We live in frightening times. A world economy based on cheap oil is beginning to feel the pinch of diminishing supplies. Unprecedented affluence in the richer nations looks ever more obscene against the backdrop of widespread poverty, disease and environmental degradation in the less developed world. In the UK, one of the richest nations of all, the gap between rich and poor shows no signs of narrowing, and a government hell-bent on encouraging competition and economic growth shows little interest in communal values. Our expectations of an ever rising standard of living may very soon turn out to be unsustainable. And when the chips are down, and cuts have to be made, where will they fall the heaviest? Not on the well-heeled, but on the poor, the disadvantaged, the marginalised and the vulnerable.
Julia Neuberger does not share such a gloomy view of the future, but implicitly bases her ‘manifesto’ on the optimistic assumptions that the economy will continue to grow and that resources will be diverted towards improving the lot of the less fortunate. She focuses on five such groups: the elderly, the mentally ill, the young and vulnerable, prisoners, and asylum seekers. In each case she details the abuses to which they have been and still are being subjected, quoting numerous sources and especially a seemingly endless stream of government and other officially sponsored reports, often repetitive in their recommendations yet rarely leading to radical action.
There is plenty of harrowing material here, from the treatment of the elderly in understaffed nursing homes, the shocking stories of child abuse with which we have all become familiar, the dire state of many of our psychiatric units and the continuing stigma of mental illness, and the overcrowding and squalour of our bursting prisons, to the heartless treatment and near-criminalisation of those who come to seek asylum.
Those who work in primary care will be familiar with much of this, but by bringing it together the author reminds us of some common themes. She perceives a diminution of kindness, and a stifling of compassion by a blanket of bureaucracy and risk assessment. She notes the low value that we put on our thousands of care workers, who are underpaid, undertrained, and without a proper career structure. She explores our predilection for imprisonment, unmatched by any concerted attempts at rehabilitation of offenders. And she reminds us that racism, ageism, and prejudices of all sorts are rampant among both individuals and institutions. Along the way she discusses a number of ethical issues such as euthanasia and advanced directives; the rights of adopted and other ‘looked-after’ children; and the conflict between protecting the public and defending the freedom of people with severe personality disorder.
For all its unflinching approach and wealth of examples, I found this book something of a disappointment. The conclusions and suggestions that end each chapter are generally uncontroversial, often vague, and sometimes downright platitudinous. On prisons, for example, she says:
‘It's not rocket science, just common sense. Get ex-offenders out there working. Get employers to take them on. Get prison officers to use their skills in talking to prisoners and supporting them. Get visits from families made easier. Don't move young offenders around too much. Give them a chance of education.’
Who could argue with that? But I'm tempted to respond, ‘Get real.’ Without a wholesale change in government policy, a new social consensus, and a massive growth in the prisons budget, it just isn't going to happen.
Of course there are more concrete proposals, and Julia Neuberger's long experience as Chief Executive of the King's Fund and as Chair of Camden and Islington Community Health Services stands her in good stead when it comes to observations on mental health. For instance, her account of changing the environments of mental health units by ‘thinking differently about space, light and art’, is impressive. Similarly, her plea for cared-for young people to be offered continuing, structured help beyond school-leaving age is well made.
The absence of an overarching thesis is underlined by the way the book ends suddenly with the concluding paragraph on asylum seekers. With no closing reflections, one is left feeling exhausted and a little cheated. Having waded through a litany of distress, abuse and failure, we could do with some help in making some sense of it all.
Rabbi Neuberger has produced a book that will feed her readers' indignation, but will not arm them with detailed plans for action, still less send them to the barricades. Few of the solutions on offer are achievable without a major redistribution of resources, and where is the political will for this? And if the will is lacking now, at a time when resources are plentiful, what can we hope for when times get hard?
- © British Journal of General Practice, 2005.