Self-neglect and hoarding often go hand in hand—it is a complex situation and can have a negative impact on a person's health and wellbeing. Many individuals who neglect themselves have capacity, with strongly held beliefs and ideas that affect the way in which they behave and hoard items (NHS website, 2018). The condition often leaves health professionals in a dilemma, with the need to respect a person's autonomy, liberty and the right to make unwise decisions, along with the duty to protect the individual from harm.
Self-neglect is a public health issue, it impacts the health and wellbeing of the person and the wider community. It can affect relationships with family and neighbours, leaving people isolated and vulnerable to abuse. Individuals are frequently admitted to hospital with falls and infections due to cluttered and unsanitary living conditions. The admission period is often lengthy owing to the complexity of the discharge required. It is vital that, on discharge, the person is given adequate support to prevent repetitive self-neglect and hoarding behaviour. A support network needs to be established that includes health and social care professionals and other public services.
More work is required to support people who hoard possessions and neglect themselves. A review of the self-neglect category within the Care Act by the Department of Health (2014) recommended that self-neglect cases should be considered on a case-by-case basis. This adds to the dilemma of knowing how and when to intervene. Currently, very little data are collected from local authorities and healthcare services on the prevalence of individuals who self-neglect and hoard. If self-neglect is to be further understood and interventions developed, reporting needs to improve. In 2014, just over a quarter of authorities in England reported that self-neglect had featured in a serious case review (Social Care Institute for Excellence, 2014). This led to changes in practice and policy. However, existing infrastructure within health and social care services have limited provision for the treatment and support of people who self-neglect. This is compounded by the ambiguity within legislation of the definition of self-neglect and the safeguarding framework.
The complexity of the condition requires time and perseverance from health professionals. Therapeutic relationships must be established. If the individual has capacity and is unwilling to engage, the health professional has limited interventions available (Social Care Institute for Excellence, 2018). The consensus is that a holistic person-centred approach must be taken. Understanding the motives and the connection the person has with the items they collect should underpin the techniques and interventions applied. Lack of resources and local service provision often impacts on what is available. In these circumstances, the use of social prescribing and third sector services could be beneficial in creating relationships that can be maintained over a longer period. A recent review of a social prescribing service in Rotherham reported that those who accessed social prescribing services were more likely to have improved health and wellbeing outcomes and less likely to attend emergency departments (Polley et al, 2017).
Despite there being a fundamental change to the law in the safeguarding of adults with the introduction of the Care Act 2014, improvements are required. To enhance the quality of care and remove the inequality within service provision, clarity is needed within the law, with more clearly defined key words and expectations of health and social care services, especially regarding the care of individuals who have capacity. Until then, health professionals will continue to have the professional ethical dilemma of respecting a person's autonomy and liberty alongside the duty to protect them from harm.