Safeguarding Diogenes

James Fuller is a Peer Researcher, Expert by Experience and a Support Worker at a Day Centre for people who are homeless in London. (1,200 words)

Brighton and Hove Safeguarding Adults Board recently published the key messages arising from a review. A Safeguarding Adults Review is held when an adult in the local authority areas dies as a result of abuse or neglect. In this case, the adult was sleeping rough and had been identified as ‘difficult to engage’. Chris Scanlon and John Adlam have written extensively about Diogenes, homelessness and what to do about people whose refusal to be included remains a problem for themselves and society as a whole. This review brought into sharp focus some of these same issues. Namely how can we safeguard Diogenes? According to the essayist Plutarch, the philosopher Diogenes the Cynic (412-323BC) lived in a barrel in Corinth and spent his time pouring vitriol on his fellow beings, who he roundly despised. One day, Alexander the Great invited Diogenes to a gathering, but the drum-dweller declined. Instead of having Diogenes executed, the usual outcome for disrespecting world conquerors, Alexander went down to see him.  Having greeted Diogenes, Alexander asked him if he wanted anything. Diogenes replied: “Yes, stand a little out of my sunshine” (Plutarch, Alexander, 14 Cf.).

If, as a civilised society, we have a moral duty towards all mankind without fear or favour, how far does that burden extend in face of such dogged resistance? Or, is our proper duty to respect another person’s right to live as they wish, even to the point of killing themselves, slowly perhaps through substance abuse and/or self-neglect, or by a single act of suicide? If this is their choice, is it not also their responsibility, or should we, by default, not only take on the emotional burden, but also contribute to their demise by funding such a lifestyle, either as individuals, or through state subsidy?

The purpose of safeguarding is to ensure that multi-agency professionals working with at risk adults do so in a coherent and coordinated manner, acting under a set of issue-specific policies and procedures, in order to achieve optimal outcomes. Although there is much rhetoric about the importance of working together holistically, this review brings into sharp focus how challenging this can be. To use the analogy of ten pin bowling, the bowling ball shown below is segmented by the issues and vulnerabilities presented by the person who was subject of this review…


*Serious Paranoid Personality Disorder

…and here are the lanes down which they are known to have travelled:

Drop-page-002The arrows are significant because they highlight that this is a one-way system and like the ball, the subject must be returned or find their way back to the start in order to re-enter the same lane, or be directed down another one. As a front-line practitioner and someone with lived experience of this game, what is of concern is how to provide a coherent safeguarding response across these parallel lines. There are plenty of multi-agency policies and procedures, committees, case conferences and working parties who meet and discuss, but extending these conversations into consistent, combined activity, particularly when human as well as financial resources are scarce, can be exceptionally difficult.

In the case outlined in the review, there was some coordination between services while the person resided in one county, but none of the accumulated narrative, or care plan was conveyed to their opposite numbers who attempted to engage with the person when they abruptly moved to an adjacent district. There appears to be no suitable network between local authorities through which file data could be passed, or national data-base from which the information might have been extracted – not even the Vulnerable Adult At Risk alert that had been raised in the first location. In any event, without a formal lead agency, who was to have taken on the search?

It is tempting to retort that the service user should have made known their circumstances and were it not for the mental health and learning difficulties, this might be a reasonable hypothesis. Even so, relying on self-reporting, as we must in many cases, often leaves services woefully ill-informed, or deliberately misled.  Nonetheless, we are dealing with adults and in an environment replete with data protection, privacy and human rights legislation designed to uphold an individual’s civil liberties.  There are lines we cannot cross, even when to do so would patently be in a person’s best interests.  Instead, we must rely on our experience, ‘professional curiosity’ and emotional intelligence to build trust and encourage disclosure. This can take time and requires a degree of tolerance and continuity, which, as argued here, are in short supply in the current climate of austerity. Your blogger feels no shame in noting that in this particular review, staff from the charitable sector were singled out for their ‘person centred’ and ‘more flexible’ approach.

Despite the challenges inherent in the system, it is also the case that achieving meaningful engagement when mental health or psychoses are present is difficult, not least because by the time people are sleeping rough, they are often ‘self-medicating’, rarely taking their prescribed drugs and living in fear of being ‘sectioned’.  In the case under review, it was acknowledged that this ‘was a difficult and potentially dangerous tenant to accommodate’. Specialist supported housing providers strive for maximum inclusion, but even they must routinely screen out applicants with a history of arson, or who are likely to be violent towards other residents or staff.

Tragically, this person deteriorated rapidly and exhibited such chronic self-neglect that local residents near the caravan where she was living sought to have her removed.  The mental health team were alerted to her worsening condition, but following a rapid assessment concluded (once again) that she had capacity. This decision did not reduce the serious concerns that surrounded them, but soon afterwards she was found dead.  A tube had been connected to a gas canister outside the caravan and run into her sleeping bag.

The coroner’s verdict was ‘misadventure to which self-neglect contributed’. No blame was laid at any agency’s door. That is surely right. Even so, the Safeguarding Adult Review that followed concluded that a failure to invoke prescribed safeguarding procedures robustly meant that ‘an integrated and coordinated multi-agency partnership led approach was not achieved’. There is a line tucked away in the review’s concluding remarks which struck a cord. We may not be able to solve Diogenes problems through our concerted offer of help and support, but respecting and listening to them is key:

“The determined focus on reconnecting [the person] with [their] local area, whilst understandable as it offered [them] the best chance of being housed, was done in such a way that risked [them] feeling unheard”.

James Fuller is a Peer Researcher, Expert by Experience and a Support Worker at a Day Centre for people who are homeless in London.


Brighton and Hove Safeguarding Adults Board: Safeguarding Adults Review Professionals Briefing (March 2017).

Scanlon, C and Adlam, J. (2008) Refusal, social exclusion and the cycle of rejection: A cynical analysis? Critical Social Policy 28(4) 529-449.

Managing dementia where there is challenging behaviour

Esme Moniz-Cook and Jill Manthorpe summarise the findings from a study on the management of dementia. (609 words)

  • Help for family carers supporting people with dementia who are distressed is much needed but services struggle to provide effective responses
  • Both families and care home staff need more support to help them to care for people with dementia – especially when the ‘going gets tough’

Bookshelf_NBK447072-page-001The findings from a large research study on the Management of Dementia with clinically significant challenging behaviour at home and in care homes led by the University of Hull and Humber NHS FT are published today (11 August 2017). The research was funded by the National Institute for Health Research (NIHR), Programme Grants for Applied Research (PGfAR). The study examined the records of over 5,300 older people and their families who were referred for specialist help to NHS mental health services across England. Nearly two thirds (61%) of those with dementia and distressing behaviour had a mild dementia rather than severe dementia. Practitioners did not always recognise that people at this stage were experiencing problems such as agitation, aggression and distress; and over a six month period, they did not manage to reduce the difficulties faced by these families. Families bore most of the care costs, and many were untouched by the evidence, guidelines and scope that services should provide them with timely individually-tailored effective responses to their challenging circumstances.

A second strand of the study took place in over 63 care homes with 2,300 residents living in the Yorkshire and Humberside region. The research team offered online training and online therapist-assisted intervention to 632 care staff who were supporting 832 residents. Despite high levels of IT support and resources from a trained dementia therapist, care homes did not embrace online training or a system of individually tailored interventions. However, smaller care homes seemed more ready to take up online training and support. The research team developed a tool-kit for specialist care home liaison teams to assess the readiness of care homes to collaborate with such developments.

These in-depth studies of people with dementia and distressing or challenging behaviours living at home or in care homes also found that prescribing practices were sub-optimal in many instances.

Professor Esme Moniz-Cook, who led the research, said:

‘Older people with dementia in its early stages can be distressed, and sometimes help with this comes too late. Our programme of work developed simple screening tools to help practitioners detect such problems in both situations of family care and care homes. These can be used across primary and secondary care, to identify such problems and monitor the effectiveness of support over time. We have also developed evidence-based e-learning and toolkits for providers, such as care homes and NHS staff supporting them as well as hospital staff and community teams supporting families and people with dementia.’

Prof Jill Manthorpe added: ‘The majority of older people with dementia live at home – among them are people whose symptoms may be distressing to themselves and their families. Help can arrive too late. Our aspiration is to disseminate work from this programme to funders and providers. We need to shift the balance of primary, secondary and hospital practice from early diagnosis of dementia to early recognition of distressing behaviour and to support practitioners in health and care services to ensure that everyone can benefit from timely evidence-based care pathways.’

This summary has been prepared by Profs Moniz-Cook and Jill Manthorpe and does not necessarily reflect views or opinions of the NIHR, collaborating institutions, the NHS or the Department of Health.

Key Collaborators included King’s College London, and the universities of Bangor (Wales), East Anglia (UEA), Swansea (Wales), Nottingham and Bradford; Northumberland, Tyne and Wear NHS FT and BUPA.

Go to report


Who wants to be an Approved Mental Health Professional?

Stephen MartineauAs the Unit embarks on a new piece of Department of Health commissioned research examining the role of the Approved Mental Health Professional (AMHP), Stephen Martineau and colleagues report from the AMHP Leads Network conference, held in London last week (10 July), and map out some of the background to the study. (977 words)

AMHPs carry out a variety of tasks when it comes to the use of compulsion under the Mental Health Act 1983 (MHA). Chief among these is coordinating the assessment under the MHA of individuals whose mental disorder is such that it fulfils the statutory criteria; the application for a formal admission to a hospital must be ‘founded’ on medical recommendation, as the pink form for a detention under the MHA has it, but the AMHP takes the decision.[1]

Form A2 Section 2 appl by AMHP for admiss for assess-page-001

Form A2. Section 2 MHA: application by an approved mental health professional for admission for assessment (photo links to pdf)

Of course, this is only the very barest description of what is involved in the job: last week, someone who had been the subject of a MHA assessment by an AMHP wrote vividly of the experience in Community Care. Elsewhere, the Masked AMHP has asked, and answered, the question: What is an AMHP?

In making a MHA assessment of a person, AMHPs bring to bear a ‘social perspective’. And it is social workers—initially under the MHA, Approved Social Workers (ASWs)—who have been historically associated with the role. But in 2008 ASWs became AMHPs, and with the change in designation came a loosening of the ties to the social work profession: it was now also possible for certain kinds of nurses, occupational therapists and psychologists to take up the role.

Nearly nine years on, AMHPs are still overwhelmingly drawn from among social workers, current estimates suggesting that out of the 3,800–4,000 AMHPs in England, the newly eligible health professionals number something under 300 (with apparently, as yet, no psychologists among them). Why, our study asks, is this figure not larger?

At the AMHP Leads Network annual conference


Indian YMCA in London

As it happens, the early phases of our study coincided with the AMHP Leads Network conference, held at the Indian YMCA in Fitzrovia on 10 July. We learnt a great deal about the current context for our research at the conference. The estimated total number of AMHPs in England, mentioned above, was reported to delegates by Steve Chamberlain, AMHP Leads Network Chair. In this, he was drawing from surveys the Network has conducted; remarkably, there is no central register of AMHPs, though plans are afoot to have Social Work England take this on when the new regulator comes into being (possibly) in September 2018.

We learnt, also, that commencement of the provisions making significant amendments to sections 135 and 136 MHA, contained in the Policing and Crime Act 2017—delayed because of the election—is scheduled for September 2017, with regulations due to be laid before Parliament over the summer (a timetable, which the results of enquiries made by Mental Health Cop seem to support).

Also scheduled for September 2017 is the publication of the report of the appreciative enquiries the Care Quality Commission (CQC) has conducted in 12 places. These visits (the idea for which sprang from the Mental Health Crisis Care Concordat) examined the AMHP service and rates of detention in the chosen localities. Concern about the rise in the number of detentions under the MHA is widespread: detentions rose by 46% in the decade to 2016.

HM Gov 2008 AMHP regs-page-001

The five areas of competence, thought by some to be repetitive and outdated, are contained in Schedule 2 of these Regulations from 2008 (photo links to pdf)

On the broader question of inspecting AMHP services, one CQC representative at the conference said that variation in the manner (as opposed to quality) of AMHP service provision was such that CQC ratings couldn’t readily be meaningfully applied. We were a decade away from that, she suggested.

Among the research that was discussed on the day was work by Robert Lewis and Karen Linde on different models of AMHP service provision, and work (discussed by Anna Beddow) reviewing the competencies that AMHPs are expected to have before they can be approved by the local authority. This latter work is completed and the results are now with Chief Social Worker for Adults, Lyn Romeo, who also spoke at the conference. If anything, this proposed reset of the competencies would give even greater prominence to the social perspective in the AMHP role.

‘As we work towards a new Mental Health Act…’

The conference took place in the wider context of potential legislative reform. Matthew Lees, the Department of Health Policy Lead on Mental Health, indicated that the idea of replacing the MHA—mention of which was made in the background briefing notes to the Queen’s Speech (‘As we work towards a new Mental Health Act…’ p. 56 of the notes)—enjoys real traction in the Department.

Matthew Lees, Lyn Romeo, Emad Lilo, Claire Barcham, and Steve Chamberlain at the AMHP Network Leads Conference, 10 July 2017

Matthew Lees, Lyn Romeo, Emad Lilo, Claire Barcham, and Steve Chamberlain at the AMHP Leads Network Conference, 10 July 2017. Photo: Emad Lilo

The Mental Health Alliance (a coalition of over 75 organisations), which published a report in June on the topic, would no doubt welcome this. Mr Lees contrasted such prospects with those for the draft bill, published by the Law Commission earlier this year, aimed at fixing the Deprivation of Liberty Safeguards; he pointed out that the same background briefing notes, the mental health reform section of which he had written himself, contained no mention of it.

In the still wider context, and well beyond the confines of the conference hall, last month also saw what may prove to be a significant intervention by the United Nations Special Rapporteur in the field. The report is worthy of brief mention here since the critique it contains has an obvious pertinence to the use of the MHA as it stands today. The Rapporteur, Dainius Pūras, calls for ‘a revolution in mental health care’; he strongly criticizes, for example, the use of a biomedical (as opposed to a psychosocial) approach and a reliance on coercive practice.

AMHPs, as we have seen, sit in an interesting position in the terms of these debates, bringing to bear a social perspective to their assessments, while also playing a central role in arranging compulsory admission under the present Act. No doubt our study will be much concerned with the systemic and other constraints on eligible health professionals taking up the AMHP role. Yet these broader debates, and their relevance for the way other professionals view the kind of work AMHPs do, will never be far away.

Follow the conference: #AMHPleads17

Stephen Martineau is a researcher on the study, ‘Who wants to be an AMHP?’. The other researchers are Martin Stevens (PI), Prof Jill Manthorpe, Caroline Norrie and Nicole Steils. All are based at the Social Care Workforce Research Unit, King’s College London.

[1] The ‘nearest relative’ under the Mental Health Act 1983 may also perform this role. Please also see Claire Barcham’s comment to this post for more on what the AMHP must do and consider when it comes to detentions under the MHA.

[On the prospects for the Law Commission proposals for DoLS, and possible alternative arrangements, see Community Care, 25 July 2017]

Researching in care homes – what was learnt from a study of handovers?

Caroline NorrieCaroline Norrie is Research Fellow at the Social Care Workforce Research Unit, King’s College London (330 words)

What can researchers of care services learn from our recent handover study?  We asked ourselves this question and discussed this at the annual conference of the British Society of Gerontology held in Swansea last week (pictured below is the new beach side campus) at the start of July. Our paper summarised the findings of our unique exploration into handovers in care homes and then we paused to ask what could be relevant to other researchers studying care home practice and systems. Continue reading

Notes from the inaugural conference of the Italian Society of Social Work Research

Gaia CetranoGaia Cetrano is a Research Associate at the Social Care Workforce Research Unit, King’s College London. (1,100 words)

In May this year I was proud to take part in the first conference organized by the new Italian Society of Social Work Research (SOCISS) in Turin, Italy.

The origins of SOCISS date back to 1983 when a group of teachers of social work founded the Italian Association of Teachers of Social Work (AIDOSS). AIDOSS assiduously worked over 30 years to develop common thinking on theories of social work, as well as on the organization of university curricula, and the role of training and research. Then what happened? The Association committee reunited in 2016 and approved a new constitution outlining its new objectives, which included strengthening the dialogue between theory and practice in social work and promoting social work research in Italy and internationally. I think it is very important that the status of the association has now changed to that of a scientific society as this will hopefully help professionals, researchers and academics to acquire a stronger voice and also be in a better position to communicate and negotiate with other disciplines. Continue reading

Providing Support and Care from a Distance

Caroline White of the University of Hull is seeking participants in a new study. (462 words)

Family members and friends often provide support, help and care to others, instead or in addition to paid sources of care and support. These people (often referred to as carers, although this term is not embraced by all) are collectively estimated to save the UK economy £132 billion per year (according to figures from Carers UK in 2015) and have been the subject of much research and policy development. The majority of existing research about carers concerns those who support someone who lives with or near to them. However, as we become an increasingly geographically mobile population many parents, adult children, siblings, other relatives and friends find themselves living at a distance from those they care for and about. A new research project at the University of Hull is working to find out more about the experiences of those who provide help, care and support to a relative or friend who lives at a distance from them (we are meaning that they have to travel for one hour or more to visit them). Continue reading

Mental Health Workers – We need your help for our research

Tasneem ClarkeTasneem Clarke, Research Officer at the Money and Mental Health Policy Institute, based at King’s College London, discusses the Institute’s latest research, which asks: what can mental health practitioners do to support people in financial difficulty? Please take this two minute quiz to register your interest and help her come up with pragmatic solutions to this difficult issue. (736 words)

Money and mental health – a toxic relationship

As practitioners in mental health services know, life can be messy. The people we work with are rarely only facing one issue; from relationship breakdown to past traumas, economic disadvantage or long-term physical and mental health problems – issues interweave and make each other worse. Continue reading

Bringing it all together – re-valuing older people by combining research, training and practice

Valerie LipmanValerie Lipman is a Postdoc Intern at the Social Care Workforce Research Unit in the Policy Institute at King’s College London.

Here’s a challenge for learning institutes in the UK: how can they deliver on-site direct services for the vulnerable groups whom they’re studying and promoting? I talked to Dr Indrani Chakravarty, the founder and Director, of the Calcutta Metropolitan Institute of Gerontology (CMIG) about her experience of doing just this and how she marries research with real practice. Continue reading

Older People & Human Rights

Dr Joan RapaportJoan Rapaport reports from the 9th Annual Joint Conference of Age UK London, the Social Care Workforce Research Unit and Making Research Count. (1,789 words)

The conference, held on the Guy’s Campus of King’s College London, was chaired by Jo Moriarty, Deputy Director of the Social Care Workforce Research Unit, and attracted a capacity audience. Speakers’ presentations are available on the SCWRU conference webpage.

Human Rights Act: overview of current changes: Caroline Green, PhD student, Social Care Workforce Research Unit

Whilst human rights have been around for hundreds of years both globally and in Britain, Caroline acknowledged that our understanding mostly relates to post World War II developments. The European Convention on Human Rights, drafted in 1950, contains numbered ‘Articles’ each of which protects a basic human right. The European Court of Human Rights, based in Strasbourg, rules on cases brought under convention from the 47 signatories. Continue reading

Adult Social Care – where’s the evidence?

Jo Moriarty Nov 2014bJo Moriarty and Martin Stevens are Senior Research Fellows at the Social Care Workforce Research Unit. (1,192 words)

People often talk about the absence of a social care evidence base, but ‘patchy’ is a far better description. Until we arMartin Stevense more explicit about this, it will be difficult to make progress in achieving evidence based policy and practice. We took part in two Meet the Researcher sessions at an event jointly organised by Research in Practice for Adults (RIPfA), the British Association of Social Workers (BASW) and the Association of Directors of Adult Social Services (ADASS). They were part of a day-long seminar designed to bring Directors and Assistant Directors of Adult Social Care and researchers together to discuss current and future adult social care research. Continue reading