News & events
05/12/2011 - Safeguarding Vulnerable Adults – a toolkit for GPs
The collapse of Southern Cross and the abuse exposed on television at Winterbourne View private hospital have shaken public confidence in the sectors. The public were rightly alarmed that abuse such as that occurring at Winterbourne View could have happened without anybody intervening.
"Safeguarding” is a familiar term but there are no statutory rules governing its operation. Each local authority is responsible within its own boundaries for dealing with adult protection issues. There is often a lack of clarity as to what is expected and where responsibilities lie between organisations. The danger is that this uncertainty can lead to safeguarding issues slipping through the net.
Because GPs have a central role in preventing abuse, the Department of Health commissioned the British Medical Association (BMA) to produce guidance. In October 2011, the BMA published "Safeguarding Vulnerable Adults – a toolkit for general practitioners”. Although aimed principally at GPs, the guidance will be useful to any professional working within a care setting with vulnerable adults.
The guidance reminds doctors of their obligation to protect vulnerable adults and the legislation in place to protect doctors who wish to speak up. It highlights the issues of vulnerability and mental capacity warns that the other extreme is that over-protection can also be damaging. Let us examine some of those main issues raised in the guidance.
Safeguarding is about protecting vulnerable adults. This involves identifying adults who may be vulnerable, assessing their needs and working with them and other agencies to protect them from avoidable harms. Adults who may be vulnerable range from those whose decision-making capacity is severely impaired, to those with no cognitive impairment but who, due to their physical situation or a brief period of illness, are temporarily unable to protect their own interests. Sometimes systematic failures in care can render adults vulnerable when in all other aspects of their life they are competent and in control.
Care must be taken, however, in labelling an adult as vulnerable. It can be stigmatising and can lead to unfounded assumptions that he lacks the ability to direct his own life. This could lead to paternalistic interventions, resulting in the kinds of disempowerment that safeguarding is intended to avoid. Equally, drawing too narrow a definition may exclude some people who may benefit from support.
Adults who have mental capacity retain the right to make their own decisions. This means that they have the right to assess and manage the risks to which they are exposed and that support will normally involve talking through those risks and offering support to minimise them where appropriate. Neglecting this decision-making right, even where the intentions are to protect the individual, can itself amount to a form of abuse. There is a presumption that people do have capacity until shown otherwise.
Professionals sometimes have to balance the respect for autonomy with the requirement to act to prevent avoidable harm. In the absence of serious crime or significant risk of harm to a third party, however, the individual's right to make their own choice should be respected.
In 2009 the Government consulted on the review of the No Secrets guidance. Several respondents to that consultation expressed frustration that the voices of adults were often insufficiently listened to. It is important to remember that sometimes, although people may wish to be informed of options, they may want to retain control.
Adults lacking capacity to make decisions still retain the right to be involved in decision-making as far as possible. The decision will, however, ultimately have to be made for them and the overall approach shifts to promoting their best interests.
The BMA guidance reminds doctors that they are advocates for their patients and that the support which GPs offer their patients often extends beyond health needs to wider welfare considerations.
The No Secrets review identified that neglect is the most serious form of abuse and that in some care settings, poor levels of services amounting to neglect were accepted as a result of staff and other resource shortages. The BMA guidance reminds doctors to be alert to these issues and points out that safeguarding does not only mean identifying abusers but it can also mean identifying both systemic failures and poor professional performance which can lead to harm.
Doctors are encouraged to speak out to protect patients and reminded that the Public Interest Act protects whistle-blowers who disclose information "in good faith” to a manager or employer. Within the NHS, disclosure to DH is protected in the same way. The guidance tells doctors to take more responsibility for patient protection in order to ensure they fulfil their professional obligations.
In summary, it is vital that GPs are aware of their professional safeguarding obligations and understand the subtleties of balancing the need for protection with the patients' best interests. GPs need to be responsive without acting defensively in a way that disempowers the individual, and they should always consult the BMA guidance in determining whether or not a safeguarding report is required.