Mapping and review of self-neglect policies and procedures from safeguarding adults boards in England

Abstract

Purpose

Local Safeguarding Adults Board (SAB) policies, procedures, guidance and related documents on self-neglect were gathered and analysed, to map what approaches are being taken across England. This paper aims to identify areas of divergence to highlight innovations or challenges faced by SABs.

Design/methodology/approach

Self-neglect documents were identified by searching SAB websites. Data were extracted into a framework enabling synthesis and comparison between documents.

Findings

This paper reports on how English SAB documentation defines self-neglect, treats executive capacity, lays out pathways for self-neglect cases, advises on refusal of service input and multi-agency coordination and draws on theories or tools. Greater coherence in understanding self-neglect has developed since it was brought within safeguarding in 2014; however, variation remains regarding scope, referral pathways and threshold criteria.

Research limitations/implications

This review was limited to published SAB documentation at one point in time and could not consider either the wider context of safeguarding guidance and training or implementation in practice.

Practical implications

This review provides an overview of how SABs are interpreting national guidance and guiding practitioners. The trends and areas of uncertainty identified offer a resource for informed research and policy-making.

Originality/value

To the best of the author’s knowledge, this is the first systematic survey of SAB self-neglect policies, procedures and guidance since self-neglect was included under safeguarding.

Citation

Orr, D. (2023), "Mapping and review of self-neglect policies and procedures from safeguarding adults boards in England", The Journal of Adult Protection, Vol. 25 No. 2, pp. 51-66. https://doi.org/10.1108/JAP-11-2022-0027

Introduction

Self-neglect refers to lack of self-care which can adversely affect the person’s own health, hygiene or domestic surroundings (DHSC, 2022). However, this definition does not in itself make clear at what threshold behaviour should be considered self-neglect or cause support services to become involved. While in the USA self-neglect has long been part of adult protection services’ mandate, Braye et al.’s (2011, p. 43) review found that self-neglect rarely featured in the policies and procedures of English safeguarding adults boards (SABs), the bodies responsible for strategic oversight of adult safeguarding in their locality. SABs have not only a statutory membership of health, social care and the police, but also non-statutory representation from several other partner agencies.

Prior to the Care Act 2014, adult safeguarding in England focused on abuse and neglect by third parties. Widespread concern that this remit left self-neglect without clear pathways or service prioritisation led to self-neglect being brought under the umbrella of adult safeguarding by the Care and Support Statutory Guidance (DH, 2014) accompanying the Care Act. SABs, whose strategic role is to coordinate and ensure the effectiveness of what each of its members does to safeguard adults [1], responded by developing policies and procedures to cover the new mandate. However, no comprehensive review of SAB documentation has yet been undertaken to update Braye et al.’s earlier findings.

Scholarly commentary on safeguarding policy generally focuses at the national level, such as the Care Act and statutory guidance. Nevertheless, it is valuable to consider, too, the intermediate-level policies that mediate between national guidance and the “street-level bureaucracy” (Lipsky, 1980) where practitioners operate. SABs are charged with interpreting higher-level policy and negotiating how it might best be implemented by their partner organisations in their local contexts. Policy around abuse and neglect aims to address a contested social problem, which may contain ambiguities or elicit disagreement between stakeholders (Manthorpe and Stevens, 2015). Self-neglect is perhaps one of the most uncertain areas of safeguarding (Howard et al., 2022; Owen et al., 2022). Not only can it be difficult to achieve consensus on how to recognise and respond to it, but self-neglect can bring into play tensions between respecting self-determination and the right to private life on the one hand, and the duty to prevent foreseeable harm on the other (Braye et al., 2017). Examining the documentation published by SABs for areas of both consensus and inconsistencies provides evidence highlighting where areas of particular difficulty lie and indicates what approaches different SABs have taken to try to resolve them.

The purpose of this article is therefore to survey the field of SAB self-neglect documentation in England. I survey the range of definitions and categorisations offered by SABs to guide practitioners in their work and consider what approaches have been devised to assist effective practice. Particular attention is paid to matters where SABs appear to differ, to provide an evidence-base, rooted in empirical policy analysis, for what aspects of self-neglect have proven most challenging for managers and practitioners to think through and address.

Methods

The total number of SABs in England has varied in recent years because of mergers. Current SABs were identified from the data returns supplied to NHS Digital (2021), with six more identified from websites. In total, 133 publicly available SAB websites were searched, over nine months between October 2021 and June 2022, for documentation specifically focusing on self-neglect.

Where SABs themselves did not have a specific self-neglect policy document, one or more organisations in the locality (e.g. Local Authority Adult Social Care) sometimes did; however, only SAB documents were included in this review. Anything found by searching other potentially relevant organisations’ websites for their own agency documents would not be directly comparable to SAB documents, which have an explicit multi-agency focus.

Once identified, data was extracted from the documents into a grid using a pre-established framework. Following framework analysis principles (Gale et al., 2013), this was derived deductively from issues identified in the research literature and Safeguarding Adults Reviews (SARs) as challenges for SABs and practitioners. Its category headings correspond to those used to structure the findings section in this article. The entries for each category were then read, reviewed and – where it was possible to categorise data according to the number of times a specific definition was used or whether a specific issue was explained, mentioned in passing or not mentioned – classified into frequency counts. All entries were also read inductively to identify shared approaches or distinctive content, which are described under each heading.

Caution is warranted regarding the precise details of the analysis, as some SABs provide guidance on information sharing principles, multi-agency working and related topics within more generic safeguarding guidance, rather than within the self-neglect documents reviewed here. Similarly, documents focusing only on hoarding were not included in the review, as their scope is narrower than self-neglect. A further complication is that some SABs share policies across a group of two or more, for example, the 4LSAB Multi-Agency Guidance (Southampton, Hampshire, Isle of Wight, Portsmouth) or the Pan-Sussex guidelines (East Sussex, West Sussex, Brighton and Hove). Statistical frequencies could therefore be counted either by the number of distinctive documents or by the number of SABs committed to each document. I have found that there is variation between the documents posted on SAB websites even when they nominally share a policy, so for purposes of this review the individual SABs have been counted. The descriptive statistics should therefore be treated only as indicative figures, as multiple SABs may fall under the same master document.

Results

No specific documents on self-neglect could be found on the websites of 48 SABs (23 of which came under the Pan-London safeguarding policies and procedures). In total, 22 SAB websites made available a guidance document, whereas 15 had a policy document, 7 had a procedures document and 14 had a single joint policy and procedures document. Twenty-seven other SABs posted documents titled with various combinations of the aforementioned and/or descriptions such as Toolkit, Framework, Learning Support Document, Briefing, Strategy, Protocol and Advice. In practice, much content is shared across these different categories and the differences between them are limited.

The length of the documents ranged from 6 to 80 pages. SARs frequently recommend expanded policies, although the reviews themselves show that practitioners are often unaware of existing policies (Preston-Shoot, 2016). SABs often seek a balance between comprehensive coverage and concision that enables busy practitioners to familiarise themselves with the guidance. Most documents fall within the 26–50 page range.

Year of publication

The documents reviewed varied in recency. The oldest (n = 3) dated from 2016. A small number (n = 3) had undergone redrafting or revisions as recently as 2022, the year in which the search was undertaken. The date of most recent substantial revision was not clear on the documents posted by 14 SABs (Table 1).

Overall, 58.1% of documents had been revised in the three years preceding the start of, or during, the search, suggesting that nearly two-thirds of SABs are actively keeping their documentation under regular review to reflect new learning or guidance. A small proportion may now have become dated. More have been revised since searching was done, reinforcing that this review can only be a snapshot of a constantly changing landscape.

Definition of self-neglect

Owen et al. (2022) note the challenge posed to policy, practice and research by inconsistency and vagueness in definitions of self-neglect (Table 2). The definitions used across the documents reviewed were not uniform. They drew principally on the following definitions of self-neglect, sometimes alone and sometimes in combination:

• Care and Support Statutory Guidance: “covers a wide range of behaviour neglecting to care for one’s personal hygiene, health or surroundings and includes behaviour such as hoarding” (DH, 2014).

• Braye et al. (2011): three main elements, which may present together or singly lack of self-care, lack of care of one’s environment and refusal of services that could alleviate these issues [2].

• Gibbons (2006, p. 16): “the inability (intentional or non-intentional) to maintain a culturally accepted standard of self-care with the potential for serious consequences for the wellbeing of the self-neglecters and perhaps even to their community.”

The policy definition provided in the Statutory Guidance unsurprisingly dominates, frequently complemented by definitions used by Braye et al. (2011) and Gibbons (2006). Often Gibbons’ definition in particular is used to flag up that the boundaries and nature of self-neglect are contested. More surprisingly, since statutory guidance sets the legal expectations, eight documents use definitions that do not explicitly reference the statutory guidance.

Fifteen documents made use of “other” definitions alongside the Statutory Guidance one. These mostly expanded on the types of situation or conditions that might constitute self-neglect as a way of fleshing out the Care and Support Guidance, or made reference to “Diogenes Syndrome”, a medical presentation observed among older adults by Clarke et al. in the mid-1970s (Martineau, 2021). Oldham and Stockport SABs, meanwhile, unusually described self-neglect as “abuse of self”, apparently subsuming neglect within abuse.

Occasionally there were inaccuracies; for example, in discussing hoarding, Bexley SAB (2018, p. 6) claimed that “the main difference between a hoarder and a collector is that hoarders have strong emotional attachments to their objects which are well in excess of their real value.” However, collectors, too, frequently have strong attachments to their collections in excess of what others would consider to be their value; the key differences relate rather to the extent of clutter and disorder and result in distress or impairment (Nordsletten and Mataix-Cols, 2012). The broad definitions in the statutory guidance risk inaccuracies creeping in as boards seek to clarify in their documentation.

To address the breadth of these definitions, several SABs made use of bullet-point lists of what are variously termed “signs of self-neglect”, “concerns regarding self-neglect”, “indicators” or “characteristics” to assist practitioners to identify what behaviours or observations might lead them to inquire into possible self-neglect. The shortest list had six items; the longest list had 23 items. The items in these lists range from common (e.g. neglect of personal hygiene, malnutrition, vermin) to more idiosyncratic indicators such as:

• “portraying alternative lifestyles which some may perceive or judge to be eccentric behaviour” (Kirklees SAB);

• “poor hair care” (Cornwall and Isles of Scilly SAB);

• “service refusal of podiatry” (Salford SAB); and

• “we agreed to expand definition of self-neglect to include unwise ‘choices’ made by a young adult who had been sexually exploited as a child” (Stockport SAB).

On the face of it, the first two set a worryingly low threshold for self-neglect concerns, though in practice they are doubtless treated in the context of other signs on the list by professionals. The last, too, could be controversial: while it prompts greater awareness of the long-term effects of trauma and may therefore lead to more responsive safeguarding efforts, the language of unwise “choices” – even if “choices” is put in scare quotes to imply how constrained those choices may in fact be – brings a potentially very broad range of decisions under scrutiny. The latter two items by Salford and Stockport SABs featured in SARs in their areas which highlighted these themes (Preston-Shoot, 2020a; Stuart-Angus, 2021). Constituent elements of self-neglect are clearly evolving according to local histories of practice, outcomes and learning.

Policies setting out the overall scope of self-neglect may easily diverge and cause confusion. Braye et al.’s (2011, p. 7) review identified debate in US policy and literature about whether “self-neglect” should cover both inability and unwillingness to self-care. It appears that this remains contested within definitions in the contemporary English context. Hertfordshire SAB’s (2022, p 5) Policy and Guidance notes that:

It is important to remember that self-neglect is not about someone being unable to care for themselves. […] Self-neglect is when someone is unwilling, for a number of reasons, to care for themselves.

However, others, such as Manchester Safeguarding Partnership (2019, p. 4) and Northamptonshire SAB (2020, p. 4), explicitly allow that self-neglect encompasses both inability and unwillingness.

Staffordshire & Stoke-on-Trent SAB’s Self-Neglect Flow Chart – though not the West Midlands Self-Neglect Best Practice Policy to which they are signed up – declares that “If someone is found to be lacking mental capacity to make decisions regarding their lifestyle/environmental conditions, they cannot be deemed to be self-neglecting.” This criterion, like Hertfordshire’s, seems to suggest that self-neglect is primarily about unwillingness to self-care rather than inability (which lack of capacity might indicate). It is not found in definitions from other SABs. It remains unclear to what extent such differences in definitions between SABs cause confusion in practice or affect the reliability of data on self-neglect such as that compiled annually by NHS Digital; however, their effect is likely to be significant.

Executive capacity

Executive capacity refers to the ability to recognise the present need for, and initiate, actions to put a decision into practice. Impairments of executive cognitive functioning may interfere with this, although the individual remains fully capable of reasoning through the decision in the abstract. Executive capacity has been implicated in self-neglect in some SARs (Preston-Shoot, 2020b) and its importance for thorough assessment highlighted (Braye et al., 2011; Cooper and Preston-Shoot, 2022, p. 16). In spite of this, it was not referred to in 47.1% (n = 40) of the self-neglect documents (Table 3).

Chester & Cheshire West SAB (2020, p. 3) advised that “All assessments of capacity must include both a consideration of both decisional and executive capacity”, the only SAB to make executive capacity a universal expectation in mental capacity act assessments. More proportionately, however, 34 SAB documents addressed executive capacity and gave some form of explanation and/or references. Bracknell SAB’s discussion, for example, provided links to up-to-date advice and research. Wigan and Suffolk SABs discuss executive capacity and present a table of screening questions showing how different self-neglect presentations might be explored practically [3], by ensuring that the person can demonstrate their ability as well as articulate their intention. Some documents contained good explanations of the nature of executive capacity, but were less clear on how to assess it.

Seven SABs explicitly mentioned executive capacity, but arguably without providing sufficient explanation. An example is the Halton’s (2020, p. 13) Self-Neglect and Hoarding Procedure, which explained executive capacity as “the process of putting that decision into effect alone or by delegating another person but someone who does not, for whatever reason, execute what they have decided or agreed cannot be considered to lack capacity for that reason” (sic). Others noted executive capacity being the ability to carry out decisions, but said no more about why or how it is an issue. Birmingham SAB (2021, p. 20) noted that Braye et al. (2011) identify “the difference between capacity to make a decision (decisional capacity) and capacity to actually carry out the decision (executive capacity),” but went on to state, “However, this distinction does not currently exist in policy or guidance [4].” They then stated that it is “good practice to consider or assess whether the person has the capacity to act on a decision that they have made (executive capacity),” but the guidance itself lacked advice on how to do so. Bristol Safe Partnership’s Multi-Agency Guidance, meanwhile, identified that practitioners may need to give consideration to executive functioning when engaging with someone who self-neglects, but then proposed general advice on assessing capacity which, in focusing on relationship-building, clear communication and engagement, is best practice generally but would be unlikely to address executive capacity directly. Although there is mention of the “show me” approach elsewhere in the document, this is not linked to the discussion of executive difficulties so it is not explicitly made clear why this might be needed.

Four SABs did not explicitly refer to “executive capacity”, but implied aspects of it. This could be very effective; for example, Barnsley SAB’s Multi-Agency Self-Neglect and Hoarding Policy and Procedure does not use the term “executive capacity” in its main discussion (p. 11), but through its discussion of why people may sometimes “talk the talk, but not walk the walk” makes the issues perhaps clearer than the jargon of executive capacity often does.

Intersection with other forms of safeguarding

Some guidance or policies explicitly distinguished self-neglect from self-harm, but the intersection of self-neglect with safeguarding from other forms of abuse or neglect was often not addressed. Forty-four SABs did not discuss this intersection. Thirty-four SABs highlighted the possibility that adult self-neglect might affect children as a matter for referral to child safeguarding. Fourteen SABs addressed the possibility that self-neglect itself could be an indicator of other kinds of abuse. These figures add up to more than the total number of documents reviewed, as some considered both child and adult abuse/neglect.

The Keeping Bristol Safe Partnership (2021, p. 6) is a good example of one SAB that highlighted how “adults who self-neglect may be vulnerable to other forms of abuse, exploitation, victimisation, bullying and radicalisation” and that self-neglect may be a coping response to abuse. Bristol’s Multi-Agency Self-Neglect Guidance suggested that a contextual safeguarding approach would be valuable in recognising and addressing these connections, though with limited discussion of what this would mean in the context of adult safeguarding (cf. Firmin, 2020). Others such as Bournemouth, Christchurch & Poole SAB (2016, p. 4) addressed the intersection by declaring that self-neglect would not usually occasion the use of safeguarding procedures in response unless somebody were supporting or colluding with the self-neglect; in other words, in Bournemouth self-neglect is to be dealt with using other pathways unless a third-party is involved in neglect or abuse of the person.

Care Act Duties: Section 9 or Section 42?

The Care Act 2014 sets out two routes through which self-neglect might be addressed. Under Section 9, where it appears to the local authority that an adult may have needs for care and support, they must assess whether this is so and what those needs are. Under Section 42, where an adult has care and support needs, is experiencing or at risk of abuse or neglect, and as a result of their needs is unable to protect themselves from the abuse or neglect, the local authority must make, or cause to be made, enquiries to inform a decision on what safeguarding action should be taken. The two approaches are not mutually exclusive: an initial response under s. 42 may result in a s. 9 needs assessment if this appears more proportionate (LGA/ADASS, 2019).

When self-neglect is best addressed under s. 9 and when under s. 42 has occasioned considerable discussion. Several SARs have criticised practitioners for not initiating safeguarding enquiries under section 42 readily enough (Preston-Shoot, 2020b, p. 138). The national Care and Support Statutory Guidance on this subject states:

It should be noted that self-neglect may not prompt a section 42 enquiry. An assessment will be made on a case by case basis. A decision on whether a response is required under safeguarding will depend on the adult’s ability to protect themselves by controlling their own behaviour. There may come a point when they are no longer able to do this, without external support. (DHSC, 2022, 14.17)

In total, 28 SABs quoted the Care and Support Statutory Guidance without further commentary, whereas 15 did not mention this question at all. Forty-two entered into further discussion. That applying this guidance is not straightforward is indicated by the phrasing used by some of the latter: “Care Act guidance (DH, 2016) merely states […]” (Lewisham SAB, n.d., para. 3.1) and “[We] are interpreting this statement to mean […]” (Oxfordshire SAB, 2017, p. 5; Calderdale SAB, 2018, p. 7). However, a consensus has emerged in some documents that safeguarding should be considered when someone experiencing self-neglect is declining support but continues to present a high risk either to themselves or to others.

Other SAB documents included a presumption, of varying strength, against section 42 inquiries being appropriate for self-neglect:

• “In summary [s. 42] is most likely to apply where it is considered that the person is being seriously harmed or likely to be because of the actions or inactions of others. This would include situations where, for example, a carer was responsible for the self-neglect or hoarding” (Bournemouth, Christchurch & Poole SAB, 2016, p. 12). In other words, s. 42 is for neglect or abuse, rather than for self-neglect.

• “In Lambeth, the starting point will be that an adult safeguarding enquiry is usually not the best response to a first incident or concern about self-neglect or hoarding” (Lambeth SAB, 2020, p. 5), though the case may progress to safeguarding if the person does not accept support.

• “It is felt [VARM (Vulnerable Adults Risk Management)], which focuses on co-ordinating a multi-agency response to risk, and with the focus on engagement with the person at risk, is likely to be a more effective approach than using the ‘usual’ safeguarding process for self-neglect, given there is no abuse by a third party in these cases” (Leicestershire & Rutland SAB, 2021).

• “In Lancashire, the LSAB has agreed that in most cases it would not be a proportionate response to raise a section 42 enquiry for people who self-neglect (including hoarding)” (Lancashire SAB, 2019, p. 3).

Other SABs were more open to use of s. 42 for self-neglect. Bath and North-East Somerset SAB highlighted that it is the responsibility of the Local Authority Adult Safeguarding and Quality Assurance Team to assess whether s. 42 would be a proportionate response to the risk indicators. For Devon SAP (2020, p. 7), s. 42 may be followed where the safeguarding adult worker is of the view that it would be “the most effective way of addressing the issues.” Surrey SAB (2018, para. 5.1) took a particular nuanced approach, starting from the default that s. 42 is unlikely to be the best response, but specifying in detail a set of considerations around risk and capacity which could indicate that safeguarding would nevertheless be appropriate; this supports flexibility and critical reflection in the professional response.

How to respond to refusal of service input

As indicated by the inclusion of service refusal as a frequent criterion for referral to safeguarding, capacitated refusal of support by people experiencing self-neglect presents practitioners with a dilemma. SAB documents varied in the extent to which they addressed refusal. Thirty-four offered advice to professionals on how to respond in this situation, which ranged from merely recommending that all steps taken should be recorded to more detailed suggestions, including ensuring that the adult knows how to obtain future help, keeping the case open, or suggesting ways to ask that might maximise the chances of engagement. Rochdale SAB (2021, p. 30) provides a useful table of pathways for practitioners to follow where adults are refusing services, depending on whether they have capacity, lack capacity or capacity is uncertain/fluctuating. Birmingham’s Self-Neglect and Hoarding Multi-Agency Guidance and Procedure is a distinctive example of how SABs might take a person-centred approach to discussing refusal. It pointed out that refusal may be because the help offered does not meet the person’s needs adequately, linked to guidance on responding to non-engagement with concerned curiosity and highlighted the importance of exploring how far choices are indeed “chosen” with a trauma-informed perspective rather than an unquestioning acceptance of an individual’s assurances that they do not need support.

Though not providing advice on responding to refusal, 19 documents reminded practitioners that assessment may be undertaken without the person’s consent if justified by the risks. The Care Act requires this if the adult is experiencing, or at risk of, abuse or neglect (s. 11(2)(b)). Whether self-neglect is considered in policies to fall within safeguarding can therefore be significant.

Thirty-one SAB documents did not explicitly discuss how to respond to service refusal. Only one document explicitly reminded professionals that carers have a right to assessment in their own right, even if the person to whom they offer care refuses assessment and/or support (Care Act, s. 10).

Guidance on multi-agency coordination

The predominant self-neglect pathway in SAB documentation has three levels of response depending on levels of risk. A few documents presented examples of self-neglect indicators that might signal each risk level and suggested corresponding referrals or actions, to inform practitioner thinking (Lambeth SAB, 2020, pp. 15–16); others left this to practitioners’ interpretation. Where risks are low, practitioners are commonly encouraged to signpost or provide usual agency responses; at moderate levels of risk, multi-agency working is recommended; at high levels of risk, the expectation is that practitioners will refer into safeguarding or to a suitable panel. These included a High Risk Panel, Self-Neglect Multi-agency Panel, Vulnerable Persons Panel, Vulnerable Adult Risk Management meeting, Complex Adult Risk Management (CARM) processes, Team Around the Individual Panel, Adults at Risk Group, Multi-Agency Risk Assessment Conference, Risk Escalation Panel or Creative Solutions Forum. SAB documents lacked discussion of expectations of the panel itself following referral; Haringey SAB was an exception in commenting on the panel terms of reference, whereas Chester & Cheshire West SAB set out matters for the panel to consider. Most such panels are not specific to self-neglect, so more detail on whether the names indicate important differences may be available in other policies than the self-neglect documentation.

Thresholds and criteria for panel referral are of key relevance, with some documentation setting out stringent criteria. Manchester SAB set out a 23-point checklist for practitioners to confirm that all alternatives have been tried before referring to the High Risk Panel. North Lincolnshire SAB, like some others, noted that panel referral should be considered “only in exceptional circumstances”. Northamptonshire SAB (2020, p. 8) requires that any practitioner making a referral to the Adult Risk Management meeting should be in no doubt that the person experiencing self-neglect has mental capacity to make the decision causing concern and should “provide proof” of this. This echoes definitions noted above where having mental capacity is central to self-neglect and is probably an effective form of demand management. However, frequent SAR findings on poor understanding of mental capacity in practice (Preston-Shoot, 2019) raise the possibility that this expectation of demonstrable certainty might discourage some practitioners from making referrals for situations where determining capacity seems not entirely straightforward.

Most SAB documents express commitment to the principle of multi-agency collaborative working, though not all discuss how this can best be achieved. Worcestershire SAB (2022, p. 2) expressed it well with the notion of a “‘no wrong door’ approach, whereby every contact is seen as an opportunity for intervention and all agencies work with the person rather than referring them elsewhere. Many documents set out brief pen-pictures of the key roles in self-neglect of the various agencies that might be involved in cases and/or lists of organisations that practitioners should consider involving. Some recognised the challenges of multi-agency collaboration, not least in arriving at common perceptions of self-neglect, and emphasised that shared assessment tools can help ensure a shared understanding. The Clutter Image Rating Scale (CIRS) for hoarding appeared frequently in appendices; Milton Keynes also provided a Self-Neglect and Hoarding Assessment and Support Tool for broader use.

Practical challenges to collaboration were often proactively addressed. Advice on information sharing between organisations was frequently provided, commonly by setting out the Caldicott principles. Bexley SAB (2018, p. 15) is a rare example of going further, by applying principles in the form of a decision-making aid on when to share information in the absence of consent from the subject.

Norfolk SAB’s concept of regular Early Help Hubs was distinctive; practitioners can present a case to get input and make connections with other agencies which they might not have been aware of. The Strategy and Guidance Document stated that referrals may be brought at Level 2 and upwards on the CIRS, a relatively low threshold. In theory at least, these hubs provide a structure which takes some of the burden off individual practitioners to make multi-agency arrangements.

A common finding in SARs is that it was unclear who was the lead agency or care coordinator (Preston-Shoot, 2021). Though most documents leave this to the discretion of the agencies involved, for example, the agency that “is best placed to lead […] and is currently involved” (Lancashire SAB, 2019, p. 7), four SABs helpfully set out explicit criteria for determining which of the practitioners involved may be best suited to taking on the lead coordinator role (e.g. BNES SAB, 2017, p. 14; Wakefield SAB, n.d., pp. 9–10). Cornwall SAB and Doncaster SAB imply that the lead organisation will usually be the local authority or mental health, leaving it to the multi-agency team to justify divergence from this approach. Another approach taken (e.g. by Suffolk SAB) is to advise practitioners to consult with their Self-Neglect and Hoarding High Risk Panel if unsure who should be the lead agency.

Only 20 SABs provided guidance on the conduct and aims of multi-agency self-neglect meetings. Levels of detail varied but could include expected timelines, non-exhaustive lists of potentially relevant agencies to invite, specifying the aims of the meeting, a template for the meeting agenda and advice on how to chair effectively. This proactively addresses concerns that less experienced practitioners may be daunted by the prospect of leading such a meeting and supports focused planning and might usefully be reproduced by others.

Many SABs emphasised that there should be no unilateral case closure. Eighteen went further in specifying a dispute escalation process when there is disagreement between agencies on how to proceed. The form this takes can vary. Some (e.g. Hertfordshire) recommended dispute escalation within practitioners’ respective agencies; Lancashire, by contrast, set out a clear three-stage escalation process for disagreements. Most SABs envisage escalation to the High Risk Panel or its equivalent, as the best-placed arbiter of difficult-to-settle disputes. Dispute resolution processes of this kind respond to SAR recommendations (Redbridge SAB, 2018) and could potentially head off premature closure or foot-dragging by individual agencies; future research might usefully explore whether and how they are used. Wakefield SAB (n.d., p. 15) went furthest in highlighting the matter’s significance by stating explicitly that a safeguarding enquiry into neglect may result where professionals “do not engage with multi-agency planning” or “seek to terminate their engagement prematurely.”

Theories and tools

As self-neglect can be diverse, contested and ill-defined (Mason and Evans, 2020), this review was interested in whether any particular theoretical basis underpinned SAB guidance and might provide a shared framework for practitioners. It considered, too, whether tools were presented to further shared practice and understandings. Some elements could be found in many documents, including guides to relevant legislation, the Making Safeguarding Personal (MSP) principles and the CIRS. Some adapted content from RiP (n.d.) training, largely based on a relationship-based model, and some posted the self-neglect toolkit developed by Barnett (n.d.) alongside their documentation. There was less frequent content too, identified under the following sub-themes.

Risk, Strengths and Professional Curiosity: While all SAB documents pointed out the person’s right to take risks and broadly promoted the MSP principles, fewer explicitly dealt with risk in more detail. Stockport SAB’s Multi-Agency Strategy was notable in explicitly discussing positive risk-taking and risk enablement. Leeds SAB and Manchester SAB overtly focused on the strengths based approach, aiming to discourage a risk-dominated perspective on safeguarding. Interestingly, Leeds’ self-neglect policy was the only one that focused attention on public input in the formulation of the policy, regularly referring to Leeds Citizens’ views; experts by experience representation may have occurred in developing other SABs’ documents but if so, this was not made clear. Manchester Safeguarding Partnership’s Strengths-Based and Impact on Wellbeing Approach informed its Self-Neglect Strategy and Toolkit, which included questions exploring what the strengths based approach is and means in the context of MSP. Wiltshire SAB’s Self-Neglect Multi-Agency Guidance went beyond recommending “professional curiosity” in inquiring more closely into risk, by including a table clearly setting out what it involves in practice. These SABs, by integrating exploration of these concepts and approaches directly into their strategy and guidance documents, attempted to give them greater effect.

Change Frameworks: The solution-focused approach was occasionally incorporated. Kent & Medway SAB (2019), for example, presented a nine-page meeting agenda template explicitly theorised as solution-focused in its design. Gateshead SAB suggested use of the “miracle question” (DeJong and Berg, 1998) – “If a miracle occurred overnight and things were different, what would you see, hear, smell, feel, be doing?” – when assessing people experiencing self-neglect, a characteristic solution-focused technique designed to get people to look beyond the problem towards how things could be different. Prochaska and DiClemente’s (1982) cycle of change was applied to self-neglect by North of Tyne, Teesside and Worcestershire SABs. As information is lacking about local training or wider use of these approaches, it is uncertain how prepared many practitioners would be to make use of them, but again they show the frameworks being used by some SABs to try to shape self-neglect practice.

Practical Guidance: Some SABs included distinctive practice aids beyond the content already covered. These included: guidance on specific steps to follow when exiting the self-neglect framework, which helped guard against premature or unilateral closure; explicit checklists to help determine threshold criteria for concerns (Buckinghamshire SAB); a Threshold of Needs Risk Matrix featuring a bespoke self-neglect section (Oxfordshire SAB); examples of the questions one might use to ask sensitively about self-neglect or hoarding concerns and a 15-point decision tree to support use of the referral pathway for self-neglect (Chester & Cheshire West SAB); and a self-neglect intervention plan template (North Somerset SAB). A few SABs proposed assessment tools: the HOMES (Health/Obstacles/Mental Health/Endangerment/Structure & Safety) Self-Neglect Hoarding Risk Assessment and the Checklist for Person-Centred Fire Risk Assessment (Haringey SAB); the Self-Neglect Assessment Triangle (Norfolk SAB); and the Signs of Safety and Wellbeing Assessment and Planning tool (Wakefield SAB).

Distinctive Aspects of Self-Neglect: Some SABs included distinctive sections on particular factors or presentations in self-neglect: obesity (North of Tyne) and substance misuse (Worcestershire). This was unusual, as self-neglect – other than hoarding – was generally treated as a generic category. Leicestershire & Rutland SAB advised that screening for dementia, depression and cognitive impairment should be central to self-neglect assessments, whereas Redbridge SAB included the Malnutrition Universal Screening Tool in its Hoarding and Self-Neglect Protocol. Making screening tools of this kind available with self-neglect procedures may help prompt awareness of the relevant issues.

Discussion

Ash (2015) points out the limitations of prescriptive attempts to solve safeguarding through top-down, rational-technical policy interventions. Her study found that “social workers demonstrated a preference for both structured adult protection procedures, and for exercising discretion and professional power in how, when and why they used the adult protection framework” (2015, p. 106, emphasis in original). The Care and Support Statutory Guidance certainly allowed for considerable discretion in its implementation, both in defining self-neglect broadly and flexibly and in allowing the decision whether self-neglect should be addressed under the section 42 provisions for safeguarding to be made “on a case by case basis” (DHSC, 2022, 14.17). It then fell to SABs to provide the “structured adult protection procedures” that would frame that discretion.

This review found that self-neglect’s profile has been raised, with many SABs having produced dedicated documentation. Self-neglect is no longer “a foggy mass of mess”, as one participant in Braye et al.’s (2011, p. 4) study put it, but benefits from more awareness and explicit guidance than in the past. Yet understanding and practice between localities have not become wholly consistent. Much as a review of state policies found in the USA some years ago (Daly and Jogerst, cited in Braye et al., 2011, p. 6), differences have emerged between Boards in England over how to define self-neglect. Bigger differences have developed regarding referral pathways and threshold criteria for self-neglect, as Boards look to balance local configurations of services and practice, demand and efficient allocation of service responsibilities, in the light of local histories of safeguarding practice and learning. How to draw the lines remains fraught; recent SARs show that even when individuals may be engaging with services and therefore not meet a common criterion for referral of self-neglect to MARM or high-risk panels, this does not always take full account of the risks individuals may be running (Cheeseman, 2021, p. 32). In working towards the goal of consistently person-centred and rights-based practice with people experiencing self-neglect, it is vital that where thresholds for referral to panels are restrictive there are strong, viable avenues for coordinated support at lower levels. Variations in approach are always likely to arise, in practice if not in policy itself as practitioners in their roles as “street-level bureaucrats” apply professional judgement in a given situation. Such variability can cause problems, especially when practitioners find themselves working across local boundaries or moving between areas, and continues to bedevil efforts at comparative data collection for purposes of research or policy monitoring.

Beyond identifying areas of divergence, the review also mapped distinctive or innovative content within SAB documentation. By signposting where potential templates for guidance on assessment, explaining executive capacity and advising on multi-agency collaboration or service refusal can be found, it offers a starting point for those seeking to consolidate the efforts of individual SABs. The limited amount of systematically collected evidence on the effectiveness of translation of this work from the page into practice constitutes a challenge and an opportunity to those in the adult safeguarding field.

Finally, this review has demonstrated the importance of the intermediate level of policy implementation. It can be seen that how the statutory guidance is translated into decisions about self-neglect by frontline practitioners is shaped by SABs’ interpretive and operational decisions, which in turn reflect local learning, local SAR recommendations and the service configurations within their area. This finding reinforces the importance of considering research into self-neglect practice against the background of its local context and history.

Limitations of the study

This study’s most obvious limitation is that it is limited to document content. Direct evaluation of the documents’ impact on practice was beyond the scope of this review. Comparing with research and learning from SARs featuring self-neglect allows some theorisation of how this policy content might address practice weaknesses, but the current evidence based on policy implementation in self-neglect is still exploratory and insufficient to allow for comprehensively prescriptive quality standards on precisely how SABs should formulate their policies and procedures.

Relatedly, there is something undeniably artificial about extracting these documents from their context. Not only does this leave the analysis disconnected from practice but also it isolates them from other local policies or training, which may in reality be filling some of the gaps identified here. This review did not explore all broader safeguarding policies and procedures posted by SABs. There may also be specialist guidance documents, for example, the authors are aware that Lancashire SAB has a very useful resource on executive capacity (Blackburn/Blackpool/Lancashire SABs, 2021), which is not mentioned within the Multi-Agency Self-Neglect Framework or clearly linked to on the SAB resources website. Possibly practitioners in these areas are aware of the resource independently, but where a resource is not evidently prominent and/or accessible, it cannot be assumed to be in widespread use. If SABs are not cross-referencing this information within their self-neglect guidance, there may be legitimate concerns over whether time-poor practitioners dealing with self-neglect cases will search for it in the absence of clear signposting.

As indicated in the discussion of year of publication, SAB documentation is under constant review, so this study became out of date even before it was completed. The results reported should be treated with this caveat in mind. However, the issues highlighted are likely to continue posing challenges to policymakers for the foreseeable future.

Conclusion

Approximately two-thirds of SABs now have self-neglect documentation available on their websites to support practitioners, though a significant minority do not. Surveying this collection reveals key areas in which sometimes significant divergence appears, notably in how self-neglect is defined and whether it covers inability as well as unwillingness to self-care; use of more or less expansive sets of indicators for self-neglect; and how far SABs see safeguarding as the indicated pathway for self-neglect, an area where the “case by case” assessments envisaged in the Statutory Guidance seem to have been operationalised by Boards in different ways. Further variation appears in whether and how documentation addresses such challenges as executive capacity, refusal of assessment and multi-agency collaboration. Encouragingly, examples were found and noted for each of these where fuller information was provided in procedures or guidance, and although there is as yet very limited evidence on how effectively this was applied by practitioners, mapping now exists of what is being done to fill these gaps. SABs continue to learn from each other how approaches to self-neglect can be improved; this review has contributed to charting how far we are along that path.

Acknowledgements

This review was funded by the National Institute of Health Research (NIHR) Health Services and Delivery Research Programme (NIHR133885). The views expressed are those of the author and not necessarily those of the NIHR or the Department of Health and Social Care. The authors would like to thank Michael Preston-Shoot, Suzy Braye, Nicky Selwyn, Andrew Voyce and Michelle Lefevre for their comments and suggestions on the paper.

Data availability statement: Repository: Self-Neglect Policies, Procedures and Documents from Safeguarding Adults Boards in England, October 2021 to June 2022: Index and Data Coding, https://doi.org/10.25377/sussex.21904413. This project contains the following underlying data: Data file: Self-Neglect Policies & Procedures Data Extraction Framework. This study is an analysis of policies which at the time of review were openly available at locations cited in the reference section. A version of the spreadsheet supporting this analysis is available at the above URL. This identifies the policy and guidance documents reviewed, notes which SABs have self-neglect documentation, and briefly categorises content. However, direct excerpts from the documentation have been redacted because of copyright restrictions. The redacted data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).

Table 1

Date of publication of SAB documents

Year of publication of most recent version	No. of SABs
2022	3
2021	12
2020	16
2019	18
2018	15
2017	4
2016	3
Not dated	14

Table 2

Definitions of self-neglect in SAB documents

Definition of self-neglect	No. of SABs
Care and support guidance alone	19
Care and support guidance and Braye et al.	21
Care and support guidance and gibbons	18
Care and support guidance, Braye et al. and Gibbons	4
Care and support guidance and other	15
Braye et al. alone	5
Gibbons alone	2
Other	1

Table 3

Executive capacity in SAB documents

Approach taken to executive capacity in policy or guidance	No. of SABs
Mentioned with explanation and/or reference	34
Mentioned with limited or no explanation	7
Not explicitly mentioned, but implied	4
Not mentioned	40

Notes

1 The strategic role of SABs is to coordinate and ensure the effectiveness of what each of its members does to safeguard adults; more specific details can be found in DHSC (2022: 14.133-13.141).

2 This definition in effect matches the one now given in Annex J of the Care and Support Statutory Guidance (DHSC, 2022).

3 The original source for the table is Naik et al. (2008).

4 This is likely to change, according to the new draft Mental Capacity Act Code of Practice (HM Government 2022, para. 4.38).