Fifteen minutes per visit: what Joan Tronto’s phases of care reveal about a home-care rota

I coordinate home-care workers in Amsterdam. In practice that means I spend my mornings building a rota: who goes to which client, for how long, in what order, with how much travel time between. Mrs de Wit, shower and breakfast, thirty minutes. Mr Boukhari, medication and compression stockings, fifteen minutes. On paper the rota is care. On the street, as every worker I send out will tell you, it is something else.

For years I had no vocabulary for the gap. Care ethics, as I first met it in Nel Noddings's Caring, described the relation between the one caring and the cared-for with real beauty: engrossment, attention, the shift of motivation towards the other person's needs. But my workers already had that. What they didn't have was time, and Noddings, at least in that book, says little about who decides how much time there is.

The thinker who gave me the vocabulary was the American political theorist Joan Tronto.

Four phases, four virtues

In 1990, with Berenice Fisher, Tronto proposed a deliberately broad definition. Caring, they wrote, 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, a world that includes our bodies, our selves and our environment. It sounds almost too wide to be useful. Its point is to stop us thinking of care as only the warm thing that happens between two people in a room.

In Moral Boundaries (1993) Tronto then divided care into four phases, each with its own moral quality:

1. Caring about: noticing that a need exists. Its virtue is attentiveness.
2. Taking care of: accepting responsibility for meeting the need and deciding how. Its virtue is responsibility.
3. Care-giving: the hands-on work. Its virtue is competence.
4. Care-receiving: the response of the person cared for, which tells us whether the need was actually met. Its virtue is responsiveness.

Twenty years later, in Caring Democracy (2013), she added a fifth: caring with, the condition in which care is shared fairly across a society and people can trust that it will be there when they need it.

Reading the rota through the phases

Here is why this changed how I see my job. Look at Mr Boukhari's fifteen minutes.

Caring about happened months ago, when a district nurse noticed his legs were swelling and his daughter, who lives in Rotterdam, could not come every day. Taking care of happened in an assessment office, where someone decided what he was entitled to and translated his need into a number of minutes. Care-giving happens every morning at 8.40, when Samira arrives, puts on his stockings, checks his pills and, because she is good at her job, notices that he hasn't eaten. Care-receiving is what Mr Boukhari says, or doesn't say, while she is there.

The phases are carried out by different people, in different places, with very different amounts of power. And the moral failures in home care rarely happen in the third phase. My workers are competent. The failures happen where the second phase meets the third: when someone who will never meet Mr Boukhari decides that fifteen minutes is enough, and Samira is left to choose between his breakfast and her next client.

Tronto has a name for the position of the person in the assessment office, and of many of us further up: privileged irresponsibility. It describes the way those with more power can enjoy the benefits of care while passing its actual work, and its moral weight, to people with less. A manager can feel caring about the elderly without ever standing in a kitchen choosing between pills and toast.

Responsiveness is the forgotten phase

The phase I think about most is the fourth. A rota has no column for it. Care-receiving is where the person cared for tells us, by words or by refusal, whether we got it right. Dima Nasser has written here about care that is generous and suffocating at once, and I hear the same from clients. Mrs de Wit does not want to be showered by a stranger at 7.30 every morning; she wants to be asked. The system records her refusal as a missed visit.

Tronto's point is that a process of care without responsiveness is not merely incomplete. It is dangerous, because those who give care start to believe they know a person's needs better than the person does. That is how care turns into control.

What follows for the rest of us

None of this makes Noddings wrong. The relation between carer and cared-for is still where care is felt. But Tronto shows that this relation sits at the end of a long chain, and that justice is decided further up the chain, where the minutes are counted. That is also why Eva Kittay's demand that carers themselves be cared for, which Farhana Akter defended here recently, is a political claim and not a sentimental one.

Some organisations in the Netherlands have tried to shorten the chain. The best known, Buurtzorg, uses small self-managing teams of nurses who assess their clients and plan their own visits, so that taking care of and care-giving are done by the same people. I don't think it solves everything, and it is easier for nurses than for the lower-paid aides I coordinate. But it shows that the gap between the phases is a design choice, not a law of nature.

When I build the rota tomorrow I will still be dividing people into minutes. Tronto hasn't changed that. What she has changed is the question I ask about each block on the screen: who decided this, did they ever meet the person, and how will we hear if it is wrong?