Family vs professional care - part 1: the considerations

In the immediate period following an accident, the starting point for many families is to look after the injured person themselves for as long is necessary. That sounds great, and I always respect and admire the strength and depth of family feeling in these difficult circumstances. On close examination though, this approach may eventually create problems. First, it is often the family which expresses that view, possibly without asking the injured person. Alternatively, sometimes neither the family nor the injured person have been able to face the difficulties hidden in the future, and the injured person perhaps has not wanted to tell the family, who have done so much to look after him or her, that he wants his independence. Also, because most severely injured people are young, there is a tendency for them to rely on their parents.

Unfortunately, it is likely that the parents will die before the injured person, and therefore the care package may disintegrate, possibly at a time when it is needed most.

What I suggest therefore is that families should keep open minds. Knowledgeable experts and lawyers will all agree that there is an increased burden on family carers, and the time may come when they can no longer manage, either because of stress caused by the burden of care, or simply due to the effect of increasing age.

The reasons for stress are many, but it is obvious that it must be very distressing to see loved ones struggling against adversity. They may be trying to regain what they have lost, and become frustrated and depressed at their limitations. Also, they may be losing their friends and their job; no longer able to pursue sports and hobbies; and perceiving the limits of recovery and achievement. Coupled to those problems, there may be great changes in the character and personality of the injured person, particularly following brain injury.

The difficulty is that, if you assume that family care will always be available, you will recover only the value of that care (traditionally assumed to be three quarters of the cost of professional care). If, after compensation has been awarded, the claimant then loses his family carers, and needs commercial care, he will not have recovered the necessary cost of such care. Families are often reluctant to do this. However, with understanding and sympathetic explanation, families often come to see the advantage of using outside help. That is the job of the lawyers - to appreciate the problems, and to guide the claimant and his family round them in a way which suits them best, both now and in the future.

One possibility is for the family to employ family members as carers. This can be done directly, or through an agency, and it can work well. However, a recent case demonstrates both the failure and success which may be caused by the hope that the family are the best people to care. A young girl injured at birth developed gradually, despite the initial optimism of her parents, to the stage where she was difficult to manage, with quite a temper. Her parents thought that an aunt would be a suitable carer, and so they employed her directly. Sadly, the aunt took advantage of what she doubtless thought was an easy job, and in the end she fell out with the girl's mother. Undaunted, the parents then decided to employ the mother's mother, but did so through an agency; the agency employed the mother as a permanent member of their staff, and the parents employed her through the agency.

Employing carers directly is always worth considering. They need not be members of the family, but could be friends or neighbours, strangers who have been recruited to the job in the ordinary way or agency carers who have proved suitable over a period of time. In the latter case, it may be necessary to pay the agency a specific fee for taking one of their carers, but that is likely to be worthwhile if the carer in question has proven himself or herself suitable for the job over a sufficiently long time.

Whilst on the subject of agencies, it is worth noting that they are all different; the level of their experience is very varied, and one has to be careful to look behind the advertising claims, to see the substance of their service. For example, it may be worth enquiring how many carers are on their books, how they recruit, how they select, what training they give their carer's, whether they run refresher training, and whether they have carers with specific experience of the disability and handicap in question. The theory behind the use of an agency is that the family does not have to worry so much about the daily arrangement of care; if a carer is sick, the agency should find another suitable one; if one becomes unsuitable, or simply leaves, then again it is the agency's responsibility to replace him or her. If it works well, that is an excellent system.

Unfortunately, families sometimes find that they have as much difficulty with the agency as they do with the carers. In the end it seems to be a process of trial and error, and families have to struggle through all sorts of difficulties before they find a solution which suits their needs.

The starting point of our discussions is usually that the family is looking after the injured person. I regard that as natural, and what I have said above is not intended to detract from the notion that, following severe injury, it is safe, secure and comforting to return to the bosom of the family. I would never try to persuade families that family care is inappropriate; what I usually ask them to do is to consider the difficulties which may be involved. For example, the husband or wife of the injured person may have given up work to become carer, as may the parents if the injured person is young. That may mean additional deprivation, both of the job itself and the money earned. Other children may become, or feel, neglected because all attention is being lavished on the injured person. Depending on how long after the accident I am seeing the family, my worries will either seem unfounded (if it is soon after) or realistic (if some time has passed).

The basic principle is that professionals must respect the views and wishes of the family. The difficulty which pervades this aspect of a claim is that families only come to a considered position after much experience and, often, heart-searching. Because I am fortunate enough to be consulted early in many cases, I have the opportunity to see families on several occasions spread over months or years. My general experience is that families do gradually come to the view that professional care is necessary, to some extent. There are very few families who, in the end, reject all outside care. I am not surprised if there has been a complete change of approach between one visit and another; when I ask why, I am told that the stresses have built up to an intolerable level. That has caused a gradual realisation that the injured person will not recover completely, and so the task which the family took on at the outset is not short term, as they hoped, but is a lifetime commitment.

When I explore this potential difficulty early on, I never expect final decisions or concluded views. The principles are so important, and the ramifications so great, that I always ask families to give this careful and lengthy consideration.