Navigating complexity: Safeguarding adults amidst the cost of living, hospital discharge and winter pressures

Through a sector-led improvement approach, we sought consensus from a wide range of stakeholders, including the National Safeguarding Adults Board (SAB) Chairs Network and the workstream reference group composed of lead representatives from the Adult Principal Social Worker Network, Association of Directors of Adult Social Services (ADASS), SAB chairs and SAB managers, as well as the safeguarding adults policy leads at the Department of Health and Social Care.

They agreed that there was a need to better understand the impact of winter pressures, hospital discharge and cost of living, to learn and share reflections, descriptions of barriers, constructive interventions and innovations in response to changing safeguarding needs.

We issued a call out to councils, safeguarding teams and SABs to fill in an online survey-feedback form, which included an opportunity to provide free text describing their experience of safeguarding adults during this period regarding winter pressures, hospital discharge and cost of living.

Whilst there have been in-depth, recent accounts of these specific areas, significantly there has not been a focus on the impact on adult safeguarding. These contextual accounts include Joseph Rowntree Foundation 'UK Poverty 2023'; Office for National Statistics 'Impact of increased cost of living on adults across Great Britain' (2022); Going under and without: JRF's cost of living tracker 2022/23; Financial Conduct Authority 'Financial Lives 2022 survey' and Partners in Care and Health 'Alleviating winter workforce pressures in adult social care'. 

Whilst all councils send data as a part of the annual Safeguarding Adults Collection (SAC) (a mandatory annual data collection from councils, which captures information about safeguarding activity, collated by NHS Digital) this does not specifically capture the impact of cost of living, hospital discharge and winter pressures. So, the possibility of capturing standardised numerical data was unfeasible and unrealistic. Further, qualitative observations seeking local good practice, such as measures taken by organisations and key partnerships, preventative action, community-centred approaches and staff resilience strategies is not collated elsewhere. 

The intention is that this qualitative intelligence collected will improve understanding of the impact on safeguarding adults of winter pressures, the complexities of hospital discharge and the cost of living locally and nationally. This will assist in identifying areas of commonality, specific areas of pressure and good practice, to help inform preparations and future planning of safeguarding adults’ activity through these shared reflections, descriptions of barriers, interventions and innovations.

There were 42 councils that took part in the survey across England and 41 who shared qualitative insight (which is 27 per cent of top tier and unitary councils in England). The council respondents are labelled from two to 43. Fifty-six per cent (23/41) of the insight was compiled or written and sent in by safeguarding adult board chairs or managers; 17 per cent (7/41) were other members of the Safeguarding Adults Board Team. Others who shared data included mental capacity clinical lead, designated nurse, services director and head of adult safeguarding. The survey asked about their experience of safeguarding activity in 2022/23 compared to 2021/22.

The scale of whether they had provided intelligence about expected levels of safeguarding regarding hospital discharge, winter pressures and the cost of living, spanned from:

• about the same as expected
• lower than expected
• much lower than expected
• much higher than expected
• slightly higher than expected.

The information they shared also sense checked their expectations of winter morbidity, people experiencing homelessness or rough sleeping, substance misuse, industrial action, workforce recruitment or retention.

The survey had space for localities to share qualitative intelligence on the impact of winter pressures, hospital discharge and cost of living locally on safeguarding activity and local actions taken to mitigate risks of abuse or neglect to help inform prevention and protection work and future planning.

More than half (56 per cent) of council respondents working within adult social care said cost of living was having a ‘severe’ impact on the lives of people accessing services, with a further 31 per cent saying the effect was ‘significant’. The concerns of partners expressed in the development of this project reflect the concerns of the County Councils Network, which warned that the cost-of-living could add £3.7 billion to the costs of delivering adult social care. There were additional concerns and fears that the could further fuel debt, mental ill health and domestic abuse; this observation was shared in commentary in the Community Care survey in August 2022.

There were growing concerns reported that safeguarding issues could emerge or become aggravating factors resulting from the cost of living and consequent pressures on people, their carers, and families. This project aimed to identify if there were reported increased levels of safeguarding activity, increased complexity in safeguarding situations or barriers to safeguarding activity associated with the cost of living. The project also explores if there were settings, support needs or abuse types that may experience changes. The project also considers contextual challenges and impacts including:

• integrated health and social care approaches
• exacerbation of inequalities
• impact of having or absence of personal support
• local voluntary or community support systems
• impact on ability to purchase care
• market capacity challenges
• impact on staff and workforce capacity
• health system pressures
• impact of winter pressures in 2022/23 (including backlogs in elective care, waits in urgent care and emergency pressures)
• impact of backlogs in adult social care delivery (assessments and reviews)
• impact of flu and COVID-19
• impact on informal carers and paid care workers.

This insight project asked councils to consider safeguarding activity between April 2022 to March 2023. The call for information included identifying local good practice surrounding safeguarding adults’ activity directly, and those interventionist activities that could prevent or better identify those adults who may meet the criteria of section 42 safeguarding enquiry^.. 

The intention of this project is that qualitative intelligence is collected to improve understanding of winter pressures, the complexities of hospital discharge and the cost-of-living locally and nationally to help inform preparations and planning. We also asked councils to consider exploring intersections between winter pressures, hospital discharge, cost of living and other factors built into the survey. They were asked to identify additional considerations in the cost of living including mental health, impact on carers, care and health charges and winter pressures. Other areas of activities that came to the fore were activities taken by councils and by key partners (or in partnerships), preventative action, community-centred approaches and staff resilience strategies.

There were significant reflections around trying to make sense of how safeguarding adults intersects with cost of living, winter pressures, hospital discharge and COVID and how this was reflected in the Safeguarding Adult Collection as submitted to NHS Digital.

Understanding the data

Council respondents did express difficulty in being able to collect and share quantitative data further to the Safeguarding Adult Collection, which is submitted to NHS Digital and to untangle and/or categorise their data in terms of areas of focus: cost of living, hospital discharge and winter pressures.

Twelve council respondents referred to data specifically and their understanding of how it related to adult safeguarding and with cost of living, winter pressures and hospital discharge. Council respondent 10 said, “I don't think anyone could legitimately answer . . . questions from a data perspective, only anecdotal feedback, as this is not recorded from a safeguarding perspective.” The same council respondent also admitted that this was not something that their SAB had been measuring but could start considering in specific questions. They were considering this in the context of homelessness. Another council respondent (14) was looking to develop this in the SAB performance dashboard to capture this data.

Council respondent 43 had captured specific areas, for example regarding poor discharge and homelessness (council respondents 23, 25 and 39), as local priority issues. Another interesting observation was that whilst council respondents did have data around the three areas specified, this was not correlated with adult safeguarding data. Council respondent 30 collected data around identification of increased number of fires as triangulated with ethnicity, captured rates of substance misuse and pressure ulcers and financial abuse increases through winter pressures, delayed discharges and post discharge support.

Council respondent 20 described how their local Healthwatch had captured responses from their own cost of living survey which identified that 2.5 per cent of council respondents had said that “they had cut down or stopped support from paid care workers”.

About the report

Individual council data is treated confidentially in this project: this report does not identify any specific individual or council, instead showing the overall picture of the situation. Identifiable information about individual councils and respondents is used internally by the LGA but is only held and processed in accordance with the LGA privacy statement.

Caveats

The impact of cost of living, hospital discharge and winter pressures varied across different areas. The councils participating in this project are small and self-selected and therefore may not be fully representative. However, this report hopes to provide a snapshot of the safeguarding adults’ activity between April 2022 to March 2023.

Multifactorial findings

For all three themes of the report, perhaps the most significant consideration was the multifactorial and interconnected nature of the issues, not only in relation to each other, but also with additional aspects such as COVID, low incomes, inflation, increased complexity of safeguarding and over-reliance of agency staff, low levels of recruitment and retention and challenges in the adult social care market. Cost of living, winter pressures and hospital discharge are entangled with multiple factors that interconnect. Council respondent 32 captured the importance of interconnectedness and partnership working, which was acutely felt when absent:

. . . coming into contact with people who were experiencing significant hardship . . . partnership working is missing . . . many cases of self-neglect . . . Substance misuse issues alongside mental health problems are leading to additional complications with individuals being taking advantage of . . . Patients are reluctant to go home when they are community ready due to the financial pressure of living at home . . . Changes in the discharge pathway/pressures particularly timelines have seen a significant number of people returning home still unwell therefore readmission has increased . . . Impact of the hospital trust operating at Level 4 escalation has impacted on services." Council respondent 32

What was also apparent was that multi-agency solutions and approaches were required to combat multifactorial difficulties. This will be discussed in 'Multifactorial interventions: interventions with broad impact section'.

Cost of living

The Institute for Government describes the current changes in the cost of living as:

 ... the fall in ‘real’ disposable incomes (that is, adjusted for inflation and after taxes and benefits) that the UK has experienced since late 2021. It is being caused predominantly by high inflation outstripping wage and benefit increases and has been further exacerbated by recent tax increases.

Research from the Joseph Rowntree Foundation (JRF) (2023) highlighted how households were more vulnerable to being unable to meet the costs of living. With increasingly squeezed household budgets people were falling behind with their bills; going without essentials; using credit to pay bills, being unable to afford an unexpected essential expense of £200. The report further identified how particular ethnic groups (particularly those of Bangladeshi and Pakistani heritage) were more likely to experience the sharp end of cost of living impact and additionally intersectionality of gender compounded this further and included the specific impact on black women.

This figure was over four in ten for people in households headed by someone of Pakistani or black ethnicity. This is over twice the rate of people in households headed by someone of white ethnicity."
The Joseph Rowntree Foundation Report, UK Poverty (2023)

Shared insights regarding safeguarding issues in relation to cost of living

Councils providing insight have reported that:

• increasingly, people with care and support needs were unable to afford their paid care workers
• people who were struggling under the cost of living impact were presenting or being referred to adult social care, which is unable to provide support as they were not meeting section 42 criteria
• seeing increased levels of domestic abuse, and the cost of living has negatively impacted on the victim’s ability to leave
• increased levels of safeguarding concerns in respect of self-neglect, neglect and acts of omission from care and health providers
• increased severity of risk
• increasing numbers of the workforce are leaving their current roles to find more sustainable salaries, including care workers and social workers; the instability of the housing market has accelerated this exodus
• an over reliance on agency workers across health and social care, more than ever before
• an increase in paid care workers financially abusing their clients (theft) because of their own financial struggles
• instability of the housing market affecting people with care and support needs, which has led to increased vulnerability to abuse, neglect and harm.
• supported housing services are seeing people with higher mental health needs and risks
• higher risk of provider failure related to the cost of living impact and the retention and recruitment of staff
• 'hidden' residents within the community, often neglected and are not bought to the attention of adult social care.

There was a recognition that the provision of subsistence payments was available to offset some of the risk and this was valued by council respondents, particularly for those struggling to access services or were experiencing multiple disadvantages. One of the initiatives to counter the impacts of the cost of living was a government measure, the Household Support Fund (HSF) which is money that government has given to local councils during this period so they can support residents who are considered most ‘vulnerable’ to struggling with essential daily costs, like buying food and paying energy bills. Two councils explicitly mentioned the HSF as an intervention. Other councils described the way that HSF had been used to make welfare offers, provide crisis support payments and was used to support ‘provider engagement on food and fuel payments and . . . winter support scheme provided information and support’.

Twenty per cent of councils mentioned foodbanks and activity surrounding this provision. All these councils noted an increase in requests for referrals to the foodbanks or identifying increased use of or requests for and providing supporting to the foodbanks themselves. There was an increased mention of signposting to third sector organisations and increases in welfare concerns where that did not necessarily lead to Care Act assessments.

There were some interesting initiatives and approaches that were looking at experiences of poverty, that were creating spaces, forums, summits, working with the voluntary sector and multi-agency hubs to find collective responses, practical actions and there were descriptions of co-ordination of resources and making collective plans. Council respondent 37 held a partnership summit which included people with lived experience of poverty to discuss and plan how they worked collectively to respond to the cost-of-living, to develop short term practical actions, based on their five key areas of support for residents (food, fuel and energy, maximisation of income and access to financial and debt advice, housing, childcare and school). This council also developed a cost of living resident support dashboard which looked at calls to the helpline, doorstep engagement, support and inclusion team engagements.

There was a recognition that, whilst these initiatives were helpful, there were people who were falling between services or people effectively 'hidden' from sight and not necessarily brought to the attention of adult social care services or did not meet the criteria for safeguarding support under section 42. Additionally, there was recognition that, as one council (42) described, “this crisis [cost of living] doesn’t lend itself to a statutory safeguarding protection plan as these are much more multi-faceted in nature and require a more comprehensive approach.”

In early 2023, the debt charity StepChange revealed in their commissioned YouGov poll the depth and breadth of the impact of the cost of living in the United Kingdom:

Two in five (40 per cent), 21 million people, are finding it difficult to keep up with household bills and credit commitments, up from one in three (34 per cent) in September 2023 – an increase of 3.5 million people in just four months."
StepChange press release (2024)

With inevitable rationing of food, heating, electricity and water, increased levels of debt in trying to manage the cost of essentials and the stopping of the household support fund, low-income households face further spiralling of financial hardship. The publication 'UK Poverty' by Joseph Rowntree Foundation (2024) (Annex 1, pp 144) gives a number of measures of poverty and consequences of poverty. The South Tyneside Safeguarding Adults Board Procedures has a chapter on 'Working with people living with poverty' and including ‘How poverty affects people with care and support needs’. 

The issues described by South Tyneside resonate very much with the theme sent through by the respondents including increased incidents of self-neglect, which are associated with poverty. Understanding safeguarding responsibilities in broader terms regarding cost of living or poverty was an approach that was mentioned or demonstrated by several council respondents.

Broader safeguarding responsibilities

Council 42 was keen to approach adults safeguarding through the lens of their poverty reduction framework. The principal social worker quoted the Care Act 2014 in describing their rationale:

Safeguarding means protecting an adult’s right to live in safety, free from abuse and neglect. It is about people and organisations working together to prevent and stop both the risks and experience of abuse or neglect, while at the same time making sure that the adult’s wellbeing is promoted including, where appropriate, having regard to their views, wishes, feelings and beliefs in deciding on any action.|"
Care Act 2014 guidance (Section 14.2) [Council 42]

Their multi-agency framework reflected broader effective outcomes and considerations of discharging preventative safeguarding responsibilities, which have been emphasised in 'Understanding what constitutes a safeguarding concern and how to support effective outcomes'. This adult safeguarding ethos was focussed on not waiting to respond to people as they reached a crisis point.

There was a recognition that early intervention to help build resilience, skills, confidence and resources within the community and a multi-agency approach could reduce deterioration and prevent escalation of care and support needs. This objective brought a recognition that the current cost of living crisis highlighted that the safeguarding risk “does not lend itself to a statutory safeguarding protection plan as these (risks) are much more multi-faceted in nature and require a more comprehensive approach”. They reflected those provisions such as “subsistence payments available offsets some of the risk, but much more support is needed - the 'hidden' residents within our community are often neglected and are not bought to the attention of ASC [adult social care]”.

Respondent council 37 described how poverty and cost of living had deeply impacted people’s resilience to the risks of experiencing abuse and neglect and safeguarding concerns.

Council teams beyond the 'safeguarding team' described how they worked with people using a strengths-based and/or trauma informed care approach. Working more widely with people who were experiencing homelessness; substance misuse; mental health issues; domestic abuse and/or involvement with the criminal justice system.

Respondent council 39 described how they commissioned additional home care services so that they were able to meet the needs of the local population. Whilst respondent council 40 described how their locality teams and the Mental Capacity Act team undertook preventative work which freed up the safeguarding team to focus on their safeguarding work.

Respondent council 38 described their cost of living hub which housed Citizen Advice Bureau, domestic abuse, substance misuse services, foodbanks.

Respondent council 37 described their focused care practitioners’ outreach where patients who were referred by GP practice staff, local community workers or even the police, when the usual care plan did not appear to be working. The focused care practitioner then works with the patient’s household to begin to unpick situations, assessing need and using local health and community contacts in order to begin to bring stability to ‘an often chaotic situation’.

Council respondents 15 and 23 both mentioned their use of social prescribers, council respondent 23 had a warm spaces initiative, opening up public buildings such as libraries for people to visit, stay warm, have a hot drink. They were also able to access social care and social prescriber services.

Focus care practitioners and social prescribing connect residents to community groups, activities and organisations that could support them to improve their health, wellbeing, and social connections. This was available for people experiencing loneliness and isolation; loss of confidence; anxiety or low mood; life changing events such as bereavement, having a baby, or retirement; living with long term health conditions; or experiencing challenges with finances, work, relationships or housing. These roles described how it helped reduce caseloads of other frontline health and social care staff (such as doctors, nurses, social workers, and so on). They had more time to work with individual having a more preventative and early intervention approach to help keep people healthy, safe and well.

Winter pressures

It has been recognised across the health and social care sectors that there are significant frontline pressures over the winter period (which is considered the period from end of November or December to March) as demand for services tends to increase significantly with the onset of cold weather, flu, COVID-19, with accompanying increased demands on health and care services, (including mental health), community and voluntary sector and ambulance service. This report considers what safeguarding adult issues had emerged during the period under review.

There is some discrepancies as to start of winter which can be from November or December dependent on organisational/sectoral pressures, see NHS England, NHS Education England or NHS Providers.

“Winter pressure, what winter pressure?”

There were only 12 council respondents (31 per cent) who answered the winter pressure questions, indicating the challenges of providing insight in this area. Those who responded all described the difficulty of capturing ‘winter pressure data’. Two council respondents mentioned a significant increase of pressure ulcers, one saying there was a ‘three-fold increase’ during this period.

We don't refer to winter pressures from a safeguarding perspective, and because services are continuously stretched, we do not see any significant trends across different times of the year. If anything, recorded safeguarding activity tends to spike in the spring.” A council respondent

Councils stressed that they were not collecting data on winter pressures and reported that they were unable to distinguish between cost of living, COVID and winter pressures.

Some council respondents did identify pressure points particular to winter pressures, Council respondent 43 described receiving a high number of referrals to their assistance scheme and anticipated that this would rise again as they approached and moved into winter, as people struggle with heating costs. They described how their front door was:

. . . inundated with referrals for people with low level self-neglect concerns and suicidal callers/people with very poor mental health and these issues are likely to get worse over winter. These rarely meet the threshold for s42 but tend to be either signposted or put through for a care and support assessment. Local authority holding lists are a concern and likely to rise over winter. They are regularly risk assessed and reprioritised but there is the risk that someone will not be seen in time.” Council respondent 43

There are increased pressures on local authorities as people without care and support needs approached them for support and concerns that if support isn’t available, people may come to services at a later point of their journey, with a more complex and/or severe presentation and higher care and support needs. This same point was a concern expressed in the context of cost of living and hospital discharge pressures in relation to service demands. It reflects the tension between prevention and protection and the challenges of being able to provide preventative support.

Shared insights regarding safeguarding issues in relation to winter pressures

The key messages from the councils that responded regarding the impact of winter pressures on safeguarding adults’ activity were:

• councils expressed that they were not collecting data on winter pressures, it was difficult to differentiate between cost of living, COVID and winter pressures
• one council (10) said that, whilst they had seen increases over specific abuse types such as including substance misuse, financial abuse and neglect and acts of omissions over the winter period it was difficult to attribute this directly to winter pressures
• difficulties in recruitment and industrial action added to the pressures in winter period
• council respondent 37 said that they saw increases in safeguarding concerns due to proactive work. Examples included: identifying individuals who experience homelessness. Another council respondent 26 described how one of their care providers had maintained a contact list of adults at risk who may be especially vulnerable during the winter period and provided regular 'check ins' with them. This organisation used volunteers to support this work and provided guidance on claiming benefits, accessing specific foods to meet dietary requirements etc. relating to faith, cultural and religious requirements
• council respondent 28 mentioned seeing increased complexity of cases as well as spikes whilst one described this as “unallocated” to any particular abuse type
• council respondent 26 respondent described how, whilst anticipating year on year increases in safeguarding referrals in line population growth, aging population and ongoing impact of reductions in public funding for health and social care was further complicated by winter pressures
• council respondent 37 reflected that winter pressures combined with hospital discharge saw increase of people not receive the correct care within residential or nursing homes and an increase in the number of out of borough placements.

Winter pressure interventions

Council respondent 43 described how within their integrated care system they had a ‘Winter Well programme’ as a central portal for advice and support, as well as a Wellness on Wheels Bus, which was jointly funded by the NHS Health and Public Health. The bus travelled across the locality supporting people from inclusion health groups and deprived communities and has a range of advice and information. Council respondent 43 also explained how they had a voluntary collation of various organisations to provide support or advice and signpost the public appropriately.

Council respondent 39 described how they activated their Severe Weather Emergency Protocol (SWEP), this included extra outreach shifts looking for anyone who is sleeping rough and encouraging them to take up the offer of accommodation. The majority of people will be supported into emergency hotels, with some people placed into accommodation with 24-hour support, depending on their needs. There are also dedicated assessment times for people to meet with the outreach staff. However, council respondent 37 described the strains put on rolling out SWEP when there are eight fewer beds than last year:

...and did not receive additional funding (along with other local authorities) to help manage demand under its Severe Weather Emergency Protocol (SWEP) accommodation due to changes in government funding. Increasing demand is being seen from groups such as resumed short-notice evictions from Home Office accommodation, prison discharges (both over-represented groups within Greater Manchester single homelessness accommodation) and hospital discharges needing to be met within transfer of care deadlines.” Council respondent 37

Council respondent 26 described a proactive approach with partners, with one care provider:

One of the care providers that are a partner on the board maintained a contact list of adults at risk who may be especially vulnerable during the winter and provided regular 'check ins' with them. The organisation used volunteers to support this work and provided guidance on claiming benefits, accessing specific foods to meet dietary requirements and so on, relating to faith, cultural and religious requirements.” Council respondent 26

Other winter pressure interventions

Councils mentioned some additional general interventions undertaken during this period:

• increased short term intervention support to expedite discharge from additional winter beds
• increasing review and assessment teams to clear backlogs
• every year adult social care uses winter pressure funding to bolster service delivery, but this is not specifically related to safeguarding activity.

Hospital discharge

Hospital discharge describes the process when a person leaves hospital. If safeguarding concerns are identified around the time of discharge, then a decision with the person should be made to determine what safeguarding process and/or arrangements for safe discharge planning should be made. Policy priorities are to reduce hospital length of stay and prevent unplanned readmission to hospital. When a person with care and support needs has been placed at risk of or has suffered significant harm, as a consequence of unsatisfactory and/or adverse discharge arrangements this may also require raising a safeguarding concern.

Shared insights regarding safeguarding issues in relation to hospital discharge

Fourteen council respondents (35 per cent of all council respondents) shared their responses regarding hospital discharge. There were a variety of responses as to whether safeguarding data was able to identify specific safeguarding adult concerns associated with hospital discharge. Council respondent 37 was able to connect safeguarding concerns and enquiries with hospital discharge in their locality, saying that they:

...saw an increase in the volume of people leaving hospital without care and support and appropriate services in place ‘to follow them home’ and then going into crisis in the community particularly from a self-neglect point of view. This was reflected in safeguarding data because whilst some people utilised wellbeing services others did not and then hidden harm was occurring and the impact of that was seen later in a person’s journey when things had deteriorated significantly for them.” Council respondent 37

For the most part council respondents expressed a difficulty in measuring the impact of hospital discharge on safeguarding (four council respondents) as they did not place them into specific categories that would identify them. Council respondent 27 described the inter-connectedness of hospital discharge with other factors including winter pressures, cost of living and COVID, inflation, and so on. Council respondents also articulated higher levels of acuity and complexity in hospital discharge, with several issues concerning unsafe discharge:

• medication not transported with the patient
• care packages not being restarted/not put in place when the patient returned home
• increased levels of out of area placements
• people discharged overnight without support
• pressure ulcers on discharge
• use of restraints
• sexual abuse allegation against staff
• vulnerable adults absconding
• people with increased complexity being discharged into care homes leading to high risks of safeguarding incidents
• lack of available/suitable accommodation and support provision has meant that some discharges and placements are taking place into emergency accommodation
• Emergency accommodation required providers to put in place plans to manage risks such as financial and other abuse, such as ‘cuckooing’ from other residents and/or acquaintances
• people with care and support needs not receiving the correct care within residential or nursing homes
• people with increased complexity being discharged into care homes led to high risks of safeguarding incidents such as people being admitted with pressure ulcers or people being admitted with increased management needs and risk factors which providers subsequently find challenging to manage.

Council respondents described increased pressures on their staff and across the health and care system. A couple of council respondents expressed that they did not see corresponding changes in safeguarding concerns, others did not comment on changes in safeguarding concerns connected with hospital discharge. Interventions of hospital discharge were more of a focus of council respondents who described how they had managed it.

Hospital discharge: intervention themes

There were some interventions that had financial investment, a reconfiguration of how money is used and/or strategic partnerships. The 'Home Recovery Hospital Discharge' scheme, which included one-off personal budgets, was described by council respondent 23. The intervention is:

...support[ed] unpaid carers to either offer short term support to a loved one being discharged, or to continue their caring role following a loved one being discharged, where there are barriers to them doing so. Through use of one-off personal budgets, the scheme offers up to £1,200 over six weeks for specific items/adaptations/one-off costs, thereby reducing risks to the person by delivery of support through a familiar family member rather than through commissioned care or supports a reduction in stressors for carers that were impacting on their ability to continue in their caring role. The scheme links as well to the enhanced link with the local carers service.” Council respondent 23

Council respondent 30 described a scheme created in partnership with a private mental health provider where they take all people discharged from hospital for the first two weeks. The scheme was funded by the mental health trust, but was monitored jointly with the local authority. They also had dedicated social work teams that oversaw the hospital discharge.

Council respondent 37 described their partnership with a hospice to ensure appropriate nursing care:

‘In Reach and Step Down’ involved allocation of four hospice beds to support hospital discharges for patients who were ‘more medically optimised’ but were waiting on social support or a certain 24-hour placement and therefore patients continued to receive appropriate nursing care until social support was available.” Council respondent 37

Council respondent 23 described how they had begun to use more immediate approaches to commissioning and care sourcing for hospital discharge, with improved oversight of where people are being transferred to in-bed based settings. They found that this made for improved safer discharges to the right care provision for the person's needs. Additionally, they had made more frequent and earlier contact with people and observations of their care delivery. 

Other interventions council respondents mentioned included:

• improved quality assurance processes
• developing learning from a Safeguarding Adult Review regarding hospital discharge
• thematic focussed discussions at Safeguarding Adult Board
• improved processes for safe discharge planning from hospital to home developed/developing toolkits and checklists
• ensuring other partner agencies check home environment before discharge (in other words Age UK) which minimises or identifies safeguarding risk
• increased short term intervention winter beds to support to expedite discharge
• promotion of ‘Give them a call’ campaign to encourage people to call others.

Multifactorial interventions: interventions with broad impact

The recognition of multifactorial factors impacting cost of living, hospital discharge and winter pressures was reflected in many of the interventions that were designed to provide an effective antidote to the complexity of the issues that arose. Interventions often were shaped by multifactorial, intersectional and interconnected approaches and solutions, which required multi-agency and partnership working both strategically and operationally across the system.

Seventeen (44 per cent) of council respondents described approaches connected to cost of living through their multi-agency partnerships. Council respondent 42 highlighted the need for a multi-agency approach to address the cost of living impact and the value of the provision of subsistence payments which was available to offset some of the risk but a recognition that ”much more support is needed - the 'hidden' residents within our community are often neglected and are not bought to the attention of ASC [adult social care].”. They reflected how the increasingly the safeguarding risks they had come across during the cost of living “doesn’t lend itself to a statutory safeguarding protection plan as these are much more multi-faceted in nature and require a more comprehensive approach”.

Council respondent 37 explained that “winter pressures, hospital discharge pressures and the cost of living were interconnected and had all impacted on each other and that these factors were not impacting services and people independently but the totality of the system conditions as a whole were” and as a result coordinated resources across partners, planning to respond and support residents earlier as winter approached.

Strategic collaboration

The importance of collaboration on a strategic level being conducive to creating shared frameworks, structures and resource allocation was emphasised. There were many collaboration opportunities across various strategic boards and sometimes involvement with experts with lived experience, which helped inform a multi-perspective strategic approach. Examples include:

• safeguarding adult board working with Joint Partnership Board (JPB) that represent carers and people with lived experience of care to promote publicity and maximising income and highlighting any safeguarding issues
• partnership working across the local safeguarding adult noard, safeguarding children partnership, domestic abuse and community safety partnerships in place to ensure interface issues are addressed
• holding thematic focused safeguarding adult board meetings on areas of concern and focusing on gaining assurance from partners that measures in place where being effective
• safeguarding partners have delivered campaigns to promote what support and services are available to support citizens, and the SAB has helped to underpin this. The SAB also facilitated a conversation on this subject and the chair has collected evidence of the impact
• a steering group met every fortnight and considered the most recent data to drive the response including the number of calls to a dedicated phone line; financial gains from welfare rights; the number of households in temporary accommodation; and parcels provide by the foodbank
• a partnership summit was held people with lived experience of poverty to discuss and plan how we collectively respond to the crisis aiming to develop short term practical actions, based on five key areas of support for residents (food, fuel and energy, maximisation of income and access to financial and debt advice, housing, childcare and school)
• convening of a hardship board (the main distributor of the household support fund). Their assistance scheme was a main route to secure assistance and support for paying for food, bills and so on.
• the local integrated care board held a multi-agency workshop on cost of living increases and potential impacts, but this was not confined to safeguarding
• partners discussing the effects of the cost of living and heard case studies from voluntary sector on the impact
• a coalition of various local voluntary organisations provided support, advice and signposting
• one council worked in partnership with their local voluntary sector to refer any safeguarding concerns resulting from winter pressures or cost of living.

Systems and contextual approach

Strategic buy-in would often be a lever that could enable change. One of the themes that respondents shared was that co-located, multi-agency initiatives, which took a systems and contextual approach to responding to adults’ needs, were helpful. These interventions were proposed and informed by multiple perspectives, some through the lived experiences of adults with care and support needs, carers and practitioners. Examples include:

• risk management panels to address issues of multiple disadvantage
• health and housing coordinators that were co-located within existing multiagency hubs
• multi agency team are at together at place
• hospital based multi-agency team in place on site to support safeguarding of children and adults
• using other resources such as fire safety to carry out safety visits in cases discussed in multi-agency panels
• joint funding panels for mental health and
• cost of living hub linked with foodbanks, support hub and so on.

Targeted interventions

There were examples of targeted initiatives to address specific groups of people, such as those who experience homelessness or socio-economic disadvantage, or to address specific issues such as mental health problems or self-neglect. Council respondent 43 described their joint funding of a “wellness on wheels bus” by the local integrated care board and public health, which travels across the county, “to support people from inclusion health groups and deprived communities and has a range of advice and information”.

Council respondent 37 described how the use of a “mental health car” had significant positive impacts on residents’ mental health and on local police resources around mental health. The respondent commented that, “The ‘mental health car’ filled a gap between Mental Health Act assessment interventions and people who were not able to access Accident and Emergency”. Other targeted interventions include:

• targeted visits and support with individuals who experience homelessness, including developing a mental health support and hoarding officer
• an acute trust, which is a board partner, provided eligible patients with support for transport costs, including the congestion charge and ULEZ
• ensuring other partner agencies check home environment before discharge (in other words,. Age UK) minimises/identifies safeguarding risk
• provision of subsistence payments available offsets some of the risk.

Significant issues highlighted

In this section findings related to key safeguarding themes are summarised, regarding self-neglect; cascading information; workforce and mental health issues.

Self-neglect

There were a variety of reflections on self-neglect by 10 council respondents. Whilst some saw increased safeguarding concerns being raised about people who self-neglected, others saw a reduction. Some council respondents reflected, that whilst they saw increased levels of concerns reported as self-neglect, this was often directly related to people having a lack of finances and resource; consequently, as a result were unable to afford care and support services or prioritising their housing, heating and food bills. Council respondent 28 stated that,

Funding care packages or non-commissioned non personal care tasks, such as shopping, cleaning, etc, some people cannot or will not pay and therefore there is an impact on the condition of property, self-neglect, deterioration in wellbeing.” Council respondent 28

Council respondent 42 reported experiencing higher than the national average incidences of activity regarding self-neglect and were looking to grow their understanding and have incorporated fire risk assessments in their assessment forms.

Council respondent 37 described how an increase in the volume of people leaving hospital without appropriate services, including care and support needs in place “to follow them home”, had led to “crisis in the community particularly from a self-neglect point of view”.

Council respondent 43 reported increased safeguarding concerns that did not meet the criteria for section 42(2) safeguarding enquiry.

We were inundated with referrals for people with low level self-neglect concerns and suicidal callers and or people with very poor mental health . . . these rarely meet the threshold for s42 but tend to be either signposted or put through for a care and support assessment.” Council respondent 43

For council respondent 22, the majority of their safeguarding adult reviews (SARs) had been focussed on self-neglect, stemming from isolation and people not accessing services. This locality aimed to address this across their partnership, including adopting a self-neglect framework, improving their information processes, improving their SAR process and working in partnership with their local Healthwatch to better embed Making Safeguarding Personal.

Council respondent 32, gave a very candid response illustrating concerns they had in their locality to better identify self-neglect and how the issues of hospital discharge, cost of living, substance misuse, financial abuse, mental health issues were combining with one another:

We are coming into contact with people who are experiencing significant hardship. Partnership working is missing many cases of self-neglect. Substance misuse issues alongside mental health problems are leading to additional complications with individuals being taking advantage of. Patients are reluctant to go home when they are community ready due to the financial pressure of living at home. Changes in the discharge pathway/pressures particularly timelines have seen a significant number of people returning home still unwell therefore readmission has increased. Impact of the hospital trust operating at Level 4 escalation has impacted on services.” Council respondent 32

This merging of issues was reflected across the councils who were encountering multiple issues including:

• police saw an increase in the number of financial abuse investigations that they led particularly ‘bogus official’ situations
• higher risk of provider failure related to the cost of living and the retention and recruitment of staff
• an increase in houses in multiple occupation (HMOs) and increasing numbers of people living together had led to increased abuse of each other
• pressure to move people out of acute settings, resulting in difficultly in completing strengths-based assessments and conversations. Council 28 observed that: “there is a tendency to be risk averse and this could have an impact on independence later on.”

Cascading information

Many responding councils emphasised that cascading information was essential and reflecting and discussing issues was key to work in this area. Initiatives included:

• developing and producing leaflets, brochures, and holding partnership events
• the safeguarding adults board provided information and sign-posting to other resources for assistance
• safeguarding partners have delivered campaigns to promote what support and services are available to support citizens, and the SAB has helped to underpin this. The SAB also facilitated a conversation on this subject and the chair collected evidence of the impact
• improved communication and engagement media options to ensure they are engaging with all partners and the public to raise awareness of adult safeguarding locally
• asking partners to discuss the effects of the cost of living and heard case studies from voluntary sector on the impact
• the safeguarding adults board provided information and sign-posted to assist in the community - they added it was difficult to say whether these amongst other interventions have made a direct impact upon safeguarding and the cost of living.

Workforce

Recruitment and retention were identified as ongoing concerns during this period, impacting on safe service delivery, which resonated in the Skills for Care’s report, ‘The state of the adult social care sector and workforce in England (2023).’ 

This highlighted the ongoing trends and challenges for the adult social care workforce in terms of workforce capacity. The report revealed that whilst the workforce grew by one per cent in 2022/23 and vacancy rates reduced from 10.6 per cent to 9.9 per cent, there were still 152,000 vacant posts a day and 390,000 people left their roles during 2022/23 with around a third of them leaving social care completely and the rest getting new jobs within social care. Over the last decade, the longer-term trend is that the vacancy rate in adult social care services is significantly higher than that of the wider economy.

Recruitment and retention

In the survey of 40 council respondents who answered the question, 70 per cent expressed higher than expected recruitment issues (30 per cent much higher, 40 per cent slightly higher than expected) and in the survey of 41 council respondents who answered the question, 68 per cent of council respondents expressed higher than expected workforce retention issues (29 per cent much higher, 39 per cent slightly higher than expected). Of those survey respondents 11 council respondents provided further insight through narrative surrounding recruitment, retention and workforce challenges.

Respondents described an increased number of their workforce, including in their partner agencies (including care workers and social workers), leaving their current roles to find more sustainable salaries. They also suggested that those applying for roles in adult social care were not as experienced or as qualified as previous applicants.

Council respondent 37 identified how their workforce were impacted by the instability of the housing market and general cost of living increases. There was also a mismatch of applicants for roles advertised where they did not meet the qualifications or experience required. Often, they were receiving applications from people who did not live in the UK. Respondents described how they had received applications for social worker posts from people unqualified and those applicants invited to interview dropped out at interview stage or when interviewed, only to secure a more favourable role elsewhere. There were descriptions of the shortlisting and interviewing processes where few people were shortlisted (some as low as 15 per cent) who would be meeting the essential criteria. 

Council respondent 37 noted that there had been an increase in the number of applicants not attending planned interviews. They also described that there was an impact on services due to the inexperience of frontline policing. Additionally, the shortage of qualified and experienced staff represented a significant number of the workforce exiting the sector altogether. As was indicated across the responses from many of the respondent councils this was not confined to winter pressures or hospital discharge but a combination of systemwide pressures and factors.

Other council respondents described using investment models in recruitment which involved providing additional mentoring and support “to be able to deliver expected standards”.

Council respondent 33 implemented ‘Work4Health’ to improve recruitment, which was a pre-employment course developed specifically to give potential employees an opportunity to develop their knowledge, skills and expertise to apply for a range of NHS positions within their local NHS Trust. The course included an overview of working in the NHS, work experience, employability skills, and a guaranteed interview on successful completion.

Council respondent 39 had a peripatetic social worker, who was able to respond to increased safeguarding concerns in an agile way, which in turn helped staff to fulfil their safeguarding duties. 

Council respondent 37 mentioned how their partner agencies (such as their local hospice and their local substance misuse service) identified people who were suitable for fast-tracking at the application stage and from “people who were a good fit for roles . . . progressed quickly within the service and were in a constant recruitment phase”. The council also developed a trainee role and an advanced practitioner role within the service to make roles more appealing in terms of progression prospects.

Councils indicated that there was an over-reliance of agency workers, council respondent 35 said:

Staff recruitment and retention within the local authority safeguarding team is having a huge impact on the statutory safeguarding function. The safeguarding team at the acute hospital has experienced the same issue. This limits the teams to expensive agency work and means it is difficult to retain continuity within the substantive team.” Council respondent 35

Council respondent 37 described how the cost of living had placed significant pressure on:

...ability to survive financially on public sector pay grades. Adult social care was acutely aware of a number of experienced social workers leaving permanent roles to take on roles as agency social workers, due to the more favourable salary in order to manage their own financial responsibilities.” Council respondent 37

Further, it was noted that where previously there were opportunities to “persuade agency workers to take on permanent roles”, this had proved to become “much more difficult”.

Mental health issues

Mental health was a significant theme for the council respondents, with 10 sharing further information about cost of living and winter pressures impacting on higher levels of mental health referrals. Mental health is threaded through the responses, whether it is a factor in complex presentations of safeguarding concerns or people experiencing risks presenting to adult social care or partner organisations. An example of partner challenges was for housing providers, who reported they were managing more people with “high risk mental health needs” in their services and that “they were not commissioned to delivery that level of care”. When these people would experience mental health crisis, this was often reported as safeguarding concerns. Additionally, respondents said that these people would often not meet the section 42(2) of the Care Act 2014 criteria and access safeguarding support.

Council respondents shared interventions and innovations such as provision of specialist emergency mental health beds, wellbeing buses, as well as mental health professionals working in partnership with the police. Council respondents also shared focused support and innovative preventative approaches for those who did not meet the section 42(2) criteria.

One of the noted examples was that from council respondent 37, who described how their local integrated care system and housing partnered in establishing a new project which provided temporary step-down accommodation and floating support to people leaving mental health wards, with a focus on rapid move-on into their own accommodation in a specified timescale.

Conclusion

A strong theme from the discourse on cost of living, hospital discharge and winter pressures is the need to build and take a more preventative, holistic, pro-active and multi-agency approach to working. early interventionist and multi-agency approach to adult safeguarding within organisations and partnerships to respond to the needs of residents which have been exacerbated by the impact of cost of living, hospital discharge and winter pressures. These approaches will not be unfamiliar to practitioners, managers and experts in the field; they require a range of preventative activities to be in a better position to deal with the impact of cost of living, hospital discharge and winter pressures.

The innovations described by respondents around the country demonstrate how often inter- and intra- partnerships/multi-agency approaches provide a powerful preventative tool, particularly strong partnership across statutory (including police, health and social care), blue light services, providers in the private, independent, community and voluntary sector. Respondents described exploring synergies between partners within the system on specific areas and have more systematised set of relationships manifested in structures such as multi-agency services/hubs. They also provided many examples of a physical presence in other parts of the system beyond health and social care spaces which allowed the growing of trust in the system (especially in a post-pandemic world).

Professional curiosity regarding linkages between cost of living, winter pressures and/or hospital discharges and safeguarding adults activity was a significant aspect of ongoing service development. Successful projects took preventative and holistic approaches to adult safeguarding where they considered broader safeguarding responsibilities ('Understanding what constitutes a safeguarding concern and how to support effective outcomes'). The Local Government Association has created a 'Cost of living' hub which has some notable examples of good practice to address the impact on residents Although not addressing safeguarding adults activity directly, there is much scope to find ways to articulate some of the positive impacts of preventative and responsive work conducted across the country.

This sometimes took the shape of individuals being able to access good universal services which took a multi-agency approach. There was also an emphasis by respondents on trying to make sense of the causes of safeguarding concerns and search for longer term solutions, beyond the moment of crisis. Respondents mentioned, along with their partners, responding to local safeguarding adult reviews and thematic reports (local and national) to improve outcomes for communities including evaluation of multi-agency or partnership breakdowns. Also, development of frameworks, policies, rethinking structures, reporting, discussion with strategic boards, partnerships, joint working, being integrated into services beyond safeguarding were featured.

Household Support Fund and cost savings

The ending of the Household Support Fund (HSF) was a significant concern for councils and their partners who recognised that this would exacerbate poverty and related safeguarding concerns. The chancellor at the time of writing this report announced in the spring budget the extension of this fund by six months until 30 September 2024. This fund will thus help address some of the concerns from councils.

Poverty for many with care and support needs, their carers and families could mean their basic needs are at risk of being unmet, increased levels of stress on households seeing increased levels of domestic abuse, substance misuse, financial and emotional abuse and increased levels of social isolation. Councils described how their websites could hold sources of information to access information and advice but also the long waiting lists to access these services.

At a time where the NHS were having to seek cost savings, council respondents described how safeguarding referrals felt indistinguishable during winter pressures and other times of the year. Preventative work was strongly recognised as a way to address the system pressure but cost saving within councils were likewise seen as more challenging to fund, although council respondents in this project have described imaginative approaches to try and support their communities. Challenges around workforce retention and recruitment has further exacerbated the issues and made preventative work even more difficult to provide.

As there are currently no specific and/or established measures of counting safeguarding concerns regarding hospital discharge. Council respondents found it difficult to articulate the direct impact. Part of the issue was also the inter-connectedness of hospital discharge with other factors including winter pressures, cost of living and COVID, inflation and so on.

One thing that was particularly striking from council respondents was the higher levels of acuity and complexity reported in hospital discharge, as discussed above. It ranged over a vast number of issues: from care package not being in place, use of restraints, information not shared adequately, safeguarding risks related to cuckooing and financial abuse going unrecognised, those with care and support needs to increased levels of poverty induced neglect, which sometimes presented wrongly as ’self-neglect’. There was a small minority of council respondents who did not see corresponding changes in safeguarding concerns and many others who were unable to comment on changes in safeguarding concerns connected with hospital discharge due to lack of data and evidence.

The benefit of exploratory work in this project, is also its shortcoming. The insight project whilst discovering some excellent innovations and preventative work is left asking more questions. The report has been instructive in being able to ask more triangulated qualitative questions to gain further insight but quantitative data would not necessarily be so easily extracted and isolated (due to current data collection requirements and the multifactorial impact on the person). 

This report perhaps leaves more questions than it answers, and suggests considering solution focussed next steps such as:

• building a resource/hub of a preventative/innovative examples of councils challenging cost of living, hospital discharge and winter pressures so that councils and their partners can share practice across the country
• having a more comprehensive examination of abuse types but particularly self-neglect, financial abuse, domestic abuse, substance misuse through the lens of cost of living
• looking at how councils are developing partnerships with their statutory, private, voluntary and community sector
• work with the sector to build in solution focussed recommendations for safeguarding adult board partners, safeguarding teams and councils.

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