Health and social care, integrated care and safeguarding adults

This report was commissioned to provide an early understanding of the impact of the NHS integrated care systems (ICS) and integrated care boards (ICBs) on adult safeguarding. 

To date the focus of the ICBs has been on putting in place their structures and recruitment. There has been less clarity on the role of ICBs in relation to safeguarding. Safeguarding is mentioned only in some, but not all, of the recent guidance, often only referring to adult safeguarding in relation to the NHS responsibilities for safeguarding within its own services or within services funded by the NHS.

Many participants in the fieldwork felt that the conversation to date placed a lot of emphasis on how health will handle its own safeguarding processes and internal assurance. There is little in the guidance or spoken about the NHS contribution to local SABs. This overlooks the role of the NHS as one of three core statutory partners with responsibility for the SAB and the safeguarding partnership. 

The findings of the review are set out under the following themes:

• geography matters
• variability in the stages of development of ICBs
• governance arrangement and awareness of safeguarding adults within ICB Boards (especially Non-Executive Directors) 
• accountability for safeguarding
• prevention
• quality improvement and safeguarding
• escalation
• organisational abuse and patient safety reporting
• named and designated roles and other important roles
• safeguarding within multiple providers and provider chains
• integrated care strategies
• updated and shared datasets
• nspection assurance processes.

General reflections

• There was universal agreement that relationships mattered, as much as legislation, policy, and guidance, when it came to operationalising the new arrangements. 
• There was concern about how the impact of the changes would be measured with respect to safeguarding of adults.
• It was of great importance that the police were included in local conversations, and a great concern that they may be inadvertently sidelined. It should not be forgotten that they are one, if not the largest, source of safeguarding referrals.
• The role of the voluntary sector, as members of SABs, in the work on prevention, was highlighted.
• It was also stressed that it is important not to overlook the importance of primary care and the new primary care networks that work at ‘place’ level.
• It was emphasised that directors of adult social services (DASS) and the safeguarding adult board (SAB) independent chairs had a key role in the ongoing discussions with the developing ICBs.
• The opportunities for shared learning and for addressing variation in practice within the ICB areas were ‘there for the taking’.
• It was suggested that ICBs should review the training and support given to members of their boards with respect to their safeguarding duties and should review their recruitment information with respect to the content about safeguarding.
• It was suggested that guidance should be updated after a year of operation of the new arrangements and the opportunity taken to include safeguarding adults where there is a gap.
• There were many issues raised that are long standing issues that predate the Health and Care Act 2022 changes. However, it was felt that there is always value in revisiting past challenges in the spirit that new approaches may yield new solutions, and these are included in the box below. 

Challenges

• maintaining the ethos and approach of Making Safeguarding Personal
• there being sufficient staff capacity across the partnership to lead and to contribute to SAB subgroups 
• the need for sufficient and consistent levels of funding for SABs and a fear that budgets could be “levelled down” between SABs across an ICB
• the development of common datasets across agencies and areas. 

There will be issues that over time will stress test the new systems. The new ‘discharge to assess and safe discharge arrangements’ is an example of an area that is already beginning to emerge. Most acute hospitals work across more than one council/SAB area and therefore this is a good example of an issue that might be better addressed on a subregional basis. 

Finally, in summary, many of the contributors to this review felt that the value of this review has been to establish a baseline that could be used to measure progress if a further review were to be repeated in a year’s time.

We were reminded at the final workshop that from one of the participants that:

We, in adult safeguarding work, often deal with the most awful moments in life. However, we are also here to learn from excellence from each other and we have got to hold on to that more than anything”.

It is hoped that this review contributes to that aim.

Deborah Cohen and Aileen Buckton (Consultants undertaking the Review)

Reason for the review and the approach

This review was commissioned to understand the impact of the new integrated care arrangements, under the Health and Care Act 2022, on safeguarding adults.  

Most of the fieldwork was conducted in the period April to September 2022 with the ICBs formally going live on 1 July 2022. This meant that for many fieldwork participants the arrangements were only just coming into being. Some of the findings in the review are impressionistic and are noted as such. For example, fears were expressed that ICBs might start to move around and streamline or consolidate the resources that the NHS puts into safeguarding partnerships to reflect new structures. However, nobody reported that this had happened. 

A three-pronged approach was taken: 

• a review of recent policy and guidance, to consider how well the accompanying guidance addresses how safeguarding adult duties are to be met in the new organisational arrangements 
• fieldwork, using appreciative inquiry, working with several reference groups from local safeguarding partnerships and with a range of individuals leading and working in safeguarding adults, to understand the impact of the new integrated care systems (ICSs) on safeguarding adults. 
• revisiting the terms of the Care Act 2014 and the accompanying statutory Care and Support Guidance with respect to safeguarding adults. 

The fieldwork included focused meetings with SAB partners from five different councils, comprising two metropolitan councils (one with a one-to-one mapping with an ICB), two county councils (that mapped to more than one ICB) and one council where the SAB had joined some years ago with the SABs in two neighbouring councils to meet as a single SAB. Two larger virtual reference group meetings were held with a wider range of people drawn from SABs, ICB and NHS England. The fieldwork concluded with an online workshop.

This review did not look specifically at those council areas where there are joint children and adults’ partnerships which may bring further complexity to the implementation of the new arrangements. 

The findings have been brought together and summarised under several themes. 

All references to ‘council’ in this report, are to upper tier authorities, that is councils with responsibility for adult social care. 

Background

The Care Act 2014, which governs the statutory duties to safeguard adults, is now over eight years old and over that time safeguarding practice and the local partnerships that comprise SABs have developed and matured, each with their own priorities and approaches within a common framework from bodies that are rooted in their local (council) areas. 

These partnerships bring together a range of representatives including from councils, NHS bodies, police, fire brigade, and the independent sector. SABs have provided leadership and assurance of the effectiveness of local safeguarding system and arrangements. This includes learning from adverse incidents, including the lessons from safeguarding adult reviews (SARs), identifying opportunities for service improvement and the development of preventative arrangements that avoid repetition of the same adverse events.   

The footprints on which health and the police work have widened so that in many parts of the country it is now only adult social care, and the SAB itself, that operates on a council boundary. However, the majority of SABs have retained their local focus. Many SABs have actively embraced the agenda of prevention, often working closely with the local voluntary sector. The interconnectedness with the work of the council-led safer community partnerships, with children’s safeguarding partnerships, and with health and wellbeing boards (HWBs) has been embedded in the practice of SABs. Many challenges remain that predate the establishment of ICSs, including the level of resourcing, sharing of information, and working across organisational and service boundaries.

The duties in the Care Act 2014 are unchanged by the Health and Care Act 2022 legislation and the statutory obligations of the clinical commissioning groups (CCGs) for safeguarding adults have transferred directly to the ICBs. 

The original start date for the ICBs of 1 April 2022 was delayed by three months, which meant that the review was carried out across the preparatory period and over the first three months of the operation of ICBs. Consequently, ICBs across the country were at different stages of readiness and many of the comments received during the fieldwork reflect this variation. 

New structures

There were many comments from participants during the fieldwork about needing clarity on the new structures and the names of the newly created bodies. 

The key terms used throughout this Review are set out below (the definitions are taken from What are integrated care systems?)

What are ICSs?

Integrated care systems (ICSs) are partnerships of organisations that come together to plan and deliver joined up health and care services, and to improve the lives of people who live and work in their area. Following several years of locally led development, recommendations of NHS England and passage of the Health and Care Act (2022), 42 ICSs were established across England on a statutory basis on 1 July 2022.

What is included in an ICS?

• An Integrated care partnership (ICP) is a statutory committee jointly formed between the NHS ICB and all upper-tier councils that fall within the ICS area. The ICP will bring together a broad alliance of partners concerned with improving the care, health and wellbeing of the population, with membership determined locally. The ICP is responsible for producing an integrated care strategy on how to meet the health and wellbeing needs of the population in the ICS area.
• An Integrated care board (ICB) is a statutory NHS organisation responsible for developing a plan for meeting the health needs of the population, managing the NHS budget and arranging for the provision of health services in the ICS area. The establishment of ICBs resulted in clinical commissioning groups (CCGs) being closed down.
• Local authorities in the ICS area are responsible for social care and public health functions as well as other vital services for local people and businesses.
• Within each ICS, place-based partnerships will lead the detailed design and delivery of integrated services across their localities and neighbourhoods. The partnerships will involve the NHS, local councils, community and voluntary organisations, local residents, people who use services, their carers and representatives, and other community partners with a role in supporting the health and wellbeing of the population.
• Provider collaboratives will bring health providers together to achieve the benefits of working at scale across multiple places and one or more ICSs, to improve quality, efficiency and outcomes and address unwarranted variation and inequalities in access and experience across different providers.

The findings from this review have been brought together and are grouped under the following themes:

This section critically examines the policy and guidance issued since January 2022 that is relevant to safeguarding adults. At the time of writing (September 2022) many of those participating in the fieldwork were still familiarising themselves with the new arrangements.

Establishment of ICBs

The Health and Care Act 2022, established on 1 July 2022, saw the establishment of 42 ICSs.

Clinical commissioning groups (CCGs) were closed down on 1 July 2022 when ICBs were established on a statutory basis. This means that ICBs for each area are effectively a merger of the pre-existing CCGs in the area covered by the ICB. This is important for safeguarding adults because the Health and Care Act 2022 transfers all legal responsibilities for safeguarding that previously lay with CCGs to the ICBs.

Geography

The table below sets out key dimensions of the 42 new ICBs. The point of specific interest to this review is the variation in the number of councils within each ICB area ranging from one to 18 with an average of five. Given that each council will have a SAB, then corresponds to the number of SABs within each ICB footprint.

The above table, authored by Edward Jones, Senior Policy Advisor, NHS Confederation ICS Network, captures the variation in ICBs and the impact of this is discussed above under “Findings”.In order to understand the extent to which ICB geography matters to the ongoing working of SABs, a range of SABs working in different geographical topographies were included in the fieldwork.

Governance arrangements and safeguarding

NHS England requires the ICBs to identify named executive board member leads for safeguarding; special educational needs; disabilities (SEND) and for children and young people’s services. These are not new statutory duties and are intended to secure visible board-level leadership of these issues. In most places these duties are held by the ICB chief nurse, who also holds the responsibility for quality and safety.

The model constitution for the new ICBs include the roles of executive and non-executive directors and the establishment of subcommittees chaired by a non-executive director. Many ICBs have a board subcommittee with responsibility for providing assurance on the quality of services commissioned, usually chaired by a non-executive director. The guidance states that “this committee must be separate from the system quality group (SQG) (see below), although the SQG will be chaired by the ICB executive director with responsibility for quality (medical director or director of nursing)”. This separation is necessary because they have different remits, membership, and lines of accountability.

Quality committees are an internal quality assurance mechanism for ICBs to ensure they are effectively discharging their statutory duties.

System Quality Group (SQGs) are for intelligence sharing, engagement and improvement across system partners, including regulators. 

Guidance to clinical commissioning groups on preparing integrated care board constitutions

As mentioned in the Findings above, a search on the word “safeguarding” was carried out on a sample of 21 out of 42 (50 per cent) ICB information packs for the recruitment of non-executive directors including person specifications. Only two of the recruitment packs mentioned safeguarding.

Place

“Place” is not defined in the legislation, but in most parts of the country corresponds to the council area, but this is not the case everywhere. Where place is the same as the council there will be a direct mapping of place with the local SAB. However, where this is not the case then it is possible that one place will relate to more than one SAB. An example of this is to be found in South East Essex that covers Essex County Council SAB, Southend SAB and South West Essex place which covers Essex County Council and Thurrock SABs. 

NHS statutory responsibility for safeguarding adults sits with the ICB. However, in the same way that SABs have worked with HWBs and safer community partnerships in furtherance of the prevention agenda, it is likely that the new place-based partnerships will be a focal point for SABs for local issues about local systems or services.

The ICB, operating across many place partnerships could be where health care concerns common across more than one SAB within the ICB area can be escalated. Concerns that are wider than health care and that relate to many services/agencies and may be about local systems or organisational abuse can be taken into the local ICPs. In the absence of explicit guidance on escalation, there was an expectation expressed at the final workshop by senior NHS Safeguarding colleagues that ICBs develop with their SABs an escalation protocol.

NHS Safeguarding Accountability and Assurance Framework (SAAF)

Purpose

The most recent edition of the SAAF, covering children, young people and adults was published by NHS England in July 2022. Safeguarding children, young people and adults at risk in the NHS: Safeguarding accountability and assurance framework has been described as the foundational NHS guidance on safeguarding adults.

The SAAF references the changes made in the Health and Care Act 2022 and sets out the expectations of every NHS and NHS funded organisation and of individuals working in healthcare with respect to safeguarding children and adults. It emphasises the fundamental importance of partnership working: “it is vital that local practitioners continue to develop relationships and work closely with colleagues across their local safeguarding system”. The SAAF provides guidance and minimum standards, sitting alongside the development of local safeguarding policies and practice.

The SAAF identifies “how NHS England and national teams work with ICB accountable leadership and ICB place-based leadership to support partnerships”. The SAAF states that the ICB executive chief nurse will be accountable for the statutory commissioning assurance functions of NHS safeguarding in the widest sense, including prevention and strategic planning.

The SAAF contains a section entitled “Parallel investigations”, which draws the connections between other types of investigation and safeguarding.

Parallel investigations: At times, the safeguarding of children and/or adults in a health setting may feature in a wider multi-agency statutory review commissioned for other purposes, for example a DHR or a mental health investigation. In these circumstances a separate safeguarding practice review may be deemed appropriate. NHS organisations should be prepared therefore, to share information and cooperate with the parallel practice review panel. Duplication of effort should be avoided where possible with each review informing the parallel process. System leaders need to be aware of the new patient safety incident response framework which may also be activated due to other incident management processes (SAAF paragraph 4.6).

Roles

All (NHS and NHS funded) providers must identity a named lead for adult safeguarding and a Mental Capacity Act (MCA) lead and one of these roles should include the management of adult safeguarding allegations against staff. This could be a named professional from any relevant professional background.

The role of the named professional is to “promote good professional practice within their own organisation, supporting the local safeguarding system and processes, providing advice and expertise for fellow professionals, and ensuring safeguarding supervision and training is in place”. They should work closely with their organisation’s safeguarding lead, with designated safeguarding leads in the ICBs and SABs. This includes named GPs/named professionals within primary care. 

The SAAF sets out the roles of designated professionals who are experts and strategic leaders for safeguarding. They are required to have direct access to the ICB Executive, to ensure that there is the right level of influence of safeguarding on the commissioning process. The ICB accountable office (the chief nurse) should meet regularly with the designated professionals to review ... adult safeguarding in their local area. The fieldwork identified concerns that there may be insufficient numbers and visibility of designated leads in the new systems.

The designated lead professional for adult safeguarding will:

• offer support and advice to the board member responsible for adult safeguarding and ensure the regular provision of training to staff and board of the ICB
• provide a health advisory role to the SAB and must attend, fully brief and support the ICB SAB member
• will take a lead for health in working with the SAB on safeguarding adult reviews
• will take forward any learning for the health economy. (para 4.7.3).

System Leadership

It is the role of NHS England to ensure that the health commissioning system is working effectively to safeguard and promote the welfare of children, young people and adults. NHS England is the policy lead for NHS safeguarding.

The National Safeguarding Steering Group (NSSG) has oversight of the ICBs to ensure that NHS England teams are appropriately engaged in the local place based multi-agency safeguarding partnerships, SABs, community safety partnerships and HWBs to raise concerns about the engagement and leadership of the local NHS.

NHS England has a statutory requirement to oversee assurance of the ICBs in their commissioning role.

Commissioning

NHS England, via national membership networks and regional safeguarding leadership, will support designated professionals and named professionals to have adaptive and collaborative conversations with local authority commissioners to ensure that effective local safeguarding arrangements are in place (paragraph 5.4)

Multiagency safeguarding arrangements

The final section of the SAAF outlines ICB membership of existing partnerships, such as: safeguarding children partnerships, community safety partnerships, SABs and the HWBs. The guidance says that the nature of the relationship between and SABs and HWBs is decided locally. 

The SAAF has the following to say about SABs: The SAB should not be subordinate to, nor subsumed within, local structures that might compromise their separate identity and voice. NHS commissioners and providers are responsible for understanding these arrangements and ensuring that they are fully engaged and working effectively to support them (paragraph 6.8.3).

Systems Quality Groups (SQGs)

The SQGs are strategic forums to support both quality and safeguarding. Their purpose and function is described in guidance published by the NHS England's National Quality Board in January 2022: National Guidance on System Quality Groups. Comments about the SQGs are set out in the “Findings” section above.

Purpose and function

As noted above, SQGs are not the ICB’s formal assurance committee for quality and are not statutory bodies. They build on and replace the predecessor CCG Quality Surveillance Groups. There is an intention to update the guidance as the systems bed in. 

[SQGs] will provide an important strategic forum within ICSs at which partners from across health, social care and wider can:

• routinely and systematically share and triangulate intelligence, insight and learning on quality matters across the ICS
• identify ICS quality concerns/risks and opportunities for improvement and learning, including addressing inequalities. This includes escalating to the ICB, council assurance (for example, safeguarding assurance boards) and regional NHS England and NHS Improvement teams as appropriate)
• develop ICS responses and actions to enable improvement, mitigate risks (respecting statutory responsibilities) and demonstrate evidence that these plans have had the desired effect. This includes commissioning other agencies, and using ICS resources, to deliver improvement programmes/solutions to the intelligence identified above (eg academic health science networks (AHSNs)/provider collaboratives/clinical networks)
• test new ideas, sharing learning and celebrating best practice (paragraph 1.5).

Safeguarding adult activity will be an important, but not the only, component of intelligence and information sharing that underpins the assurance of care quality. The flow of information should be in both directions, that is from the member agencies to the SQG and from the SQG to the members (for example to SABs). SQGs would be expected to escalate concerns to SABs. The guidance sets out the types of issues that “could reasonably come through an SQG”.

• Place-based quality: for example, triangulating quality performance, safeguarding and safety reporting to identify patterns and trends in the data, gaps, and support improvement, access and patient flow
• Pathways and journeys of care: for example, children’s mental health, urgent and emergency care, frailty, autism and learning disability (eg embedding key system learning from a LeDeR Review)
• Inequalities and variation: including full consideration of how the ICS can reduce inequalities and address wider determinants of health (eg housing, fuel poverty) to improve the quality of care
• Quality within multiple providers and provider chains: for example, provider collaboratives, independent chains) – eg triangulation of learning from deaths information (eg Regulation 28 Prevention of Future Deaths reports, patient safety incidents and investigations, national clinical audit), with learning shared and embedded across the ICS
• Safeguarding concerns: for example, within a learning disability or autism unit

Participants commented that the earlier CCG Quality Surveillance Groups had not fully embraced safeguarding adults’ issues and systems. It was hoped that the SQGs would have a different approach. It was felt that a helpful approach would be to see quality and safeguarding as the opposite ends of a spectrum (as one participant put it “safeguarding is what happens when quality fails”). 

Membership

The membership of SQGs is drawn from all parts of the system, including the ICB and councils. The guidance does not refer to the independent chairs of SABs, although participants expected to be involved in the SQGs and one participant reported that their SQG had invited all the independent chairs within their ICS area. Another participant reported that in their ICB, a single place on the SQG had been made available for a SAB chair to attend as a representative of all the SAB chairs.

Accountability for safeguarding

It is important to note that SQGs work at ICS/ICB level (ie at sub regional level), even though the guidance says that they may wish to include ‘place’ quality leads in their membership and to develop equivalent groups at ‘place’ level. However, “risks should only be escalated from place level when an ICS-level solution is required” (paragraph 3.13). 

The box below is from the guidance, setting out the areas for SQGs to consider. It should be noted that there is no direct reference to SABs. 

SQG Guidance: areas to consider

• How they will ensure effective engagement with local authority representatives (directors of children’s services and directors of adult social care) on the group: for example, a local authority representative may be designated as co-chair.
• How they will ensure that issues, risks, learning and trends from councils (eg emerging safeguarding concerns, annual reports) are brought to the SQG, triangulated with wider intelligence and inform priorities and actions.
• How they will inform council areas of priority and plans.
• How they will partner with local authority partners on areas and concerns of mutual interest. (paragraph 3.)

The guidance goes on to say that the role of the ICB is “to be accountable for the effective oversight and management of healthcare risk (where they do not fall under council assurance, eg safeguarding)” (paragraph 3.12). The guidance might be read to say that the only ICB accountability was for healthcare risk.

Safeguarding and the Patient Safety Incident Response Framework (PSIRF)

The Patient Safety Incident Response Framework was published in August 2022 by NHS England, replacing the Serious Incident Framework. Some participants expressed disappointment that the opportunity had not been taken to include the linkage and overlap between patient safety and safeguarding adults in the new guidance. Indeed, the document does not have a single reference to safeguarding adults. This guidance will not therefore be of assistance to clinicians and other frontline staff in identifying safeguarding adult concerns that should be reported as such and responded to accordingly. It was felt that   it may fall to the SQGs to put in place additional policies and procedures to fill this gap.

Links between safeguarding and patient safety are highlighted in the SAAF (described above) and NHS England Safeguarding adults pocket guide. The guidance states that safeguarding is a “fundamental part of patient safety and wellbeing”.

Safeguarding within multiple providers and provider chains

The issue of working with multiple providers, provider collaboratives, independent providers and provider chains, was mentioned by several participants in the fieldwork for this review. For example, participants referred to recent SARs concerning individuals placed in private assessment and treatment units distant from the individuals’ home. There was reference to safeguarding concerns, common across a number of neighbouring SABs, about staffing in organisations that provide services across several SAB areas. The view was expressed in the fieldwork that the lines of escalation to the ICBs and the role of the SQGs was not clear in the guidance on SQGs (discussed above).

The guidance refers to provider collaboratives, which are included in the membership of the SQG. However, there is an absence of detail about provider collaboratives and safeguarding adults. Likewise, there is an absence of reference to the safeguarding responsibilities of provider collaboratives in the guidance produced by NHS England - Working together at scale: guidance on provider collaboratives, August 2021.

It should be noted that provider collaboratives are not statutory entities. However, looking to the future, as the role of provider collaboratives is expected to grow, and the role of competition and commissioning to lessen, guidance on their relationships with not just SQGs but also with SABs should be considered.

Provider collaboratives

These are partnerships that bring together two or more NHS trusts (public providers of NHS services including hospitals and mental health services) to work together at scale to benefit their populations. While providers have worked together for many years, the move to formalise this way of working is part of a fundamental shift in the way the health and care system is organised, moving from an emphasis on organisational autonomy and competition to collaboration and partnership working.

From: Provider collaboratives: explaining their role in system working (Kings Fund, April 2022) 

Escalation of issues of common concern in more than one SAB

The issue of escalation of matters arising in SARs that cannot be addressed by an individual SAB led to the development in July 2021 by the National Network of SAB Independent Chairs of a national escalation protocol. This included escalation of matters to the Department of Health and Social Care (DHSC). 

Many participants considered that the merger of the CCGs into ICBs provided an opportunity to escalate concerns that were common across more than one SAB, which related to a single organisation or service that operated across more than one place or across the whole of the ICB footprint. This may apply to provider chains and provider collaboratives that offered services across an ICB area. This was welcomed as a positive development, along with the opportunity for shared learning from SARs between SABs. Fieldwork participants said that they expected that escalation procedures were needed particularly where more than one SAB had concerns about organisational abuse within a single provider that worked across more than one council area. 

Organisational abuse

Including neglect and poor care practice within an institution or specific care setting such as a hospital or care home, for example, or in relation to care provided in one’s own home. This may range from one off incidents to on-going ill-treatment. It can be through neglect or poor professional practice as a result of the structure, policies, processes and practices within an organisation (Care and Support Statutory Guidance paragraph 14.17).

Development of the escalation processes, at the time of this fieldwork had not yet been put in place by ICBs, but it was acknowledged that this was still early days.

Relevant guidance on escalation is the “National Guidance on Quality Risk Response and Escalation in ICS”, published by the National Quality Board in June 2022; National Guidance on Quality Risk Response and Escalation in ICS.

This document is for systems leaders as they develop their approach to quality management, managing system-level concerns and risk, managing quality concerns and risks. This guidance “builds on the guidance on SQGs” (considered above). It has little to say about safeguarding adults. The guidance takes an approach that sees quality as separate from safeguarding, which is an activity that happens at place level (page 8). 

Fieldwork participants proposed that formal escalation processes and protocols should be put in place in ICBs for SABs to use. The protocol could clarify what action can be expected from the ICB in response to any escalation.

Integrated care strategies and expected ways of working between ICPs and adult social care providers

Purpose

Guidance on the preparation of integrated care strategies was published in July 2022

The guidance states that the preparation of an integrated care strategy, ‘should set the direction of the system across the area of the ICB and integrated care partnership . . . setting out how commissioners in the NHS and local authorities, working with providers and other partners, can deliver more joined-up, preventive, and person-centred care for their whole population, across the course of their life’.

This guidance is about addressing needs at system level, but the integrated care strategy should facilitate, ’subsidiarity in decision making, ensuring that it only addresses priorities that are best managed at system-level, and not replace or supersede the priorities that are best done locally through the joint local health and wellbeing strategies’ and the local HWBs.

The guidance continues to note that “for a few integrated care partnerships, there will be just one joint local health and wellbeing strategy in their area. For most ICPs there will be multiple HWBs in their area”.

This is relevant because content about HWBs could apply to SABs. For example, most ICPs will have multiple SABs in their area. In this context, the point about subsidiarity in decision making should be noted.

The section of the guidance on the content of the integrated care strategies covers ’quality improvement’ referencing to the National Quality Board published guidance, which will include the guidance on SQGs discussed above. There is a single reference to safeguarding adults within the context of prevention, see below (there are other references to safeguarding children).

Preventative action takes many forms including the commissioning of prevention services, the promotion of health and wellbeing, population health management, intermediate care services, measures to prevent harm, suicide, violence and abuse, including through the safeguarding, of adults and children; and adopting a broad-based approach which includes action on social and economic drivers of health and wellbeing (page 23).

The guidance states that 2022 to 2023 will be a transition period. This means that ICPs are expected to publish an initial strategy by December 2022. It is recognised ’that integrated care partnerships are at different levels of maturity and development, and this will be reflected in the breadth and depth of the work that can be done in preparing the strategy and, subsequently, what is included in the initial strategy’. Going forward, ICPs will be required to produce five-year joint plans. Discussion in the workshops stressed the opportunity and importance of SABs inputting into these plans.

Other relevant guidance published at the same time as that on integrated care strategies is guidance on ways of working between ICPs and adult social care providers Expected ways of working between integrated care partnerships and adult social care providers guidance states that ICPs and adult social care providers (statutory and non-statutory) should ’build on the existing place-based partnership arrangement and local foster new working relationships’.

The guidance documents do not mention safeguarding adults or SABs explicitly, which is a missed opportunity to take advantage of the intelligence that SABs accrue about systems. This intelligence would be of value as part of the plans and priorities for ICPs.

Introduction

The Care Act 2014 provides the legal framework for safeguarding adults, building on the earlier guidance, ‘No Secrets’, launched in 1999 to provide ‘guidance on developing and implementing multiagency policies and procedures to protect vulnerable adults from abuse’. It had established the local authority as the lead agency in safeguarding and it required all agencies operating in that local authority area to report all owners of abuse to them.

The Care Act 2014 made safeguarding adults statutory. Three new categories of abuse were added to those in ‘No Secrets’: modern slavery, self-neglect, and domestic abuse or violence. The category of institutional abuse was changed to organisational abuse. Most significantly, this legislation placed SABs (previously named adult protection committees) onto a statutory footing and set out the responsibilities of councils and partners regarding safeguarding adults.

The six underpinning safeguarding principles in the statutory guidance are: empowerment, protection, prevention, proportionality, partnership, and accountability. In addition, the Care Act 2014 enshrined the principles of Making Safeguarding Personal meaning that safeguarding “should be person-led and outcome-focussed. ‘It is about engaging the person in a conversation about how best to respond to their safeguarding situation in a way that enhances involvement, choice and control as well as improving quality of life, wellbeing and safety” (DHSC, Care and Support Statutory Guidance, 2021).   

The Care and Support Statutory Guidance paragraph 14.17 identifies 10 types of abuse:

•  Physical abuse
• Domestic violence or abuse
• Sexual abuse
• Psychological or emotional abuse
• Financial or material abuse
• Modern slavery
• Discriminatory abuse
• Organisational or institutional abuse
• Neglect or acts of omission
• Self-neglect

From “vulnerable adult” to “adult/person at risk”

The term “vulnerable adult” (used in ‘No Secrets’) was replaced by “adult/person at risk”. This was more than a change in language, it represented a move away from the labelling of an individual as “vulnerable” to an approach, embedded in current practice, that requires an assessment and quantification of risk to the individual in a way that is evidenced based and enables the development of strategies to manage identified risks that is helpful to both the individual and to practitioners. This approach invites a recognition that some people might choose to take certain risks and it opens the area of positive risk taking (from Adult Safeguarding: could we do better? A Trainer’s Perspective by Bob Dawson 2021 The Choir Press).

The word ‘investigation’ was replaced by ‘enquiries’. The term ‘alert’ has been replaced by raising a ‘concern’.

Three criteria for safeguarding adults

Safeguarding duties apply to an adult who meets the following three criteria:

1. Has needs for care and support (whether or not the council is meeting those needs)
2. Is experiencing, or at risk of, abuse or neglect
3. as a result of their care and support needs is unable to protect themselves from either the risk, or the experience of abuse or neglect.

Prevention

Section 2 of the Care Act 2014 puts the duty on councils, ’to provide or arrange for the provision of services, facilities or resources, or take other steps, which it considers will contribute towards preventing or delaying the development by adults in its area of needs for care and support’. The application of this principle to safeguarding adults is developed further in the guidance and sits in addition to the safeguarding responsibility for those covered by the above three criteria.

Prevention: Responsibility for ’promoting prevention, early intervention and partnership working is a key part of a DASS’s role and also critical in the development of effective safeguarding’. However, all officers, including the chief executive of the local authority, NHS, police chief officers and executives should lead and promote the development of initiatives to improve the prevention, identification and response to abuse and neglect (from the Care and Support Statutory Guidance paragraph 14.216).

The Care and Support Statutory Guidance chapter 14 states that, ’strategies for the prevention of abuse and neglect is a core responsibility of a SAB and it (the SAB) should have an overview of how this is taking place in the area and how this work ties in with the HWBs, quality surveillance groups (QSG), community safety partnerships and the Care Quality Commission’s (CQC) stated approach and practice’.

Care quality: This could be about commissioners and the regulator, together with providers, acting to address poor quality care and the intelligence that indicates there is risk that care may be deteriorating and becoming abusive or neglectful. It could also be about addressing hate crime or anti-social behaviour in a particular neighbourhood. The SAB will need to have effective links and communication across a number of networks in order to make this work effectively (from the Care and Support Statutory Guidance paragraph 14.140).

Role of the council

The Care Act 2014 requires that each council must:

• make enquiries, or cause others to do so, if it believes an adult is experiencing, or is at risk of, abuse or neglect. An enquiry should establish whether any action needs to be taken to prevent or stop abuse or neglect and if so, by who
• set up a Safeguarding Adults Board (SAB)
• arrange, where appropriate, for an independent advocate to represent and support an adult who is the subject of a safeguarding enquiry or Safeguarding Adult Review (SAR) where the adult has ‘substantial difficulty’ in being involved in the process and where there is no other suitable person to represent and support them
• co-operate with each of its relevant partners in order to protect the adult. In their turn each relevant partner must also co-operate with the council.

Establishment of SABs

Each council must set up a SAB. The main objective of a SAB, ’is to assure itself that local safeguarding arrangements and partners act to help and protect adults who meet the three criteria’ (Care and Support Statutory Guidance paragraph 14.133).

The core membership of every SAB comprises the council, the CCG and the police. The Health and Care Act 2022 Schedule 4: Integrated Care System minor and consequential amendments amends the Care Act 2014, to replace references to clinical commissioning groups with ICBs. This took effect from 1 July 2022.

However, others may be invited to join the SAB, and in practice SABs have a wide-ranging membership drawn from across both the local statutory and non-statutory providers, service user and care representation, fire brigade, Department of Work and Pensions (DWP), probation, other council departments including housing and advocacy organisations. 

SABs must publish a strategic plan, publish an annual report and conduct SARs for cases that meet the statutory criteria.

The Care and Support Statutory Guidance paragraph 14.140 states that each SAB should:

• identify the role, responsibility, authority and accountability with regard to the action each agency and professional group should take to ensure the protection of adults
• establish ways of analysing and interrogating data on safeguarding notifications that increase the SAB’s understanding of prevalence of abuse and neglect locally that builds up a picture over time
• establish how it will hold partners to account and gain assurance of the effectiveness of its arrangements
• determine its arrangements for peer review and self-audit
• establish mechanisms for developing policies and strategies for protecting adults which should be formulated, not only in collaboration and consultation with all relevant agencies but also take account of the views of adults who have needs for care and support, their families, advocates and carer representatives
• develop preventative strategies that aim to reduce instances of abuse and neglect in its area
• identify types of circumstances giving grounds for concern and when they should be considered as a referral to the local authority as an enquiry
• formulate guidance about the arrangements for managing adult safeguarding, and dealing with complaints, grievances and professional and administrative malpractice in relation to safeguarding adults
• develop strategies to deal with the impact of issues of race, ethnicity, religion, gender and gender orientation, sexual orientation, age, disadvantage and disability on abuse and neglect
• balance the requirements of confidentiality with the consideration that, to protect adults, it may be necessary to share information on a ‘need-to-know’ basis
• identify mechanisms for monitoring and reviewing the implementation and impact of policy and training
• carry out SARs and determine any publication arrangements;
• produce a strategic plan and an annual report
• evidence how SAB members have challenged one another and held other boards to account
• promote multi-agency training and consider any specialist training that may be required. Consider any scope to jointly commission some training with other partnerships, such as the Community Safety Partnership.

Safeguarding adult reviews (SARs) 

Under section 44 Care Act 2014 SABs must arrange a SAR where an adult in its area dies as a result of abuse or neglect, whether known or suspected, or the adult has experienced serious abuse or neglect, and there is concern that partner agencies could have worked more effectively to protect the adult. 

Supply of information (section 45 Care Act 2014)

A SAB may request a person to supply information to it or to another person. The person who receives the request must provide the information to the SAB if:

• the request is made in order to enable or assist the SAB to do its job
• the request is made of a person who is likely to have relevant information and then either
  • the information requested relates to the person to whom the request is made and their functions or activities
  • the information requested has already been supplied to another person subject to an SAB request for information.

Agencies are expected to draw up a common agreement relating to confidentiality and setting out the principles governing the sharing of information, based on the welfare of the adult or of other potentially affected adults.

Leadership of the multiagency system

The lead agency with responsibility for coordinating adult safeguarding arrangements is the council. The council has the legal duty under section 42 Care Act 2014 to make safeguarding enquiries or secure others to do so, where a concern is raised or suspected, and to take the decision as to whether a referral progresses to a safeguarding enquiry. This means that in some cases the council will carry out the section 42 enquiry and in other cases they will ask the referring agency to carry out the enquiry and feed back to them. In all cases the council retains a responsibility until the risk is assessed and managed effectively or resolved.

There is a legal requirement on all health and social care and support agencies to pass concerns on to the council where it is believed abuse may have occurred ’Safeguarding requires collaboration between partners in order to create a framework of inter-agency arrangements’ (Care and Support Statutory Guidance paragraph 14.137).

While the council has lead responsibility for coordinating adult safeguarding arrangements, all the members of the SAB should designate a lead officer, and other agencies should consider doing likewise.

Information and advice on adult safeguarding

The council must provide information and advice on how to raise concerns about the safety or wellbeing of an adult who has needs for care and support and should support public knowledge and awareness of different types of abuse and neglect, how to keep yourself physically, sexually, financially and emotionally safe, and how to support people to keep safe. The information and advice provided must also cover who to tell when there are concerns about abuse or neglect and what will happen when such concerns are raised, including information on how the local SAB works.

Local authority members

The Care Act guidance states that councillors, ’need to have a good understanding of the range of abuse and neglect issues that can affect adults and of the importance of balancing safeguarding with empowerment’. Councillors need to understand ’prevention, proportionate interventions, and the dangers of risk adverse practice and the importance of upholding human rights’.

Some SABs include councillors, especially lead members, and this is one way of increasing awareness and ownership at a political level. Others take the view that councillors are more able to hold their officers to account if they have not been party to SAB decision making, though they should always be aware of the work of the SAB. There is guidance for members on safeguarding published by the LGA: Must Know: How do you know your council is doing all it can to safeguard adults?

Safeguarding adults collection (SAC)

The SAC is a mandatory (but not statutory) annual data collection which records information about individuals for whom safeguarding referrals were opened during the reporting period (also referred to as adults at risk) and case details (also referred to as allegations) for safeguarding referrals which concluded during the reporting period. The purpose of the collection is to provide information which can help stakeholders to understand where abuse may occur and improve services for individuals affected by abuse. Responsibility for making this return sits with the council.

The data are recorded by adult safeguarding teams based in the councils with adult social services responsibilities in England. At the end of the reporting year these data are submitted to NHS Digital. Information within the return includes:

• the number of safeguarding concerns raised
• the number of safeguarding enquiries started
• the number of safeguarding enquiries completed throughout the year under Section 42 of the Care Act 2014.

Enquiries are broken down by the type and location of safeguarding risk. All data is available at a local, regional and national level.

The return also provides demographic information about individuals who were the subject of a Section 42 enquiry that was started within the year; and the outcomes of completed enquiries where a safeguarding risk was identified.

Checklist for DASS, SAB chairs, ICB council leads, and adult social care portfolio holders

This checklist is the result of a review to provide an early understanding of the impact of the NHS integrated care systems (ICS) and integrated care boards (ICBs) on adult safeguarding. The review was funded by the Department of Health and Social Care (DHSC) and delivered by the Local Government Association (LGA) in association with the Association of Directors of Adult Social Services (ADASS).

The approach taken included a review of recent policy and guidance, to consider how safeguarding duties are to be met in the new organisational arrangements; fieldwork, using appreciative inquiry, with a range of individuals leading and working in safeguarding adults to understand the impact of the new integrated care systems (ICSs on safeguarding adults; and revisiting Care Act 2014 and the accompanying Care and Support Guidance with respect to safeguarding adults and health responsibilities. ]

• Do you know who in your ICS and ICB has responsibility for safeguarding adults?
• Are you connected to the SQG and involved in its establishment and development?
• Are you seeking assurance that the ICB Board is sufficiently cited on its responsibilities for safeguarding adults and that the whole board is safeguarding literate?
• Are you working with the SQG and the chief nurse (or whoever in the ICB has lead responsibility for safeguarding adults) to ensure that an escalation policy and protocol are in place that make clear what action is expected from the ICB in response to any escalation? 
• Do you have an ICB member on your SAB who is sufficiently senior, and a consistent attender, and appropriate ICB leads engaged in the work of the subgroups? 
• Is the SAB board/business manager connecting with relevant people in the ICB?
• Are there sufficient designates in post to do the work to safeguard adults?
• Are you part of and engaged in (or setting up if not in place) a network with colleague DASS and SAB chairs across the ICB footprint?
• Is there agreement between the DASS and the independent SAB Chair on your respective areas of engagement with the ICB – including the SQGs and with the local ICP?
• Are you negotiating what data your SAB expects from the ICB and NHS / NHS funded providers? Is it, or could it be, the same dataset across all the SABs in the ICB footprint?
• Does the SAB annual strategic plan capture relevant ICB priorities / developments? Do existing plans need updating?  
• How does the SAB annual report feed into the work of the ICB and the ICP strategy?
• Do data sharing policies need updating?

Guidance for adult social care portfolio holders published in April 2022

Must Know: How do you know your council is doing all it can to safeguard adults?