Social care has the wrong view of risk – to the detriment of learning disabled people

This is one of three articles supplied by the Adult Principal Social Workers Network for National Mental Capacity Act Action Day, on 15 March. 

By Chris Hatton

The five principles of the Mental Capacity Act 2005 should be a crucial legal bulwark against services that deny people the right to be authors of their own lives in the name of protecting them. So why are people with learning disabilities so often prevented from making the unwise decisions that most people take for granted?

I believe part of the answer to this question is in how social care thinks about risk, particularly as manifested in risk assessments. Whether risk is thought of as a bad thing to be avoided, or a positive thing to be supported, social care tends to view risk as being about a ‘vulnerable’ individual wanting to leave a place of safety to go ‘out’ and do something, which might result in something bad happening to them in the pretty immediate future.

The challenge from public health

A public health view of risk, and what we know about the health and wellbeing of people with learning disabilities, challenges each one of these elements of a social care view of risk.

1. First, risks to the health, safety and wellbeing of people with learning disabilities are not solely the property of people being ‘vulnerable’. What looks risky in one place might not be risky in another place, and people cannot be expected to carry the burden of being ‘safe’ when it is the environment that is the problem. If a person is living in a neighbourhood where they are being subjected to hate crime when they are out locally, should that person be expected to be ‘safe’ by never leaving their house?
2. Second, there is no ‘place of safety’ from which ‘risk’ occurs. We know that staying at home all day, never going out, and doing nothing are massive risk factors for poor physical health (for example obesity, diabetes and heart problems) and mental health (for example depression and anxiety). This is just as much the case for people with learning disabilities as it is for anyone else. We also know that ‘closed’ social care services that are not open to the outside world are more likely to be places where neglect and abuse occur.
3. Third, the ‘protection’ claimed by risk assessments does not protect people. The major causes of death for people with learning disabilities are not the result of external agents encountered when ‘outside’ – they are the same major causes of death, in the main, as everyone else. According to the Confidential Inquiry into Premature Deaths of People with Learning Disabilities, the major underlying causes of death for people with learning disabilities were heart & circulatory disorders (22% of deaths), cancer (20%), respiratory disorders (including choking, 16%), and the nervous system (including epilepsy, 16%). Deaths from external causes, the perennial spectre raised by risk assessments, only accounted for 4% of deaths. Doing nothing in a ‘risk free’ lifestyle actually increases the risks of these major causes of death happening.
4. Finally, social care notions of risk only focus on the very short term (what might happen on this trip?). Quite apart from the bureaucratically stifling impact of always having to complete a risk assessment whenever a person wants to go out and do anything, this short-term focus ignores the long-term risks to a person’s health and wellbeing. These long-term risks, vastly increased by staying in and doing nothing, are never part of the risk assessment equation.

The public health evidence strongly supports the encouragement of those ‘unwise decisions’ that are a fundamental part of the Mental Capacity Act. Indeed, they should be a vital component of any strategy designed to increase the self-determination, physical activity and social connectedness necessary for a long, fulfilling and healthy life.

Chris Hatton is professor of psychology, health and social care at Lancaster University and also works at the Public Health England Learning Disabilities Observatory