Summary of the impact

The research has had significant impact in three key areas:

• shaping the Care Bill 2013: it influenced the Law Commission's recommendations on legal reform and directly shaped key elements of the legislation;
• stimulating changes to the governance arrangements of Safeguarding Adults Boards (SABs): it produced a benchmarking template for SABs, informed guidance to Directors, and led to strengthened SAB governance arrangements;
• influencing procedures, practice and workforce development strategies in self-neglect work: supporting new multi-agency procedures in localities, and providing an evidence base that has improved capacity assessment and approaches to intervention, to the benefit of service-users.

Underpinning research

Braye and Orr's research into adult safeguarding was commissioned from Sussex by the Department of Health (DH) — executed by Sussex with a contribution from the University of Bedfordshire, 1 December 2009 to 31 May 2010. It comprised two studies: first, effective governance for Safeguarding Adults Boards (SABs) and, second, self-neglect within safeguarding arrangements. Braye has been Professor of Social Work at Sussex since 1 April 2005; Orr was initially a Research Fellow (February 2010) and became a Lecturer on 18 July 2011.

• Effective governance for SABs

The significance of adult safeguarding is increasingly recognised; the UK Study of Abuse and Neglect of Older People Prevalence Survey Report (O'Keefe et al. 2007) estimates that 4 per cent of over-65s are subjected to abuse and neglect each year. Existing guidance (No Secrets, DH, 2000) encouraged but did not require the establishment of multi-agency SABs. Our study explored the strategic goals, structures, membership, networks, functions and accountability of SABs and made recommendations to government on SAB governance arrangements. It gathered data from a systematic literature review, 5 workshops with senior managers and safeguarding specialists, 5 key informant interviews, and detailed documentation from 47 Boards. It revealed the diversity of practice between boards and identified barriers to effective SAB governance. We developed a benchmarking template from these findings, providing detailed standards for SAB performance review. We also recommended legislating for statutory SABs in order to facilitate participation and commitment by different agencies, and to set consistent standards.

• Self-neglect

Because safeguarding's remit currently only covers actions or omissions by a third party, it is often unclear where risk from self-neglect fits; health and social-care workers thus lack clarity on assessment and intervention pathways. These cases are frequently complex, involving ethical dilemmas between promoting autonomy and fulfilling a duty of care. Our research systematically reviewed the international literature and drew on the above-mentioned interviews and workshops (plus a practitioner workshop) to determine how self-neglect practice could be improved. It found that SABs mostly excluded self-neglect from their remit, highlighting the need for alternative multi-agency processes. The findings illustrated the diversity of contributing factors to self-neglect, and showed that the complex nature of the capacity for autonomous decision-making is not always adequately addressed in practice. Our research evidence provided guidance on effective assessment and intervention, multi-agency information-sharing and risk management.

Findings from both studies were presented through a range of media, including SCIE reports [see Section 3, R1, R2], journal articles [R3, R4] and online videos feeding live, online, webinars (e.g. https://knowledgehub.local.gov.uk/group/adultsafeguardingcommunityofpractice/forum/-/message_boards/message/6943054). They have stimulated overwhelming interest; the researchers have delivered 16 invited national conference plenaries and 5 international conference papers (2 invited), and participated by invitation in 4 DH expert panels and 17 policy/practice development workshops, involving approximately 45 local authorities and their interagency safeguarding networks.

The high profile which this work gained led to a sector skills council Skills for Care (SfC) research commission for Sussex to investigate social-care workforce-development needs on self-neglect (Braye and Orr, 15 January 2013 to 30 April 2013) [R5], a national consultation by SfC (https://www.surveymonkey.com/s/sfc_self_neglect), and a further DH research commission from Sussex to identify best practice in self-neglect, including the first-ever England study of service-users' perspectives (Braye and Orr, 1 March 2013 to 30 November 2013).

References to the research

This report was peer-reviewed at the Department of Health and was further quality-assured by the Social Care Institute for Excellence before publication.

This report was peer-reviewed at the Department of Health and was further quality-assured by the Social Care Institute for Excellence before publication.

This peer-reviewed journal article was awarded `Outstanding Paper of the Year' in the Emerald Publishing Group Literati Awards for Excellence 2013.

This peer-reviewed journal article was awarded `Highly Commended Paper of the Year' in the Emerald Publishing Group Literati Awards for Excellence 2012.

Outputs can be supplied by the University on request.

Details of the impact

• Shaping the Care Bill

The Care Bill, currently passing through Parliament, is a significant part of `the most comprehensive overhaul since 1948 [of the] care and support system' (http://caringforourfuture.dh.gov.uk/). Our research findings influenced policy debate and directly shaped key elements of this legislation.

Our governance report argued that making SABs a legal requirement would help to improve safeguarding governance. DH accepted the recommendation, announcing in May 2011 that establishing a SAB would become a legal requirement for all local authorities in England. The research evidence on the value of such legislation was given as the grounds for this decision, with our then-unpublished report cited [see Section 5, C1]. Our recommendation also influenced the Law Commission's review of adult-social-care law, which called for statutory boards [C2, C3]. Our research also evaluated Board configurations, exploring different models without specifying any single one for universal adoption. DH has said that this `played a major part in informing our thinking' on how prescriptive the legislation should be about SAB membership and chairing arrangements, leading them to allow a strong degree of flexibility to reflect local circumstances [C4]. The overview of current Board practices was used by DH in evaluating the feasibility of the SAB reform proposals, informing and being directly cited in the impact assessments accompanying the Care Bill [C5, C6].

Our self-neglect report led the Law Commission to recommend that self-neglect should be expressly included within the new duty on local authorities to investigate cases of abuse and neglect [C2]. The government accepted the need to address self-neglect and will do so in the linked Code of Practice, in direct response to the issues highlighted by the research [C3].

• Stimulating changes to the governance arrangements of SABs

The research has also had wide impact on local governance arrangements. The template developed in our governance report to benchmark best practice in safeguarding governance was itself used by the DH in setting principles against which SABs are required to assess their arrangements [C1]. The template was used by chairs of 30 SABs to benchmark their arrangements in two national events on 15 February 2011 and 22 February 2011, organised by the Local Government Association and the Association of Directors of Adult Social Services (ADASS) [C7]. Four SABs invited the researchers to work directly with their whole board. In Camden, for example, the research served as the basis for a review of SAB arrangements and led to the restructuring of sub-groups (January 2013), the adoption of independent chairing arrangements (April 2013) and revision of the communications strategy (July 2013) [C7, C8]. In Oxfordshire, the research-based workshop on 8 June 2012 `helped the board to consider its structure', `helped tremendously in establishing greater clarity about the role of the board' and `directly influenced the business plan' and future priorities [C9]. The governance report informed the ADASS Adult Safeguarding Network in preparing guidance for all Directors of local authorities in England and was directly cited in that document [C10].

• Influencing procedures, practice and workforce development strategies in self-neglect work

Some authorities participating in development workshops on self-neglect [see Section 2] reported subsequently changing their systems or practices. For example, an event for the Camden SAB on 21 June 2012 highlighted gaps in services and inter-agency systems and facilitated the identification of solutions. Camden have since trialled and established a `high-risk panel' to manage self-neglect cases which, with 35 referrals by July 2013, `has been very successful in building networks and reducing risk' [C7, C8]. High-risk panels have also been established by Brighton and Hove, East Sussex and West Sussex, accompanied by a tiered, multi-agency training strategy on self-neglect, with content shaped by the research: `The published research has been particularly informative in shaping the need for successful learning intervention' [C7]. West Sussex drew on the research in developing its own guidance to staff [C11]. Wirral NHS Foundation Trust changed its approach to mental-capacity assessment as a result of our findings [C7]. The national organisation Research in Practice for Adults included in its current work-plan the development of a practice tool based on our research, to support evidence-informed practice by its local authority members [C7].

We have ensured, too, that the research implications are addressed at individual practitioner level. Every practice development event involves action planning for personal and organisational change. Social workers, health professionals, team leaders and safeguarding leads in many localities have set targets for their own personal practice development, in locations as diverse as Brighton and Hove, Buckinghamshire, East Sussex, Liverpool, Merton, Middlesbrough, Milton Keynes, Oxfordshire, Reading, Sutton and York. The research has been described by the DH, as a result of the expert seminars they have run, as `exceptionally well-received' [C4].

Finally, benefits for service-users are emerging; one example is from a hospital-based safeguarding lead:

I just wanted to let you know that your presentation ... may already be having an impact on people who are self-neglecting. I had a call yesterday about an elderly couple who are living in very unsafe surroundings and are really struggling, but have declined all interventions. I have asked social services to review their decision about (mental) capacity and have directed them to your research findings. I am hopeful that they will now at least engage in a conversation about how we help to minimise the risks to this very vulnerable couple [C7].

Sources to corroborate the impact

C1 DH (2011) Statement of Government Policy on Adult Safeguarding. London: Department of Health: `Research commissioned by the Department of Health has shown that specific legislation for statutory Safeguarding Adults Boards would help to hold agencies accountable in ways which guidance, differentially binding on the partners, has not so far been able to do' (p. 5). http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_126748

C2 Law Commission (2011) Adult Social Care, LC326. London: Law Commission, (Rec. 44, p. 136; Rec, 39, p. 133; Rec. 7, p. 38):
http://lawcommission.justice.gov.uk/docs/lc326_adult_social_care.pdf `[The] research played an important role in our final recommendations' [C3].

C3 Chief Executive, Law Commission: `Braye was able to secure the early release of the research reports in order to inform our review of adult social care. This work led us to recommend that the new duty on a local authority to investigate cases of abuse and neglect should apply expressly to cases of self-neglect. The Government has taken this recommendation into account in the resulting Care Bill, which was introduced into Parliament earlier this year. Whilst the Bill does not include an express reference to self-neglect, the Government has agreed to clarify this matter in the code of practice, which is due to be published in 2014'.

C4 Senior Policy Manager, Adult Safeguarding, Department of Health: `The research was particularly helpful in informing how prescriptive the legislation should be... Government has reflected this by prescribing (minimally) about the form, opting for small core statutory membership and allowing a lot of local flexibility to reflect local circumstances. What the legislation does emphasise is the need for accountability and transparency of Boards, including to the local community and for the Boards to concentrate on improving outcomes rather than focusing on procedure and processes. The research played a major part in informing our thinking on this'.

C5 Department of Health, External Relations Directorate: `I found your research very helpful in supplementing our strategic view of the current range of local safeguarding board arrangements, and our discussions on the matter were also incredibly helpful. I remain extremely grateful for the time you offered to support this work and I do believe I was able to produce better documentation to support the development of policy as a result of your research'.

C6 DH (2013) Care and Support Legal Reform: Impact Assessment. London: Department of Health (para. 5.10, p. 43; para. 5.17, p. 44).
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/197938/Care_and_Support_Legal_Reform_IA__FINAL_.pdf `Your work was directly cited in the impact assessments that accompanied the social care bill (ref.69)' [C5].

C7 Departmental record of impact feedback from a range of stakeholders, available for audit.

C8 Safeguarding Development Officer, Camden Housing and Adult Social Care: `Sussex's safeguarding governance research was invaluable, offering depth of analysis, breadth of coverage, and an insight into what other Boards were doing and were finding to be effective. Without the safeguarding governance research we would have had very little to draw on'.

C9 Independent Chair of Safeguarding Adults Boards, Oxfordshire/Hounslow: `Your influence was particularly important when the board moved on to consider its priorities, and your engagement in the discussion, calling on your research findings, provided depth to our discussion'.

C10 ADASS (2013) Safeguarding Adults: Advice and Guidance to Directors of Adult Social Services. `Current research has shown that Safeguarding Adults Boards are variable in their structure and effectiveness, for example see The governance of adult safeguarding: findings from research into Safeguarding Adults Boards. However, while there is not a magical template, there are clear principles that make for a high performing Board' (p. 11):
http://www.adass.org.uk/images/stories/Policy%20Networks/Safeguarding_Adults/Key_Documents/LGA%20ADASS_SafeguardingAdviceAndGuidanceToDASS_Mar13.pdf

C11 West Sussex County Council (2013) Self-Neglect and Social Care Intervention: Adults' Services Policy. `The literature study reviewed definitions of self-neglect and trends in how self-neglect was conceptualised in research as well as considering the interface with adult safeguarding, and reviewing the evidence relating to professional interventions. In total, over 3,000 papers published since 2000 were screened and 160 papers were reviewed in greater detail' (p.7). http://www.westsussex.gov.uk/idoc.ashx?docid=20379951-7931-45c2-9685e70360fe5d3e&version=-1.