Risky Business?

Julia Neuberger became a rabbi in 1977 and served the
South London Liberal Synagogue for 12 years. She has chaired Camden
and Islington Community Health Services NHS Trust and was chief
executive of the King’s Fund. She is a Liberal Democrat member of
the House of Lords. Her new book The Moral State We’re In, is
published by Harper Collins.

So how many care workers does it take to change a light bulb? While
writing about care for vulnerable people and the role of care
professionals, I was struck by the risk-averse behaviour that is
increasingly the norm.

A Department of Health advertisement last year read: “If you could
do the small things that make a big difference, you could earn a
living in social care.” Yet despite the accompanying photograph
showing a care worker reaching up to replace a bulb, it turned out
many local authorities were forbidding staff to do this on their
own. Indeed, you needed one person to replace the bulb, one to hold
the ladder, one to switch off the power – on the basis that many
older people live in houses where the wiring is old and possibly
faulty, and a fourth to comfort the older person.

This is an extreme example. But you only have to look at the
behaviour of many health and social care professionals in the field
of mental health to realise it is no joke. We are increasingly
living in a fear-driven system. Although a declining proportion of
homicides are committed by people with a history of mental health
problems – the number of homicides is rising but the numbers
committed by people with mental health problems has stayed constant
for 20 years – the fear of the “mad axeman” has acquired greater
potency. So those who work in mental health are inclined to err on
the side of caution, particularly as professionals are rarely
criticised for keeping people against their will in a psychiatric

Risk assessment is an uncertain business, and we can never get it
completely right. Yet cases where a homicide has been committed by
someone with a known history of mental health problems often
involve a mistake in letting them go or in failing to keep in touch
with them, rather than a discussion about the level of risk they
pose to themselves or to others. Services have often been
understaffed and unable to recruit, with the remaining staff
carrying impossible case loads.

Equally, those whose diagnosis is not a mental illness but
so-called dangerous and severe personality disorder (DSPD), which
most psychiatrists in the UK argue is untreatable, cannot at
present be detained. The government wants to legislate to allow
people with DSPD to be detained for public protection, despite the
difficulty of predicting who will kill, and the likelihood that
hundreds will be detained against their will in order to save even
one life.

But that’s the point. So risk-averse have we become that government
does not see this removal of liberty from vulnerable people as a
problem. To their credit, almost every mental health charity is
critical of the idea, as is the Royal College of Psychiatrists and
almost all social services organisations. And, most importantly,
the joint scrutiny committee of the Houses of Commons and Lords,
chaired by Lord Carlile, has also criticised this proposal

But why did government believe it was acceptable in the first
place? Is it that we are growing more and more afraid?
Evidence from child protection suggests that we are. There are
fears about children going out in case of attack by a paedophile, a
kidnapper or a terrorist. Despite evidence that they are more
likely to be attacked sexually in their own homes, children fear
the outside world. And so, increasingly do the rest of us,
especially older people who see media reports of muggings and
attacks on themselves as posing a threat, even though all the
evidence shows that the most likely victims of violent crime are
young men.

Indeed, fear among older people, combined with their growing
numbers, will pose a problem in the future. People are increasingly
averse to “one size fits all” services. The days of the day centre
are numbered, and baby boomers will want to pick and mix from a
variety of classes, meals and health interventions. But real choice
is expensive.

Demographic trends suggest that by 2050, four times as many older
people as now will need services. What will this mean in a
risk-averse, expensive and increasingly distrusted social services

Will it be about giving older people a bit of money – tax credits,
perhaps – and getting them, however vulnerable they are, to buy
their own services? Will older people trust their care workers when
they pay for them personally? Under such a regime, social care
professionals would become enablers and inspectors of the quality
of care.

Or will it mean increasing the regulation and bureaucracy we see
now, with rules about the sizes of rooms in which people live ever
more common, but far too little attention given to the quality of
care? A bit of dirt and a cat might be preferable for many older
people to pristine, but soulless, conditions.

Will we still largely depend on untrained, often poorly motivated
and badly paid care assistants, many of whom do a good job
nevertheless? Or will we, in an ageing society, be unable to find
enough care assistants, and so rely increasingly on the “younger
old” to take care of the truly dependent? Unless immigration is
increased considerably, the latter option is much more likely.
Older people will need to form co-operatives for care provision,
running small businesses into their seventies, as full retirement
becomes too expensive.

Whatever we provide, we will be paying more for it. But at the same
time we could change the way we care for older people in hospital,
encouraging more in the way of tender loving care, and less in the
way of expensive and invasive interventions. It cannot be right for
some older people to find themselves in intensive care, being
artificially fed, because health professionals fear being sued by
angry relatives if they do not do everything in their power to keep
people alive. Many older people would prefer to be allowed to die
with dignity, in a hospice or at home, rather than in

We will have to think hard about whether quality of life and
quality of care mean keeping older people alive in all
circumstances, or whether for some people death with dignity, with
less invasive care, might not be preferable. This is not
euthanasia. I hope we never go down the path that says older people
are a burden, and once they have outlived their usefulness should
be put to death. But unless we understand that our welfare state
was founded on utilitarian principles, to keep the population fit
for work at a time when most people died not long after retirement,
we will never be able to rethink its values for an age when we live
increasingly long lives. And we need to do so urgently, given
changes in life expectancy.

Thus far, our levels of kindness and care, whether provided by
professionals or neighbours, have all too frequently been
inadequate. We will have to change, because there will be no other
way of providing care for the vulnerable.

Social care professionals are erring on the side of
caution with risk assessments as we live in an increasingly
fear-driven system; this is particularly the case for mental health
workers. So risk-averse have we become that the government does not
see removing vulnerable people’s liberty as a problem. This article
highlights the problem and the effect it may have on older people’s
services as demographics change.

Contact the author
Julia Neuberger can be contacted at

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