Adult Social Care Glossary, v 0.6

A vulnerable customer is someone who, due to their personal circumstances, is especially susceptible to harm - particularly when a firm is not acting with appropriate levels of care.

[The FCA has an excellent guidance document available via the link.]

OFCOM have not set rigid rules for this definition, they are leaving this to Communication Providers. More information can be found at Guidance: Protecting access to emergency organisations when there is a power cut at the customer’s premises.

Any person unable to take care of themselves or protect themselves from exploitation or at higher risk of illness.

Protecting access to emergency organisations when there is a power cut at the customer’s premises: Guidance on General Condition A3.2(b)

OFCOM published the above guidance note to telecommunication providers in October 2018. It makes particular reference to "the need to protect those customers who are reliant on their landline such as those without access to a mobile or reliable indoor mobile coverage, or who are housebound or have a greater need to call emergency organisations due to their circumstances" (para 1.8) - effectively their defintion of 'vulnerable'.

OFCOM sets out the following four principles in para 1.9:

1. Providers should have at least one solution available that enables access to emergency organisations for a minimum of one hour in the event of a power outage in the premises;

2. The solution should be suitable for customers’ needs and should be offered free of charge to those who are at risk as they are dependent on their landline;

3. Providers should i) take steps to identify at risk customers and ii) engage in effective communications to ensure all customers understand the risk and eligibility criteria and can request the protection solution; and

4. Providers should have a process to ensure that customers who move to a new house or whose circumstances change in some other way are aware of the risk and protection solution available.

The full guidance is available in Annex 1 of the source document.

Investigate programme to include vulnerability flags on NHS records

A series of blogs about words that make me go hmmm would not be complete (and it is far from complete!) without a post focusing on ‘the v word’.

While it’s by no means a new term in the world of social work and social care, during the COVID-19 pandemic the word ‘vulnerable’ has been used ubiquitously – and I know I’m far from alone in feeling very uncomfortable about how the label continues to be used.

To explain more, here are ten reasons why ‘vulnerable’ makes me go hmmm…

1. It’s meaningless

When we refer to ‘vulnerable people’, most of the time we don’t explain who we mean, why we’re suggesting people are vulnerable, or what they’re vulnerable to. It’s a nebulous term used to label individuals and groups, and as such it’s pretty meaningless.

Last summer, then Health and Social Care Secretary Matt Hancock said that “from the earliest days of this crisis, we recognise that people in social care were uniquely vulnerable.”[1] Putting aside the exasperating reference to ‘in social care’, what does that phrase ‘uniquely vulnerable’ in the context of the pandemic actually mean?

A quick Google search reveals that the following people and places have all been described as ‘uniquely vulnerable’ to COVID-19:

People living in urban slums.
Women and girls.
Los Angeles.
Rural communities.
Refugees and asylum seekers.
The US economy.
Farm workers.
Small businesses.
Hammersmith.
Disabled people.
9/11 heroes.
People living with schizophrenia.
People experiencing homelessness.
Black Americans.
Windsor.
Pregnant women.
Support staff in schools.
People in prisons.
Babies.
The US.

2. It’s othering

The vulnerable label distances and divides.

Vulnerable people. Vulnerable families. Vulnerable communities.

Carers and the cared for. Protectors and the protected. Heroes and the vulnerable.

Them and us.

We may not be explicit in who we mean when we apply the label – but we don’t mean ‘us’. We’re talking about different, separate, others.

Those who are vulnerable.

Frequently we combine the term with additional labels to further distance: ‘vulnerable service users’, ‘vulnerable clients’, ‘vulnerable customers’, ‘vulnerable cases’.

Often, it’s used alongside or interchangeably with other objectifying labels like ‘the disabled’ or ‘the elderly’.

This categorisation means any sense of individuality and personhood is lost as people are grouped together and classified as ‘the vulnerable’.

3. It’s dehumanising

As this small selection of recent headlines demonstrates, not only do we ‘other’ people through our use of the term vulnerable, we also dehumanise them.

It seems copy editors in particular have taken to dropping any sense of humanity. So now we don’t even refer to vulnerable people, or vulnerable groups – just ‘vulnerable’.

4. It’s possessive

“The measures we have taken during this pandemic have always been to protect our most vulnerable.” [Department of Health and Social Care [2]]

Often, we add the possessive ‘our’ alongside the vulnerable label, extending the protective, paternalistic power dynamic and further legitimising decisions made about people, not by or with them.

Our vulnerable service users. Our vulnerable customers. Our vulnerable residents.

We’re in charge. We know best.

5. It’s excluding

Our welfare system is based on demonstrating sufficient vulnerability to qualify for help. Our services are for ‘the vulnerable’. We care for ‘our most vulnerable’. If you don’t tick the right boxes, you’re either not vulnerable enough – or the wrong kind of vulnerable – to be eligible.

How many people are we failing by not recognising and responding to their vulnerability?

How many people are we excluding?

6. It’s stigmatising

Weak. Feeble. Frail. Fragile. Ailing. Weedy. Doddery. Sickly. Helpless.

These are all synonyms for the term vulnerable – a term so frequently applied to social care ‘service users’. A blanket term that defines individuals and groups – eliciting assumptions and judgements, and stifling conversations, curiosity, choice.

Not only does this stereotype people who draw on social care, but it also stereotypes social care workers and social care in general as ‘looking after vulnerable people’ or ‘caring for the vulnerable’ – rather than a broader definition encompassing good lives, human rights and social justice.

Vulnerable has become a term with negative connotations, a label to distance yourself from. And yet as human beings we are all vulnerable. Being open and honest about our vulnerabilities allows us to connect with each other as equal human beings. To build trusted relationships. To let people in to see who we really are, not what we’re pretending to be.

Not only does our use of the term vulnerable stigmatise people, it also stigmatises vulnerability.

7. It’s paternalistic

“Our social care workforce has shown such courage in the last year caring for our most vulnerable during one of the most challenging periods many will ever experience.” [Department of Health and Social Care [3]

When we label individuals or groups as vulnerable, we’re removing any sense of agency from people. The term suggests helplessness and it promotes and perpetuates a protective approach, which further removes choice and control from people.

During the pandemic, the government and media have repeatedly referred to ‘protecting the vulnerable’. Local authorities describe their role in ‘caring for vulnerable residents’. Social workers “support and protect some of society’s most deprived and vulnerable people” [4]. Social care workers ‘care for our most vulnerable’. Unpaid carers ‘look after vulnerable relatives’. Voluntary and community organisations justify their existence and behaviour as ‘helping vulnerable people’.

Use of the term legitimises and even celebrates ‘doing to’ – illustrated during the pandemic with the focus on the ‘brave heroes’ who have ‘looked after’, ‘protected’ and ‘cared for’ ‘the vulnerable’.

8. It’s blaming

“The broad definition of a ‘vulnerable adult’ referred to in the 1997 Consultation Paper Who decides?, issued by the Lord Chancellor’s Department, is a person: “who is or may be in need of community care services by reason of mental or other disability, age or illness; and who is or may be unable to take care of him or herself, or unable to protect him or herself against significant harm or exploitation.” [Department of Health and Social Care [5]]

Despite the Care Act 2014 shift in terminology away from ‘vulnerable adult’ to ‘adult at risk’, this definition – or similar – is still very prevalent in our policies, papers and practice.

Vulnerable adults are ‘unable to take care of themselves’ and ‘unable to protect themselves from abuse’. Adults are vulnerable due to age, disability, or mental health problems.

Vulnerability is inherent, due to individual characteristics.

Broken people. Broken families. Broken communities. Broken lives.

Replacing the term with ‘adults at risk’ was a deliberate attempt to move away from this blaming narrative. To acknowledge that people are not intrinsically vulnerable, that we are all vulnerable at times, and that vulnerability is the result of external factors. Situations and circumstances. Politics and policies and prejudice and power dynamics.

We haven’t moved far.

The deficit-based, medical model is alive and kicking.

By labelling people as vulnerable, we’re suggesting there’s something wrong with them. We’re blaming people rather than recognising the external factors that make people vulnerable.

We’re not only failing to see people as unique individuals with pasts and futures, gifts and goals – human beings with human rights – we’re also failing to acknowledge or attempt to change the situations or circumstances that create vulnerability.

And during the pandemic, there’s been a distinct undercurrent of blaming ‘the vulnerable’.

“Boris Johnson speaks of ‘heavy heart’ as Christmas is sacrificed to protect the vulnerable” [Daily Telegraph headline [6]]

9. It’s dangerous

The vulnerable label is dangerous.

It suggests difference. Them, not us. Others. Those.

Its blanket use suggests individuals and groups are not quite so human. Not quite so visible. Not quite so valuable.

Its blanket use leads to blanket responses.

Who do we not save?

“Medically, very difficult decisions will need to be made, about who will get treatment and who will not… When these decisions are made not on the basis of medical judgement, but rather on the basis of ingrained, discriminatory attitudes about whose life has more value, that is when we have a societal problem” [Sanchita Hosali [7]]

Our use of the term also suggests an inevitability to abuse or to death, precluding too many questions, too much scrutiny.

“When a vulnerable person is murdered, or abused, or dies from Covid in a care home or avoidably in hospital because of the failure of medical professionals, the term already implies that it was at least in part because it was harder to protect them”. [Neil Crowther [8]]
“I’m sure we will see a high mortality rate in care homes sadly because this is a very vulnerable group.” [Chris Whitty [9]]

Herd immunity.
The Clinical Frailty Scale.
Blanket do not resuscitate orders.
Hospital discharge guidance.
Delays in testing.
Lack of adequate personal protective equipment.
Staff shortages / agency staff working across multiple sites / lack of sick pay.
Visiting restrictions.
Congregate living.
A very vulnerable group.

10. It makes people more vulnerable

“the national focus on ‘vulnerability’ and the ‘needs’ of people has created a division in which the skills and strengths of millions of people are overlooked in a way that also puts their mental health and wellbeing at risk”. [Community Catalysts [10]]

For all the reasons outlined above, I firmly believe that labelling people as vulnerable makes people more vulnerable.

It’s othering and dehumanising. Possessive and paternalistic. Excluding and stigmatising. Blaming and dangerous.

We are all vulnerable in different – and similar – ways. Our vulnerability makes us human but does not – and should not – define us. The blanket labelling of people as vulnerable erodes individual identity, removes choice, limits independence and legitimises doing to, not with. It also turns our attention away from addressing the attitudes and practices and policies and institutions that create and perpetuate vulnerability.

So, what term should we use instead?

I’m not suggesting that we stop talking about vulnerability. Far from it. But what I am calling for is an end to the discriminating and patronising use of the term. That we stop the lazy, blanket application without reason or context.

“If I put you in a room with a lion, you would be vulnerable.” [Anna Severwright [11]]

Changing our language and removing the vulnerable label is not about denying vulnerability. It’s about challenging the decisions and actions that enforce and reinforce vulnerability.

It’s about acknowledging our common humanity and celebrating our diversity.

It’s about shifting the narrative from ‘them and us’, to all of us.

“The opposite of othering is not “saming”, it is belonging. And belonging does not insist that we are all the same. It means we recognise and celebrate our differences, in a society where “we the people” includes all the people.” [john a powell [12]]

References

[1] Health and Social Care Secretary’s statement on coronavirus (COVID-19): 8 June 2020, Department of Health and Social Care, 9 June 2020

[2] More restrictions eased for care homes, Press release, Department of Health and Social Care, 10 May 2021

[3] New award to recognise exceptional practice in adult social care workforce, Press release, Department of Health and Social Care, 19 May 2021

[4] Developing your career – Social work, The Open University

[5] No secrets, Department of Health and Social Care, 20 March 2000

[6] Boris Johnson speaks of ‘heavy heart’ as Christmas is sacrificed to protect the vulnerable, Daily Telegraph, 19 December 2020

[7] The fight against Covid-19: Whose life counts? Sanchita Hosali, The British Institute of Human Rights, 2 April 2020

[8] A ‘larger us’ or ‘them and us’, Neil Crowther, Community Catalysts

[9] Coronavirus will affect everyday life for ‘really quite a long time’ Professor Whitty says, ITV News, 22 April 2020

[10] Valuable and vulnerable, Community Catalysts

[11] Opinion: we are so much more, Anna Severwright, Community Catalysts

[12] Us vs them: the sinister techniques of ‘Othering’ – and how to avoid them, john a Powell, The Guardian, 8 November 2017