10 June 2005
Nurses who withhold a comforting hand; schools that stop children playing outside; community hospitals that ban home-made cakes at a party. The risk-averse culture has gone far too far, argues Julia Neuberger, and it is time public servants said so
In March last year, a wonderful story appeared in the Guardian, headed: 'Q. How many care workers does it take to change a light bulb? A. Ask a risk assessor.'
This followed a Department of Health recruitment advertising campaign, which had shown a care worker reaching up to put a new bulb in for an old man. The advertisement read: 'If you could do the small things that make a big difference, you could earn a living in social care.'
Then it emerged that many care workers were not allowed to change light bulbs – not on their own, at least. One local authority said it might take four people to do it – one to hold the ladder, one to turn off the electricity at the mains, one to stay with the old person, and one to change the light bulb. This was to comply with both health and safety rules and electrical safety legislation, but it obviously leads to some considerable difficulties.
While I was working on my book, The moral state we're in, last year, I came across a plethora of similar stories. They included the community hospital in Saffron Walden, Essex, which stopped the long-established custom of monthly visits by local Women's Institute members, who would bring home-baked cakes and have a bit of a party for the frail patients. The hospital argued that it was impossible to establish the degree of cleanliness of the members' kitchens. One cannot help wondering what bureaucrat decided that removing such a small health risk (if such it was) should take precedence over an occasion obviously much appreciated by the patients.
Then there was Bury St Edmund's District Council, which was reported to have banned hanging baskets on lamp posts in case they fell and hit someone on the head – even though there was no recorded instance of this ever happening.
What about local authorities that have instructed teachers to be very careful about sending young children out to play in hot weather, in case of sunburn, and make it clear that teachers should not apply sun cream to children themselves? Quite apart from the mess involved, it beggars belief that teachers should not be allowed to carry out normal tasks designed for the child's protection.
In another case, an 11-year-old boy fell on the school football pitch and was injured. The staff on duty had been told not to put an arm round injured children – but the boy was in distress and crying for his mother. Surely a teacher should have been allowed to comfort him?
Add to that the unwillingness of many nurses to do what once they did best – to hold the hand of an elderly person and to give a bit of loving care when no medical intervention will make a ha'porth of difference, because of a fear of accusation of assault. Or being unwilling to tempt a dying person with a drink of orange juice or water in case they choke, and the nurse – or more likely, the hospital – might be sued for maltreatment. There are also cases where, because of health and safety rules, nurses cannot lift elderly people who have fallen until suitable hoists can be found.
The bureaucracy involved in 'serious untoward incidents', as they are called when things go wrong, is now so enormous that many senior nurses spend huge amounts of their time filling out forms, making a nonsense of their nursing and caring role in an increasingly risk-averse culture.
It is as if professionals have become polarised into those who do case management – including when things go wrong – and the other, more junior, staff, who do the actual caring.
None of these things is necessarily wrong in itself. But the cumulative effect of a risk-averse culture, where individual blame is so readily accorded in inquiry after inquiry, is one of a lack of the milk of human kindness. The nurse will put a line into an elderly person for drugs to be given intravenously but will not hold a hand or stroke an aching back.
We have all watched this happening, clutched at our foreheads and said that we are going the way of the US, ready to sue at the slightest opportunity. And it is clear that medical negligence cases are growing year on year. Even so, we must think differently.
Those who work in public services must let out the first howl of protest. Instead of accepting the instruction from 'on high' that children are not to be sent out to play on a rainy day in case they slip and hurt themselves, teachers and school governors should be saying that there is a risk in being a child and a risk in growing up, a risk in playing inside or outside, and that parents are going to have to accept it. Unless we start saying that loud and clear, children will live pathetic indoor lives, glued to computer or television screens and frightened of going outside. In fact, this is already happening, as the Demos/Green Alliance report, A child's place: why environment matters to children, showed last year.
So where are the public servants shouting and screaming about all this? It would be good to hear nurses, teachers, doctors, civil servants and other public servants saying that this risk aversion is ridiculous, that accountants might have done more harm than good in insisting on constant risk assessment.
What should matter is the measurement of reasonable and unreasonable risk. If unreasonable risks are taken, people – parents, patients and whoever – have every right to complain or even to sue. If people working in the public services are truly negligent, then they should pay the price. But making some mistakes in human interactions is normal. Eight out of ten is good enough – it is 80%, a high score in most other endeavours.
If public servants do not get that message across loud and clear, the consequences will be horrible. For the doctors, the nurses and the teachers who have all accepted this risk-averse culture, more or less willingly, are not bad people. They have just allowed themselves to be lulled into believing this is normal, or bludgeoned into accepting it as standard.
Yet, if they all complained in unison, they could easily bring about a change of culture. And that is what we need urgently, lest our public services fail to provide what people need: kindness, care, consideration, and skilled interventions, all done in the spirit of a duty of care for the recipient, patient, client, pupil – and less for the worker or their employing authority.
Will it happen? I do not know. At present, risk aversion takes precedence over common sense. The smallest of risks (and some are not so small) takes precedence over what we used to call kindness and care. The result is that the kindness one sees in hospitals often comes from porters and care assistants rather than from senior staff, because their relative lack of training means they have not been so heavily exposed to the risk-aversion culture.
Caring also often comes to the most vulnerable from ordinary people who have not had it frightened out of them. People with severe mental health problems can receive more kindness from the owners of the cafés where they sit for much of the day, or the staff in public libraries, than from the nurses and outreach workers who are in the best position to extend a hand.
And this is not because of ill will or lack of feeling on the part of professionals, but because the system is increasingly loath to allow them to take on any risk.
An arm around the shoulders might be thought to be common assault. An invitation to come and have a meal might be seen as some kind of sexually predatory lure.
Whether change comes will be a test of the courage of those who work in our public services and those who manage them – whether they are clear-sighted enough to see that we could do much better by avoiding risk a little less, and providing kindly support a little more.
Baroness Neuberger is the Liberal Democrat spokeswoman on health in the House of Lords. She will be speaking on 'Reforming the NHS: is the medicine working?' at the CIPFA conference on Thursday, June 16. Her book, The moral state we're in, is published by Harper Collins