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On May 15th 2008 I turned up at the Molineux Stadium in Wolverhampton, (home to the Wolverhampton Wanderers) to attend one of three events convened by the Integrated Care Network (ICN), part of the Care Services Improvement Partnership (CSIP), on behalf of the Dept of Health.

This was aimed at the Social Care Community and their “key partners” as the Pre-consultation phase on “Reviewing No Secrets- reviewing Safeguarding”. I had received an online invitation as Trust Clinical Lead, and hoped to learn something, never having heard of CSIP or ICN before.

The Chair for the day was Ruth Eley, CSIP National Programme Lead for Older and Disabled People. The audience was mixed and included commissioners in Social Care and Primary Care. It is possible that there might have been other Acute Trust representatives but it was discovered that I was the only doctor in the audience!

The event was opened by an introductory talk by Leo Quigley (on behalf of Lucy Bonnerjea, Dept of Health), who outlined the need for change. No Secrets had been introduced as a “revenue neutral” initiative in 2000, as a Section 7 guidance – and thus ‘almost mandatory’ for Social Services. It advised multi-agency networks to safeguard against abuse of adults. Public services needed to become more tailored to prevent and address complex needs, such as chronic health conditions, including tailoring services around the whole family. Among other drivers for this is “Putting People First”: a vision of Adult Social Services policy, developed and owned by the various partners and is expected to have made significant progress by 2011 http://self-assess.personalisation.org.uk. He emphasised the importance of leadership in the commissioning process to ensure that it was personalised, innovative and safeguarding. A review of ‘No Secrets’ would need to look at how it was working in health and criminal justice, how it affected carers and where individual budgets fitted in. Thus any successor to this would have to set out what ‘wrongs’ we want to put right, designate the seriousness of the “wrong”, provide guidance on when people need help, which groups of people would be included or excluded and determine how to measure the outcome.

Peter Hay, Strategic Director, Adults and Communities, Birmingham City Council, gave an overview of the way Birmingham tackled the ‘No Secrets’ agenda, with an emphasis on aiming for excellence not adequacy. There was a plan to use a traffic light system, independent of CSCI to grade residential/nursing homes, possibly using red if pressure sores had occurred. He welcomed the greater focus on safeguarding, hoping that it would act as a stimulus to raise their game.

Sarah Hollinshead-Bland, an Adult Protection Manager gave a practical talk on the nitty-gritty of adult protection. She alluded to the lack of legislation and especially the lack of any extra money to implement ‘No secrets’. Training, data collection and performance indicators would also help drive the agenda forward, sensibly realising that indicators would differ in different organisations e.g. Health, police, CPS etc.

The Acute Hospital viewpoint was represented by the Medical Director of Heart of England Trust, Dr Hugh Rayner, a nephrologist. He pointed out the lack of knowledge amongst the medical fraternity around this issue, the lack of readily identifiable signs and tests, the lack of evidence-based treatment, and the fact that it would not be a condition cost-effective to screen in A&E attendees. This could account for the lack of case-finding in the acute sector. However, he guessed that there might be a way of targeting the high-risk if they could be identified, especially care home residents, but this would require much more information and linkage with Primary and Social Care. He suggested Indices of Organisational Safeguarding could include HCAI, falls, tissue viability, nutritional assessments, falls, and standardised mortality rates. He followed up the issue of lack of training, questioning how this could be done in an acute hospital. Three levels of training were mooted: Basic awareness – 10,000 staff, Enhanced awareness – e.g. A&E, Elderly Care, mortuary staff and Investigative awareness – very few. There should be multi-agency learning but the challenges included who should be responsible for this training and how to cross cultural and language barriers.

Detective Sergeant Anna Freeman delivered a presentation jointly with Rose Thompson from the CPS. They touched on their roles in this field, explaining that they were keen to engage with all groups. They clarified roles: that of the police was to investigate criminal abuse, while the CPS took a prosecuting role as an offence of this nature was chargeable under their Code of Practice. This translated into few prosecutions and even less convictions. Several aspects of the current system worked well; including the Local Authority’s role in developing local policy/procedure, Strategy committees, a Partnership approach, and Multi-agency training, as well as the Role of the Adult Protection Co-ordinator and the Vulnerable Persons Officer. Criminal legislation worked well; we were reminded that this was for ill-treatment or neglect of a person lacking mental capacity (section 44 Mental Capacity Act 2005) and ill-treatment or willful neglect of a patient (section 127 Mental Health Act). Other pertinent legislation included Sections 30 - 44 Sexual Offences Act 2003, Fraud by abuse of position (Section 4 Fraud Act 2006), Causing or allowing the death of a child or vulnerable adult (Section 5 Domestic Violence, Crime and Victims Act 2004 ). Support at court for vulnerable witnesses is helped by: Code of practice for victims of crime, Section 146 Criminal Justice Act 2003, Disability Hate Crime Policy, Hate Crime Scrutiny panels and Special Measures.

The speakers felt that there were current limitations around such issues as the definition of a vulnerable adult and abuse, lack of clarity of roles, responsibilities and involvement in Partnership working and there were grey areas surrounding Human Rights Act v Duty Of Care, that delays occurred in decision making due to loss of and contamination of evidence; also that there was insufficient information exchange (third party material and impact on disclosure), and that neither Public Protection strategies nor Serious case review processes worked well. They therefore wanted to see change occurring in the following spheres. First, the inclusion of criminal abuse in the definitions of vulnerability and abuse. Secondly, they wanted clarity regarding intervention when duty of care conflicts with adults’ rights to make risky decisions. They felt that there was a need to review legislation looking at criminal neglect for adults with capacity which should be on the same statutory footing as safeguarding children, including commitment to working in partnership, a duty to share information and duty to co-operate with investigations. In addition, a review of powers of entry for the police to protect vulnerable adults, as well as national co-ordination and dissemination of recommendations from serious case review processes was required. They further wished to see effective monitoring systems for CPS and police to identify vulnerable adults who are victims of abuse.

The last session of the day was comprised of facilitated break-out group sessions. There were commissioners of Health and Social Care in my group, as well as community nurses who undertake CHC assessments. There appeared to be resentment by the Social Care community (except their leaders) around the fact that acute hospitals did not report cases of possible “mistreatment” (e.g. falls and pressure ulcers) to Social Services. Indeed, all the markers that Dr Rayner mentioned as suitable for Care Homes was raised as potential markers against hospitals - falls, HCAIs, pressure ulcers, a tissue viability service, lack of privacy and dignity, nutritional status, internal and external reporting mechanisms). Other discussions were around the lack of ear-marked budgets for adult protection work, lack of inter-agency communication, and lack of legislation in the field.

The next step will be a consultative Phase, scheduled to begin in July.

So what had I learnt? First, the change in the designation of procedures from Vulnerable Adult Protection to Safeguarding Adults. Secondly, the journey of a potential victim could progress from Health Care to Social Care (if reported) and then could progress to the Police (if reported). Nobody thought the current system was comprehensive enough and certainly not implementable without money. Perhaps this review would bring some of these, which should be positive.

There did not appear to be any representation from Mental Health at the meeting which was worrying. I was quite alarmed at the concept of institutionalised hospital abuse including falls and HCAIs, which Social Services claimed they wanted to be informed about! I felt there was a strong parallel between the Mental Capacity/ Adult Protection aspect of patient care and of continuing health care assessments in my in-patients. Most of my patients have all these issues married strongly together, each assessing group waiting for the other group’s verdict. Indeed, I can think of a recent sad patient with all of these (end-stage dementia, fractured hip, C Diff, husband unrealistic and force-feeding, aspiration pneumonia). She finally passed away in hospital after agreement for CHC funding was approved.

Please visit http:icn.csip.org.uk

Ruma Dutta
Geriatrician
Worcester

BGS Newsletter, Aug 2008
Issue 17 ISSN 1748-6343 17