Emerald Group Publishing Limited
Copyright © 2011, Emerald Group Publishing Limited
Article Type: Editorial From: The Journal of Adult Protection, Volume 13, Issue 4
This edition is for safeguarding students and practitioners with an abiding interest in, and tolerance for, complexity. The tasks of protecting adults at risk of abuse recognise that the currency of uncertainties, subtleties, irregularities and unanticipated events in which interpretation is a creative process in its own right. Articles featured in the Journal of Adult Protection since its inception confirm the remoteness of experience from the neat, simplified and easily describable: physical, sexual, emotional, financial abuse and neglect, e.g. punitive responses to challenging behaviour such as perversions of restraint, the appointment of staff to positions of responsibility without considerations of their histories or suitability, cyber bullying, internet scamming and the use of Facebook to “post” intentions of assault, boldly illustrate emergent contours of harm. That is not forgetting what may be helpfully described as “corporate impropriety.” Southern Cross is the largest provider of homes for older people in the UK. The Darlington based care home operator has 31,000 elderly residents, 44,000 staff, 751 care homes and 80 landlords – and debts approaching £2bn. They had believed that an aging population would ensure that their homes were full – what they did not anticipate was the willingness and means of residents and local authorities to pay their fees. Most of us are challenged by private equity and the ethics of buying a business with borrowed money and then transferring responsibility for servicing the debt to the company. Should local authorities and regulators be assessing business models before placing contracts and rating their adequacy?
The edition contains two, far sighted and reflective reviews. The first was commissioned by the Department of Health and considers the perplexing condition of self-neglect by Suzy Braye, David Orr and Michael Preston-Shoot. The topic is contentious in the world of adult safeguarding because, if responsibility for harm is perceived as residing solely with the individual, who is simultaneously a victim and perpetrator, there is no case for undertaking a safeguarding investigation. This position tends to accompany the belief that self-neglect resides within the purview of mental health services – and pre-determines the solution in mental health legislation and services. If we turn the microscope around to take in other vantage points, then such appraisals and certainty are challenged.
Is self-neglect a form of deliberate self-harm or a long, slow suicide? It is a subject crying out for a conceptual footing. The media has a role in contributing to the debate:
“A Life of Grime” was a successful BBC series because it captured our fascination with the squalid circumstances of some people’s lives. What was once described as “Diogenes Syndrome” or “senile squalor syndrome” referred to the blissful unawareness of individuals unconcerned about their inattention to hygiene, skin care and bodily waste.
In “The Lady in the Van,” Alan Bennett (1989) eloquently described his revulsion at cleaning his bathroom after it had been used by a woman who took up residence in his drive in her broken-down van. Some services become attuned to the longer term harms associated with self-neglect with staff required to wear barrier clothing.
Jessie Sholl (2010) wrote “Dirty secret: a daughter comes clean about her mother’s compulsive hoarding,” in which the hardship of visiting and dealing with the resulting infections will be familiar to many professionals.
Self-neglect has been centre-stage in two Serious Case Reviews: the first in Blackburn with Darwen – which hosted a seminar for professionals on the subject earlier in the year. The event confirmed that the condition is crucially associated with essential service refusal, and that it rendering individuals at serious risk of health crises. Safeguarding practitioners in Blackburn with Darwen underlined the importance of being prepared for, and mitigating the danger of, staff “mirroring” the behaviour of self-neglecting individuals and of intervening, with the full backing of managers across services, at the earliest opportunity; and the second in Sheffield, where a tool for managing the risks associated with complex people has been developed (the Vulnerable Adults Risk Management Model). There, the SCR endorsed the fact that expertise regarding self-neglect transcends a single sector, even though ultimately, responsibility is associated with Adult Social Care and latterly, safeguarding. It noted too that “Professionals in Sheffield should know that in seeking to understand Ann’s perspective and work within the legislation that they have made an important contribution to service responses to self-neglect.” Both SCRs considered the importance of decisively bringing to the foreground the support of staff working with people who self-neglect – and reflects their learning from the assembled personal experiences of practitioners and managers – a position which Michael Preston-Shoot and Suzy Braye endorse.
The second review arises from work undertaken by Hilary Brown. It was commissioned by the Office of the Public Guardian – exploring what it is that makes a case appear “complex” to those charged with the process of case identification, assessment and deliberation. It proposes that the Mental Capacity Act 2005, omits to take into account the distinctive experience of emotions. We are reminded that there is something uncomfortably non-educational about health exhortations to lose weight, drink less alcohol, take exercise, avoid violent and damaging relationships – because they don’t work, they do not access history and memory, motivation, mood and openness to influence. The review takes readers beyond the face value of an ostensibly reasoned decision. Perhaps in telescoping considerations about a person’s decision-making into understanding the relevant information, retaining it and reasonably forseeing the consequences, the context-sensitivity of a decision should be enlarged to embrace emotion and sometimes emotional chaos. As the authors observe – this is familiar territory. Cinemas and publishing houses could not flourish without the breadth of emotional experience. (Speaking of which, Maggie Gee’s “The White Family” should be added to summer holiday suitcases. It unashamedly explores justice, kinship, self-righteousness and racism, and for those of you who never got around to reading it – “A short history of tractors in Ukrainian” by Marina Lewyka. This is notable too for the raw and reverberating impacts of emotionally significant events – which are remarkably laced with comedy.) Back to Hilary Brown’s paper, it crucially acknowledges the indispensible role of the Court of Protection, which in turn, does not hesitate to engage with feelings which are synonymous with emotions.
The website of the British and Irish Legal Information Institute is a must for safeguarding practitioners. Go to www.bailii.org and check out the most down-loaded judgements. The London Borough of Hillingdon v. Neary & Anor  EWHC 1377 (COP) (09 June 2011) is essential reading. It is instructive and thought-provoking, capturing the hellish difficulty of challenging those who have an individual’s “best interests” at heart, without recourse to the Court of Protection.
The third and final report of the Munro review of child protection was published in May: http://www.education.gov.uk/munroreview/
It is relevant to adult safeguarding, not least because Serious Case Reviews are a distinctive process lifted from children’s safeguarding. Professor Munro proposes a shift away from central prescription towards individual discretion in decision-making. In the North West, a programme of work funded by the North West Joint Improvement Partnership and the Association of Directors of Adult Social Services confirmed that the process of “learning lessons” is subject to locally determined means of deciding when and how to review cases and, although a SCR suggests a formal course of action built on a body of practice, there are different forms of scrutinising adverse incidents (Margaret Flynn and Shirley Williams, (2010) “Lessons learned about learning lessons: The experience of adult SCRs in the North West,” Briefing Paper 2).
The two practice papers outline work in North West England and were funded by the North West Joint Improvement Partnership and the Association of Directors of Adult Social Services. Written by Margaret Flynn and Shirley Williams, and by Margaret Flynn, Kirsty Keywood and Shirley Williams, one considers the work and challenges of Adult Safeguarding Boards and the second considers Serious Case Reviews. There had been an expectation that the second paper would provide a template. However, as the authors noted, they sought to “promote more thinking rather than provide more guidance for doing.” The result is a text interspersed with question-prompts concerning, inter alia, ethical and legal matters. The paper seeks to remove over-attention to a single method and to cease borrowing from and tiptoeing in overly prescriptive children’s SCRs.
Finally, as the turbo-charged programme of “cuts” prevails, keep an eye on those unnecessary layers, managers and red-tape. The best of genograms organise family assessment information, identify patterns for targeted treatment and interpret the results … Most of us would be challenged to produce a genogram of the reforming NHS. It has spawned dismantling Primary Care Trusts, plus governing boards, “clusters” with their own boards, including the outcasts – the GPs who do not want to grow up to be commissioners. Clinical senates and health and wellbeing boards are step-parents and citizens panels and Health Watch the poor relations. Monitor is the embarrassing uncle who wants to the keep the nieces and nephews of Foundation Trusts, and their boards, integrated as well as competitive. The CQC is the troubled and anguished aunt, and the NHS Commissioning Board is the stern and anxious grandparent.