is a thought-provoking exploration of mental health care in the United States and beyond. Although all the affluent democracies pursued deinstitutionalization, some failed to provide adequate services, while others overcame challenges of stigma and limited resources and successfully expanded care. Isabel M. Perera examines the role of the “welfare workforce” in providing social services to those who cannot demand them. Drawing on extensive research in four countries – the United States, France, Norway, and Sweden – Perera sheds light on postindustrial politics and the critical part played by those who work for the welfare state. A must-read for anyone interested in mental health care, social services, and the politics of welfare, The Welfare Workforce challenges conventional wisdom and offers new insights into the complex factors that contribute to the success or failure of mental health care systems. This title is also available as Open Access on Cambridge Core.

Scholars and policy-makers interested in exploring and applying the insights of this book to current events should be mindful of the evolving definition of the “welfare workforce.” Throughout this book, I have defined public sector workers as those who are directly employed by national or local governments and depend on government funds for most of their wages. That definition is suitable for the policy area and time period of interest.

A highly polarized medical specialty, mental health care faces a sharp public/private divide. Its clients are either unable to afford costly long-term treatments (and thus rely on public generosity) or sufficiently moneyed to cover the substantial out-of-pocket health and social care costs associated with mental illness. Psychiatric workers tend to serve one clientele or the other, thereby depending on government funds for their wages either heavily or hardly at all. Moreover, the distinction between public and private mental health workers was especially clear during the period of psychiatric deinstitutionalization; the large-scale delegation of social welfare services to private and not-for-profit actors was not yet underway. This trend, though now a common feature of mature welfare states, developed only in the late 20th and early 21st centuries. By then, the mental health transformation had begun, with a discernible role for government employees.

The boundaries between public and private welfare are becoming ever less clear, especially in policy areas where clients are less vulnerable. Over the past several decades, governments have introduced a variety of market-based mechanisms into public services (Gingrich 2011), delegated social protection to private actors (Hackett 2020; Mettler 2011; Morgan and Campbell 2011; Mori 2020), and financialized provision through private instruments (Naczyk 2013; Thurston 2018; van der Zwan 2014). In fact, just as welfare services have become more comprehensive, so too has their reliance on decentralized authority and privatization (Bode 2017). Moreover, the distinction between income transfers and in-kind services is blurring; beneficiaries often use pensions, tax credits, and vouchers for health, education, and childcare services (Martinelli 2017). The result is an entangled web of overlapping public and private jurisdictions that complicates the identities of welfare workers.

In fact, labor market dualization is occurring not just between the welfare workforce and other occupational groups but also within the welfare workforce itself (Hermann and Flecker 2015; Mori 2020). Protected, stable public sector employment benefits some welfare workers, in particular high-skilled professionals in interpersonal professions, such as health and education (see Oesch 2006). At the same time, newer, and frequently outsourced, services often lack these protections. The care sector is a case in point (Martinelli et al. 2017). The increasing demand for child and elderly care has expanded non-state provision of these services, which are often provided by low-skilled, immigrant women (especially where labor market regulations, wages, and unionization rates are lower, see Morgan 2005). Although public subsidies may support these services, the employees delivering them do not always benefit from the same protections and pay available to other welfare workers.

Consider for example how contemporary bargaining regimes governing nonprofit or contracted social service work may influence policy in ways different from those governing public sector work (e.g., Finger and Lastra‐Anadón 2021; Salamon 1995). Subsequent scholarship might examine how these different bargaining regimes shape the content of social services, as well as how effects may differ by level of government or by policy area.¹ What is more, the scope of bargaining or the availability of alternative levers could allow workers to influence policy in ways that go beyond pay and into other areas, such as gender equity and safe staffing (Bach and Bordogna 2019).

Updated definitions of public sector work, then, should consider a variety of context-specific questions. For example, are the relevant employees subject to public or private labor law? To that end, is the legal status of charitable, not-for-profit, or third sector providers distinct? How do welfare workers interact with other labor market institutions, such as vocational training or collective bargaining? Are the relevant licensing and entrance procedures unique to the public service, or are they transferable to the private sector? Furthermore, to what extent is the role of the state visible to these workers? Indeed, social policy may be “hidden” from welfare workers in the same way that it can be “hidden” from recipients (see Howard 1997; Mettler 2005; Morgan and Campbell 2011). How governments license, finance, and contract social services, then, could shape how scholars classify their employees.