Safeguarding Adults and the
NHS
Sylvia Manson
Introduction – Review of
No Secrets
• Our society is redefining how we enable
adults to be safe from harm and abuse.
• No Secrets is being reviewed to provide a
framework and principles that can guide
local practice
• The NHS have a key role in safeguarding
adults
Inquests,
Inquiries and
research
Specific Guidance
No Secrets
Consultation
No Secrets 2
Legislation
and case law
Safeguarding Adults Principles
Government
Policy
Safeguarding Adults Vision
Drivers for Change
Primary Driver 1- Government
Policy
•Strengthened regulatory role
• Shift power from state to local
communities and individuals
•Break down barriers between
Health and Social Care
• Big Society – greater
involvement of voluntary
agencies and communities;
•Increased collaboration across
statutory and 3rd sector
•Maximise autonomy - limited
state intervention
•Decisions closer to people –
GP consortia
•Accountability to patients
•Quality of care - Patient Safety
•Democratic legitimacy
• Quality Innovation Prevention
& Productivity
•Informed choice & control
‘no decision about me without
•Outcome focused
me’
AFFORDABILITY
Primary Driver 2 - Legislative
Framework
Existing Legislation
• Human Rights Act 1998
• Mental Capacity Act 2005 amended 2007
• NHS & Community Care Act 1990
• Health and Social Care Act 2008 – regulation;
direct payments
• Equalities Act 2010
• Domestic Violence Crimes and Victims Act 2004
• SVG Act
• ……… and the rest!
• Law Commission Review – April 2011
• Social Care Bill – Autumn 2011
Case Law
•
Limitations of Local Authority duty and authority
- to investigate, act where person lacks capacity, support, guide, inform and
involve police where necessary Justice Hedley: Re Z (Local Authority: Duty (2004) EWHC 2817 (Fam).
- to support not to control…. Court authority required before any attempt to
control, coerce Justice Munby -A & C [2010] EWHC 978 (Fam)
•
Best Interest and Risk Enablement
- sensible risk appraisal not striving to avoid all risk….. in particular to
achieve the vital good of the elderly or vulnerable persons happiness. What
good is making someone safer if it merely makes them miserable?’ Justice
Munby MM (An Adult) (2007) EWHC 2003 (Fam), (2009)
•
Use of Inherent Jurisdiction for those with Capacity
- Capacitated persons ability and free choice to make decisions and give
true consent may be impaired if under constraint, coersion, undue influence.
Court may be asked to intervene but jurisdiction will be used sparingly and
only to enable the person to make decisions without the external pressures
Re SA (2005) EWHC 2942 (Fam)(Case related to forced marriage) – Justice Munby
(JE 2009 unreported)
Primary Driver 3 – No
Secrets Consultation
People experiencing safeguarding
reported
• They got lost in the system
• Safeguarding should not be at
the cost of other qualities of life
• Wanted to be listened to & and
to make choices
• They are not children
General
•
•
Prevention – pro active
safeguarding system
Balance protection and levels of
intervention – enable people to
take considered risk.
The NHS
• Struggling to engage with
safeguarding – seen as the LA
responsibility
• Failure to recognise
safeguarding concerns arise in
NHS care
• Need to create culture of
openness and learning
• Need for leadership and
accountability
• Need to integrate clinical
governance and safeguarding
Primary Driver 4 – Learning from
Inquests, Inquiries & Research
•
•
•
•
Steven Hoskins 2006- failures in identifying vulnerability & risk indicators; partnerships –
information sharing; eligibility criteria; assessment of decision making capacity;
Fiona Pilkington 2007 – failures in identifying vulnerability & risk indicators; failure to share
information and refer on
Margaret Panting 2001 – self determination balanced with duty of care
•
•
Mid Staffordshire – failures to focus on quality; failure to listen to patients; need for early
warning systems; role of commissioners and regulators - failure to use intelligent information
Death by Indifference – institutional discrimination led to deaths
Cornwall Partnership NHS Trust 2006 inadequate arrangements to protect vulnerable adults;
staff largely unaware of what constituted abuse.
Shipman Inquiry 2004; Kerr & Haslam 2005
Etc Etc
•
•
•
•
•
AEA Prevalence Study 2007
Womens Aid – Making the Links: Disabled Women and Domestic Violence 2008
Domestic Abuse in older women; University of Sheffield ( Autumn 2010)
CSCI/HCC research – restrictive care; institutional abuse
Demographic Change – National Office Statistics
•
•
Distilling the Primary Drivers
For Individuals
• Choice and control
• Enablement
• Full and informed consent
• Representation and making best interests decision for those lacking
capacity.
• Least intrusive means
For Services and Systems
• Focus on prevention
• Limited intervention - proportionality
• Partnerships and cooperation
• Greater community involvement
• Managing across plurality of providers and under new commissioning systems
• Accountability for quality of services – to public , commissioners and regulators
• Systems need to be affordable
We want people to be safe from harm
and exploitation, and in control of
their own lives
Consent +
patient led
outcome
Representation
for those
lacking capacity
Prevention
Safeguarding
Principles
Engagement
and
Accountability
Proportionality
& least intrusion
Cooperation
between
agencies
Safeguarding Adults
Pathways
FAMILY LIFE AND COMMUNITIES
SAFEGUARDING PATHWAY
SERVICES SAFEGUARDING PATHWAY
Prevention
•safer communities strategies
• user enablement and empowerment
• ‘stay safe’ initiatives
•Personalised care plans -risk enablement plans
etc.
•Vigilant neighbourhoods
• ‘Big society’ – safeguarding as everyone’s
business
Prevention
•commissioning for quality
• monitoring and early intervention
•Integrated clinical governance systems
• service planning - health and wellbeing
partnerships
•supporting self funders and Personal Budget
holders as commissioners
•People and communities hold services to account
Responses
• Person defined outcome, consent,
representation
•Proportionality
•Levels of response – advice; mediation; single
agency; multi agency; statutory interventions etc
Responses
• Person defined outcome – for decisions affecting
the person
•Duty to address service failures and protect
others
•Proportionality of response – role of
commissioners and regulators; internal or
independent investigation
Restoration
•for individual – e.g. counselling; justice
• for source of harm e.g. support to a carer
Restoration
•for individual
• service improvement
What does this mean for
the NHS?
• The NHS have a key role to play in their
own services -preventing harm
occurring and responding effectively
where harm occurs
• The NHS also have a key role in
supporting adults at risk within their own
communities and within other services.
Safeguarding is Integral
to Quality & Outcomes
Clinical
Effectiveness
Patient
safety
Dignity in Care
Safeguarding
Policy areas –
Prevention
Patient
Experience
E.G Dementia
Strategy
6 Lives
Carers strategy
Safeguarding as a
continuum
Safeguarding
Procedures
Early
Intervention
Prevention
Addressing Safeguarding –
prevention and early
intervention
Patient empowerment
• Build resilience factors – personal, social, environmental
• Maximise decision making
• Minimise the impact of disability/condition – Aids; adaptations;
assistive technology; relapse prevention planning
• Person centred planning - risk enablement ; ‘Stay safe’ personal
plans
• Effective communication - Information , choices
• Promote advance planning – LPA; Advance decisions; statements of
preference
• Access to complaints
• Patient involvement in service /strategic planning & review
Addressing Safeguarding –
prevention and early
intervention
Care and Environment
• Identify patients at greater risk of harm - e.g. assistance to eat and
drink; pressure care; communication needs; enhanced discharge
planning; privacy & dignity; consent; advocacy requirements?
• How is use of restriction and restraint governed?
• How are carers identified – carers assessments and support plans?
• What are your organisations critical points of care? – e.g. Pressure
ulcers; medication; discharge; capacity and capability of staff;
managing challenging patient behaviours;
• Which wards/services present highest risk?
• How is clinical governance informing preventative/early intervention?
• How do commissioners know that quality care is being delivered?
• Strategic partnerships – Wellbeing and Health; Safer Communities
Addressing
Safeguarding Concerns
in Community Pathway
• What is the patient’s desired outcome and how can they be
supported to achieve this?
• Does the patient have capacity to make decisions about their
safeguarding? – Maximise involvement; representation
• Who else may be at risk of harm?
• Who needs to be involved?
 Relationship with the patient
 Clinical/ specialist skills & knowledge required
 Roles & responsibilities required for investigation; risk
assessment; support/protection plan & review
 Single agency or multi agency?
• How do we know we have improved the outcome for the patient?
Addressing
Safeguarding Concerns
in Services
•
•
•
•
•
How are concerns identified and managed ?
How are complaints and incidents integrated within safeguarding?
How are decisions made about when to refer?
How do you work with local multi agency safeguarding partners?
Cooperation
Accountability
Proportionality
How are decisions made within your interagency procedures about
internal or independent investigation? What’s the role of
commissioners and regulators in this?
• How is the patient supported throughout?
• How do we know we have improved the outcome for the patient?
• How do we know lessons learned have improved outcomes?
Clinical Governance &
Safeguarding
Serious case
review - IMRs
Serious
Incident reporting &
investigation
Clinical
incident –e.g.
near miss
Safeguarding
Procedures
Preventative
/Early
Intervention
Safeguarding
Making it Happen
Leadership and Workforce
Strategic
Leadership
• Connecting strategic
agendas
• Driving strategic
partnerships
Operational
Leadership
• Specialist advisors
• Designated managers
• Practitioners –
investigations/protection
plans/reviews
Wider
workforce
• Awareness
• Responsibility and
accountability
Making it Happen Assurance & Accountability
Public, Patients &
Partners
•
•
•
•
•
Patient experience
LSAB reporting
Quality accounts
LINkS/HealthWatch
Overview & Scrutiny
Organisational
Governance
• Assurance framework
• Clinical governance and
safeguarding
Assurance for
Commissioners
and Regulatory
Bodies
• Safeguarding across
commissioning cycle
• Proportionate responses
• CQC regulations
Safeguarding
Outcomes
Safeguarding is the business of the NHS