Introduction
This evidence summary seeks to address the following question relating to collaborative practice to support vulnerable adults with complex needs:
What evidence is available of models of collaborative practice involving health and social care, social work and police services in relation to work to support and protect vulnerable adults with complex needs?
About the evidence presented below
Although the three point criteria includes several examples of when an adult may be at risk of harm, this review focuses on collaborative practice between agencies supporting adults with significant mental health problems, because this was identified as a priority for the original enquirer.
We searched for academic research, grey literature and other evidence (including serious case reviews) using a wide range of search terms including: vulnerable adults, adults at risk, mental health, mental illness, borderline personality disorder (BPD), emotionally unstable personality disorder (EUPD). We searched for programmes, policies and interventions that used terms including partnership, collaboration, interagency, interprofessional, interorganisational, multidisciplinary, multi-agency, joint working, health and social care, social work, and police. We also specifically sought evidence applicable in a rural context, although there was a shortage of sources explicitly discussing this characteristic.
Much of the evidence relates to a UK context and focuses on legislation relevant in England and Wales. There was less evidence specifically relating to Scottish legislation. Additionally, much of the evidence was produced prior to the introduction of GDPR and this should therefore be taken into account when seeking to apply any recommendations or practices.
Accessing resources
We have provided links to the materials referenced in the summary. Some materials are paywalled, which means they are published in academic journals and are only available with a subscription. Some of these are available through the The Knowledge Network with an NHS Scotland OpenAthens username. The Knowledge Network offers accounts to everyone who helps provide health and social care in Scotland in conjunction with the NHS and Scottish Local Authorities, including many in the third and independent sectors. You can register here. Where resources are identified as 'available through document delivery', these have been provided to the original enquirer and may be requested through NHS Scotland's fetch item service (subject to eligibility).
Where possible we identify where evidence is published open access, which means the author has chosen to publish their work in a way that makes it freely available to the public. Some are identified as author repository copies, manuscripts, or other copies, which means the author has made a version of the otherwise paywalled publication available to the public. Other referenced sources are pdfs and websites that are available publicly.
Background
Collaborative working between social support services and other services including police and health providers is important to ensure vulnerable and at risk adults are appropriately supported. It is of increasing significance in the context of health and social care integration, and increasing pressure on police as first response to mental health crises. In the Scottish context, the Adult Support and Protection (Scotland) Act 2007 lays out principles for protecting adults:
Three point criteria: Adult Support and Protection (Scotland) Act 2007
The South Lanarkshire Adult Protection Committee summarise the three point criteria:
The main aim of the Adult Support and Protection (Scotland) Act 2007 is to keep adults safe and protect them from harm.
The Act defines an adult at risk as people aged 16 years or over who:
- Are unable to safeguard their own well-being, property, rights or other interests; and
- Are at risk of harm; and
- Because they are affected by disability, mental disorder, illness or physical or mental infirmity, are more vulnerable to being harmed than adults who are not so affected.
This is commonly known as the three point criteria. For an adult to be at risk in terms of the Adult Support and Protection (Scotland) Act 2007, the adult must meet all three points above.
Some adults may be at risk of harm because of:
- Mental ill health
- Old age
- Frailty or physical weakness
- Physical or learning disability
- Visual or hearing impairment
- Engaging in self harming behaviours
Some areas identified for improvement in recent case reviews in Scotland and across the UK (e.g. NHS Northern Region 2015) relating to people with serious mental health problems include the need to improve decision-making, care planning and service user involvement by:
- Developing shared understanding of the roles and responsibilities of different agencies
- Improving the quality of communication and collaboration between agencies (Dorset Safeguarding Adults Board 2011)
- Developing methods for routine sharing of information on involvement and withdrawal from vulnerable cases
- "Where multiple health care providers are involved in the treatment and care of a patient, the discharging service should seek the permission of the patient to send discharge summaries to all involved agencies" (NHS Northern Region 2015)
- "When it is known that a patient has a forensic history NTW's clinicians must seek to obtain information from the police and probation service in order to inform both risk assessments and support plans" (NHS Northern Region 2015)
- "NTW's mental health inpatient service's Discharge Summaries should provide both a narrative description and the context of a patient's risk and protective factors as well as potential triggers" (NHS Northern Region 2015)
- Improving record-keeping and the management of information
- "Management of information within and between agencies and by individual professionals" (Cantrill 2012)
- "Improved system of routinely monitoring the quality of records" (Cantrill 2012)
- Ensuring that services for adults with diagnoses of [serious mental health problems] are personalised in design and delivery
Research indicates that these actions for improvement may create the conditions for improved joint working. For example, Krayer et al. (2018) discuss how "understanding of roles and responsibilities, valuing other professionals' contributions and a willingness to work towards shared goals and outcomes" were observed as the foundations for joint working between mental health, social care and two police services in Wales.
Voices of adults with complex needs
A recurring theme in the literature around good collaborative practice for adults with complex and mental health needs is the need to ensure the voice of the individual as well as practitioners and researchers is heard when developing policy and practice. Literature on what consumers want to experience when suffering from severe mental illness, stress the importance of:
- Participation in decision making
- Timely access to treatment and referral
- The preference of alternatives to compulsory sectioning or hospitalisation (Allen Consulting Group 2012)
Better collaboration between agencies has been suggested as a method of achieving positive outcomes that meet the needs and preferences of people experiencing severe mental illness and complex needs (Allen Consulting Group 2012.
Collaborative practice
Collaborative practice can be understood as partnership or joint working:
[A] shared commitment, where all partners have a right and an obligation to participate and will be affected equally by the benefits and disadvantages arising from the partnership. (Krayer et al. 2018)
The nature of collaboration can take many forms, within a "continuum of joint working" (Krayer et al. 2018). The following sources provide examples of the context for collaboration and inter-agency working in the context of adult mental health.
Herrington, V (2012) Inter-agency co-operation and joined-up working in police responses to persons with a mental illness: lessons from New South Wales. Policing, 6(4), pp.388–97 (paywalled)
This article reports New South Wales Police Force's considerations of how they might better engage with specialist mental health care providers in tailoring their policing response. It discusses the importance of joined-up working in responding to mental health crises in the community and considers the experience of the programme for partnership development and collaboration at the macro (legislative), meso (organizational) and micro (front line) levels. It concludes by identifying the lessons learnt and the implications for police and partners seeking to work together. (Adapted from author abstract)
National Police Chief's Council et al. (2018) Policing, health and social care consensus: working together to protect and prevent harm to vulnerable people (pdf)
In February 2018, the National Police Chief's Council in England published a consensus document in partnership with several other agencies, identifying several points of focus for the improvement of health and wellbeing, crime prevention and protection of vulnerable people through cross-sectoral collaboration of the police, health and social care services, and the voluntary and community sector. The agreements are:
- To move beyond single service-based practice to whole place approaches to commissioning and delivering preventative services in response to assessments of threat, harm, risk and vulnerability.
- To get better at identifying and supporting vulnerable people through the millions of interactions between community members, health and police services and our partners each year.
- To enable the police service, public health teams and other partners to work better together to support families enrolled in the troubled families programme, domestic abuse victims, children subject to Child Protection Plans and the management of sexual and violent offenders and those with complex dependencies such as drugs, alcohol or mental health.
- To identify and explore opportunities where national bodies can promote guidance, promote the sharing of information, support education and training needs and share learning to improve local services.
- To ensure staff have the skills and knowledge necessary to prevent crime, recognise risk factors earlier, protect the public, improve health and wellbeing and secure public trust.
- To work together to use our shared capabilities and resources more effectively to enhance the lives of those with complex needs and the people they interact with.
- To offer an integrated approach through the better co-ordination, prevention and early intervention that will increase the reach and impact of all services.
This consensus is specific to England, however the NPCC states they will work with our counterparts in Wales, Scotland and Northern Ireland, wherever possible and appropriate, to share learning and address joint objectives.
Challenges to collaborative practice
The following articles identify challenges to collaborative practice in this context that may be useful to consider when developing a strategic plan for inter-agency working:
Anderson, S (2011) Complex Responses - understanding poor frontline responses to adults with multiple needs: a review of the literature and analysis of contributing factors. Revolving Doors (pdf)
This review aims to increase the understanding of the negative experiences frequently had by adults with multiple needs when they are accessing frontline services. It explores the primary and underlying factors that contribute to this poor service response, considering interpersonal, professional, organisational and structural factors.
- Service users' experience of front-line services include:
- Poor relationship with staff
- Failure to involve service user in care planning
- Delay in receiving help
- Problems navigating systems
- Refusal of or exclusion from service
- Poor continuity of care
- A fragmented service response
Several key learning points are identified that may be beneficial to consider in policy development.
Hollander, Y et al. (2012) Challenges relating to the interface between crisis mental health clinicians and police when engaging with people with a mental illness. Psychiatry, Psychology and Law, 19(3) pp.402-411 (paywalled)
This study explored how crisis mental health clinicians and police officers
experience the service interface to identify perceived challenges to collaboration and possible solutions. A number of challenges to effective interface were identified. These included: inefficient communication before or following a joint event; difficulty accessing support from the interfacing service and delays in handing over care in hospital emergency departments; and staff occasionally not respecting the professional abilities of staff from interfacing services. (From author abstract)
McGregor et al. (2018) Multidisciplinary working: moving beyond rhetoric. In MacIntyre, G et al. (Eds) Safeguarding adults: key themes and issues (book - available through NHS libraries)
Chapter 5 of this book, by Kaye McGregor and Eileen Niblo focuses on multi-disciplinary working, including barriers to interdisciplinary working and how these may be overcome.
Braye, S (2015) Serious case review findings on the challenges of self-neglect: indicators for good practice. The Journal of Adult Protection, 17(2), pp.75-87 (paywalled or author repository copy)
In an analysis of forty serious case reviews (SCRs) involving adults who self-neglect, the authors identify the professional and interagency challenges involved, and extract learning that can be applied in developing notions of good self-neglect practice. Key challenges fell into four domains: the practice interface with the individual adult; the professional team around the adult; the organisations around the professional team; and interagency governance exercised through the LSAB. The themes within these categories are presented in the table below:
| Domain | Theme |
| The practice interface with the individual adult (and their family/carer context) | Person-centred approaches to intervention
Assessment of mental capacity Consideration of the individual's household, family and carers Securing or maintaining engagement History and patterns of behaviour |
| The professional team around the adult | Interagency communication and collaboration
Information-sharing Assessment, care planning, monitoring and review processes Recording of information Safeguarding literacy Legal literacy |
| The organisations around the professional team | Supervision and management
Organisational culture Staffing Organisational policies |
| Interagency governance exercised through the LSAB | The process and function of SCRs
Monitoring and action planning Interagency procedures and guidance Training |
The authors argue that these four domains are interlinked, and advocate a whole system approach to change.
Within the paper the challenges are explored in depth and connected to outcomes within the SCRs, including an absence of formalised mechanisms for information sharing, both within different parts of the same agency and across agencies. Problems with the recording of information were also identified:
Missing or inadequate records, or divergent accounts of discussions between professionals, made it difficult to see patterns or escalation of risk or to account for practice. There were cases in which communications from other agencies were not placed on file. Written records did not routinely evidence what concerns were expressed, what help was offered and accepted or declined by the individual, what referrals were made and later followed-up, or what information was shared with others and what decisions taken. Records made reference to capacity assessment but did not consistently indicate whether an individual was deemed capable of making valid and informed decisions; records relating to best interests were sometimes contradictory, and did not evidence Mental Capacity Act compliance. The IT system in two cases did not allow flagging of adults who were vulnerable or involved in safeguarding.
Issues with legal literacy were identified in the CSRs, relating to "varying and confused levels of understanding" in several areas including rules on information sharing. Procedural gaps in interagency governance around information sharing were also identified.
Social Care Institute for Excellence (2015) Sharing information barriers and solutions - adult safeguarding: sharing information (website)
SCIE have produced a guide that focuses on the sharing of sensitive or personal information between the local authority and its safeguarding partners (including GPs and health, the police, service providers, housing, regulators and the Office of the Public Guardian) for safeguarding purposes. This may include information about individuals who are at risk, service providers or those who may pose a risk to others. It aims to enable partners to share information appropriately and lawfully in order to improve the speed and quality of safeguarding responses. Communication between agencies is identified as a key point of failure in adult safeguarding:
Adult serious case reviews frequently highlight failures between safeguarding partners (local authorities, GPs and health, the police, housing, care providers) to communicate and work jointly. Such failures can lead to serious abuse and harm and in some cases, even death.
They make suggestions as to how to improve communication and joint working:
- Strategic
- Improve links between public protection forums: safeguarding boards, (children and adults), multi-agency risk assessment conferences (MARACs), multi-agency public protection arrangements (MAPPAs), health and wellbeing boards and community safety partnerships.
- Develop joint approaches to resolve concerns where the individual may not be eligible for social care support, for people who refuse support and those who self-neglect.
- Where appropriate, include partner agencies in enquiries, safeguarding meetings and investigations.
- Keep referring agencies informed of progress and outcomes.
- Monitor information-sharing practice.
- Joint training and policy development
- Ensure designated adult safeguarding managers play a role in providing advice and guidance within their respective organisations.
- Ensure all staff understand the basic principles of confidentiality, data protection, human rights and mental capacity in relation to information-sharing.
- Improve understanding of the different roles and responsibilities of safeguarding partners to reduce negative attitudes.
- Bring together people from different organisations to develop shared perceptions of risk.
- Agree common language, terms and definitions.
- Increase knowledge and understanding of multi-agency procedures.
Stevens, E (2013) Safeguarding vulnerable adults: exploring the challenges to best practice across multi-agency settings. The Journal of Adult Protection, 15(2), pp.85-95 (paywalled or author manuscript)
This paper highlights contemporary issues in achieving best practice in safeguarding adults across multi-agency settings. It draws on relevant literature and policy to identify challenges in achieving best practice in multi-agency approaches to safeguarding. Challenges identified include balancing empowerment and risk, communication between agencies, clarity around agency responsibilities, and deciding at what stage and how to intervene. Good practice recommendations include: ensuring safeguarding systems are thorough, transparent and timely; ensuring clarity around the roles and responsibilities of agencies; ensuring all agencies are aware of the responsibility to prevent and report abuse; and aiming to identify abuse as early as possible.
Winters, S et al. (2015) Interprofessional collaboration in mental health crisis response systems: a scoping review. Disability and Rehabilitation, 37(23), pp.2212-2224 (paywalled or author copy)
This scoping review explores the evidence around interprofessional collaboration (IPC) in mental health crisis response systems (MHCRS). Based on 18 included papers, the review identified the following themes:
- Support for interprofessional collaboration
- Quest for improved care delivery system
- Merging distinct visions of care
- Challenges to interprofessional collaboration
Issues raised about the nature of current evidence includes:
- Lack of conceptual clarity
- Absent client perspectives
- Unequal representation across sectors
- Descriptions of interventions rather than reporting on outcomes
An important aspects for successful implementation of collaborative practices identified was sufficient resource allocation.
A key issue raised was antagonism and animosity across sectors, including an example of the language used to discuss the same situation which highlighted the different viewpoints related to mental illness:
''[W]acko'' was used early on in their study by police personnel and the perceived orientation toward individuals with mental health from the ''other'' sector was often negative.
Wood, JD and Watson, AC (2016) Improving police interventions during mental health-related encounters: past, present and future. Policing and Society, 27(3), pp.289–299 (paywalled or author manuscript)
This paper reviews the first wave of reform efforts designed to re-shape police sensibilities and practices in the handling of mental health-related encounters in the United States. The authors suggest three opportunities to improve practice: enhancing experiences of procedural justice during mental health-related encounters; building the evidence base through integrated data sets; and balancing a "case-based" focus with a "place-based" focus.
Research evidence
Studies indicate that inter-organisational partnership working is under-developed and poorly understood (Krayer et al. 2018). However, the following sources provide some insight into collaborative models that indicate promise and/or provide insight into effective approaches.
Parker, A et al. (2018) Interagency collaboration models for people with mental ill health in contact with the police: a systematic scoping review. BMJ Open, 8(e019312) (open access)
This review of 125 studies focusing on interagency collaboration between law enforcement, emergency services, statutory services and third sector agencies regarding people with mental ill health identified 13 different interagency collaboration models catering for a range of mental health-related interactions, although these include "overlaps in agency composition":
The models identified involved collaborations between the police and a wide range of other services. The 'consultation model' and 'joint investigation training' only involved the police and mental health services; the remaining models were highly multidisciplinary involving a range of organisations. Information sharing agreements and court diversion models involved the widest combination of agencies. Across all collaborations with the police, mental health clinicians, mental health services and criminal justice agencies were the most frequently occurring partners.
The models are identified as:
- Prearrest diversion
- Coresponse
- Postbooking jail diversion
- Information sharing agreement models
- Court diversion models
- Colocation
- Comprehensive systems model
- Consultation model
- Service integration models
- Special protective measures
- Joint investigation training
- Re-entry programmes
- Integrated model
A limitation of the review is that the studies included are themselves limited in strength: "the study designs used are unlikely to provide robust evidence about effectiveness". However, the review may provide an informative overview of approaches that can be taken to collaborative practice in this context.
Paton, F et al. (2016) Improving outcomes for people in mental health crisis: a rapid synthesis of the evidence for available models of care. Health Technology Assessment, 20(3) (open access)
Crisis Concordat was established to improve outcomes for people experiencing a mental health crisis. The Crisis Concordat sets out four stages of the crisis care pathway: (1) access to support before crisis point; (2) urgent and emergency access to crisis care; (3) quality treatment and care in crisis; and (4) promoting recovery. This study evaluates the clinical effectiveness and cost-effectiveness of the models of care for improving outcomes at each stage of the care pathway. One review of reviews, six systematic reviews, nine guidelines and 15 primary studies were included. There was very limited evidence for access to support before crisis point. There was evidence of benefits for liaison psychiatry teams in improving service-related outcomes in emergency departments, but this was often limited by potential confounding in most studies. There was limited evidence regarding models to improve urgent and emergency access to crisis care to guide police officers in their Mental Health Act responsibilities. There was positive evidence on clinical effectiveness and cost-effectiveness of crisis resolution teams but variability in implementation. Current work from the Crisis resolution team Optimisation and RElapse prevention study aims to improve fidelity in delivering these models. Crisis houses and acute day hospital care are also currently recommended by NICE. There was a large evidence base on promoting recovery with a range of interventions recommended by NICE likely to be important in helping people stay well. (Author abstract)
Multi-agency safeguarding hubs (MASH)
The Home Office (2014) identifies a spectrum of multi-agency working using different information sharing models, which are based on three common principles: information sharing, joint decision making and coordinated intervention. The most common model is Multi-Agency Safeguarding Hub (MASH). These hubs "aim to improve the safeguarding response for children and vulnerable adults through better information sharing and high quality and timely safeguarding responses" (Home Office 2014).
In their analysis of MASHes, the Home Office (2014) identified that the agreed core functions of a multi-agency hub were:
- Acting as a single point of entry – gather all notifications related to safeguarding in one place.
- Enabling thorough research of each case to identify potential risk (and therefore the opportunity to address that risk)
- Sharing information between agencies, supported by a joint information sharing protocol
- Triaging referrals, exemplified in the use of agreed risk ratings.
- Facilitating early intervention to prevent the need for more intensive interventions at a later stage.
- Managing cases through co-ordinated interventions.
Simply having a MASH or other type of multi-agency safeguarding model does not guarantee a good safeguarding response, which can only be achieved if each agency effectively conducts its own safeguarding duties.
Positive outcomes of MASHes reported include:
- More accurate assessment of risk and need due to increased ability to compile intelligence from a wider range of sources
- Reduction in repeat referrals
- Derious risks may be assessed more accurately
- More thorough and driven management of cases - avoids cases getting 'lost' in the system
- Better understanding between professions
- Greater efficiencies in processes and resources
Conditions for success identified included:
- Several agencies working together in an integrated way
- Involvement of a health care and education professionals
- Co-location of agencies
- Timely exchange of information between agencies
- Greater understanding and mutual respect among different agencies
- Shared risk assessment tool
- Good leadership & clear governance
- Frequent scrutiny/review
- Strategic buy-in
- Integrated IT system
- Rotating staff between triage, risk assessment and frontline work
- Joint training and joint information sharing protocols
Barriers to success included:
- Misunderstandings among professionals about what information can be shared
- Cultural barriers across different agencies
- Underdeveloped performance assessment
- Risk thresholds that may be too high
- Lack of resources
- Lack of co-terminus boundaries
- Lack of clarity as to who was accountable for the multi agency hub
Participants identified the complexities of adult safeguarding in comparison to child safeguarding:
[T]here was widespread agreement that adult safeguarding is different, and in many ways more complex than child safeguarding, (one difference, for example, is the legal right for adults with capacity to choose to remain in risky situations) and that these differences will need to be thought through when setting up any MASH.
The report includes suggestions for setting up multi-agency models (Annex C).
SCIE (2016) identify several questions to ask when establishing a MASH:
- Will the hub take the form of a single location for staff from all the agencies?
- How will it be resourced and by whom?
- What are the thresholds that will trigger referral to the hub?
- Which agencies will represent health and social care?
- At what levels will agencies be represented?
- Are decisions regarding action made by the hub or does it just make recommendations to the individual agencies that are members?
- How will the hub link to/work with safeguarding children systems and processes?
- Is there an information-sharing protocol in place stating how and which information can be requested, how it will be shared, the uses to which it can be put, how it will be stored and for how long?
- Are IT information systems compatible?
Scottish Institute for Policing Research (2015) Interagency adult support and protection practice of police and health and social care professionals: a realistic evaluation approach (pdf)
This report presents the findings of a research project that explored the interagency Adult Support and Protection practices of police, health and social care professionals in Scotland. Thirteen focus groups involving 101 professionals were conducted. Key themes were identified, including: information sharing; relationships; people and processes; lessons from child protection; environment; implementation of the act; regional variations and training; rights of the service users. Tensions across the agencies in relation to information sharing were identified:
[I]ssues with information sharing across the different professions often exacerbated by the need to protect confidentiality. There were differences highlighted between the professions with police and social work demonstrating frustration at healthcare professionals' seeming reluctance to share vital information.
Early intervention
There needs to be greater emphasis on early intervention and preventing people reaching crisis point. When a person is experiencing a mental health crisis, mental health input needs to be quickly available via whichever service that person first comes into contact with. Local areas need to develop robust community partnerships involving health, criminal justice, housing etc. to offer people appropriate support. Options need to be available so people can be supported in the least restrictive setting possible and with minimal criminal justice input. (Reid 2014)
Allen Consulting Group (2012) Police, Ambulance and Clinical Early Response (PACER) Evaluation final report (pdf)
The PACER project is an evidence informed model of collaborative practice between the police, ambulance service and clinical early response in Victoria, Australia:
The PACER project trials a new model of early intervention that builds on the evidence of what works in other countries and the particular skills and knowledge of police and mental health agencies to deliver a more cost effective response to the management and resolution of mental health crises. Importantly, the objectives of the model are consistent with the reported perspectives of consumers and carers who value timely access to mental health treatment and referral and avoidance of compulsory sectioning or hospitalisation where possible.
The project evaluation sought the assess the effectiveness and efficiency of PACER, conduct a cost effectiveness analysis, and identify enablers and challenges.
Outcomes reported include:
- More timely access to mental health assessment for the person in crisis
- More streamlined approach to emergency response through sharing of police and mental health databases and networks
- Fewer referrals to hospital emergency departments
- Shorter length of stay in hospital emergency departments for mental health patients
Understanding the roles of agencies
One significant challenge in successful collaborative practice is ensuring that the agencies involved have clearly understood roles. Krayer et al. (2018) report different perceptions of the police role in mental health and tensions over the role that the police play in mental healthcare carry over into interpretations of police roles in partnership working. They suggest that a lack of understanding can lead to inter-organisational conflict (Krayer et al. 2018). Several of the sources provided throughout this summary discuss potentially effective ways of ensuring clear roles of involved agencies.
Information sharing protocols
Information sharing between agencies is a key aspect of collaborative working. Inverclyde Council (no date) explain that "whilst confidentiality is important, it is not an absolute right. Co-operation in sharing information is necessary to enable a council to undertake the required inquiries and investigations." SCIE (2015) discuss the benefits of information sharing protocols and agreements:
Information-sharing agreements or protocols:
- Are useful tools to enable inter-agency communication and support decision-making
- Should clarify the channels of communication and procedures for sharing information
- Should be inclusive of all safeguarding partners
- Should apply to and be understood by staff (in relation to their role) in all safeguarding partner organisations at all levels.
However, information sharing is identified as a significant challenge in effective collaboration:
A finding of many serious case reviews has been poor information-sharing between agencies. The ability to share information in a timely and effective manner to facilitate joint decision-making is key to SABs meeting their objectives. (SCIE 2016)
Several barriers to information sharing have been identified, including incompatible computer systems and restrictions due to data protection/confidentiality requirements (Lennox et al. 2012).
The following resources contain relevant thought, advice and guidance around information sharing and balancing privacy and safeguarding considerations, several of which are used in practice by multi-agency partnerships.
Co-ordinated action against domestic abuse (2012) MARAC Information Sharing Protocol checklist (pdf)
This checklist maps out the key contents of an MARAC Information Sharing Protocol (ISP) and is designed to act as a guide to help you draw up your own protocol locally.
Grace, J (2015) Better information sharing, or 'share or be damned'? Journal of Adult Protection, 17(5), pp.308–320 (author repository copy or paywalled)
This paper explores the issues of information sharing between professionals and agencies in the context of safeguarding. It considers the implications of surveillance technology, human rights considerations of proportionate information sharing.
The author discusses a 'politics of public protection' that the author argues sometimes does not have "rational regard for a proportionate balance between "the broader needs and human rights of (potential) victims, and the particular procedural, human rights of (alleged) offenders in multi-agency working settings in relation to safeguarding or public protection".
The author concludes:
[D]evelopments in surveillance policies and technologies as part of the "public protection routine" will result in a damaging and hasty culture of "share or be damned" unless a more careful approach to new information sharing approaches is developed. Otherwise, an increasing bureaucratisation of risk management through surveillance will lead to a disregard for the fine balance between public protection, procedural rights and privacy.
HM Government (2018) Information sharing: advice for practitioners providing safeguarding services services to children, young people, parents and carers (pdf)
This guidance provides seven golden rules to information sharing in the context of child safeguarding, but is likely to be relevant in the context of adult mental health support. This guidance has been updated to reflect the General Data Protection Regulation (GDPR) and Data Protection Act 2018, and it supersedes the HM Government Information sharing: guidance for practitioners and managers published in March 2015.
Lennox, C et al. (2012) Information sharing between the National Health Service and criminal justice system in the United Kingdom. Journal of Forensic Nursing, 8(3), pp.131–137 (open access)
This study focused on the sharing of information about people with mental health problems in contact with the criminal justice system by health and criminal justice personnel.
Key findings include:
- Over half of respondents (59%, n = 136) stated the service user information they received from other agencies was not detailed enough for them to do their job.
- Forty-seven percent (n= 107) noted difficulties in sharing service user information because of incompatible information technology systems
- 41% (n = 93) said they were unclear about what type of service user information could be shared with other agencies
- Ninety-four percent (n = 218) of respondents stated that they were aware that all public bodies must comply with the European Convention on Human Rights
- Fewer respondents (56%, n = 131) were aware that health professionals had a duty to breach confidentiality in order to protect the public from harm
- Almost a quarter (22%, n = 51) thought that they could not breach confidentiality under any circumstance
The information sharing questionnaire (ISQ) used as the data collection tool in this study may be a useful resource for agencies seeking an evidence informed approach to policy and workforce development around effective information sharing.
SCIE (2016) Information-sharing agreements or protocols - adult safeguarding: sharing information (website)
This discussion of the Care Act 2014 includes recommendations relating to information sharing:
The agreement or protocol should cover these key points from the Data Sharing Code of Practice:
- The information that needs to be shared
- The organisations that will be involved
- What you need to tell people about the data sharing and how you will communicate that information
- Measures to ensure adequate security is in place to protect the data
- The arrangements that need to be in place to provide individuals with access to their personal data if they request it
- Agreed common retention periods for the data
- Processes to ensure secure deletion takes place
Social Care Institute for Excellence (2015) Adult safeguarding: sharing information (pdf)
This guide is part of a range of products to support implementation of the adult safeguarding aspects of the Care Act 2014. It summarises key parts of several relevant laws (Data Protection Act, Human Rights Act, Crime and Disorder Act and Mental Capacity Act) to help increase understanding of the basic principles in relation to safeguarding practice and, in particular, the sharing of safeguarding information. This guide will be useful to frontline workers and managers from a range of sectors who work with people with care and support needs. The Scottish legislative context will need to be taken into consideration.
Key messages include:
- Adults have a general right to independence, choice and self-determination including control over information about themselves. In the context of adult safeguarding these rights can be overridden in certain circumstances
- Emergency or life-threatening situations may warrant the sharing of relevant information with the relevant emergency services without consent
- The law does not prevent the sharing of sensitive, personal information between organisations where the public interest served outweighs the public interest served by protecting confidentiality – for example, where a serious crime may be prevented
- There should be a local agreement or protocol in place setting out the processes and principles for sharing information between organisations.
- It is good practice to try to gain the person's consent to share information
- The management interests of an organisation should not override the need to share information to safeguard adults at risk of abuse
Scottish Government (2014) Health & Social Care Information Sharing - A Strategic Framework 2014-2020 (website)
Section 2 of this report discusses equalities and rights, information governance, information sharing agreements, data ownership, and access to jointly held records.
Mapping resources
Reid, P (2014) Mental health and criminal justice: What can we learn from liaison and diversion in the USA and Canada? (pdf)
In this report, the author suggests that many of the challenges faced in liaison and diversion "require a community response, with mental health, criminal justice, housing, welfare and other support services working together to support individuals with complex needs". One method of achieving this is through mapping community resources, for which the author discusses the Sequential Intercept Model:
[The model] was designed as a framework for understanding mental health and criminal justice interactions. It has been used by a number of communities in the USA to help them understand how and where people affected by mental illness may come into contact with the criminal justice system. The model is designed to identify intervention points, the different target populations at these points and help illustrate where there might be gaps in existing services.
This may be a relevant approach in the Scottish context worth further exploration.
Considerations for rural areas
Nilson, C (2017) Collaborative risk-driven intervention : research supporting technology-enabled opportunities for upstream virtual services in rural and remote communities. Journal of Community Safety and Wellbeing, 2(3), pp.76–86 (open access)
In 2011, Canada's Hub Model of Collaborative Risk-Driven Intervention was launched in Prince Albert, SK. This article discusses the expansion of the Hub Model of collaborative risk-driven intervention into rural and remote areas, focusing on tech-enabled hubs.
The following lessons are identified:
- Be prepared to adjust expectations and roles
- Strive for equal ownership and a shared value of the initiative among community partners
- Allow for more time in the preparation stage than in other less remote environments
- Be willing to adjust training and logistical needs to meet service provider capacity and need
- Look within the community to find and mobilize what resources are available (as opposed to focusing on resources that are not available)
- Consider a regional perspective for expanding service access and resource availability
- Implement video communication technology to overcome limitations in service access or quality
- Incorporate culture and tradition into delivery of the model
- Be prepared for variation in the adaptation practices across rural and remote communities
- Keep the model simple and easy to implement
- Make sure ongoing support is accessible and responsive to community needs
- Allow for cultural infusion, which will foster community ownership, stakeholder buy-in, and target group engagement
Skubby, D et al. (2013) Crisis Intervention Team (CIT) programs in rural communities: a focus group study. Community Mental Health Journal, 49(6), pp.756–764 (paywalled or author copy)
The Crisis Intervention Teams model (CIT) was originally developed as an urban model for police officers responding to calls about persons experiencing a mental illness crisis. Literature suggests that there is reason to believe that there may be unique challenges to adapting this model in rural settings. This study attempts to better understand these unique challenges. Thematic analysis of focus group interviews revealed that there were both external and internal barriers to developing CIT in their respective communities. Some of these barriers were a consequence of working in small communities and working within small police departments. Participants actively overcame these barriers through the realization that CIT was needed in their community, through collaborative efforts across disciplines, and through the involvement of mental health advocacy groups. These results indicate that CIT can be successfully implemented in rural communities. (Author abstract)
Recommendations for good practice
Durcan, D (2014) Keys to diversion: best practice for offenders with multiple needs. London: Centre for Mental Health (pdf)
Keys to Diversion identifies the key elements of successful liaison and diversion services in Lewisham, Manchester, Portsmouth and in Plymouth, Bodmin and Truro. It finds that the most successful teams offer support for a wide range of a person's needs, they build packages of support from a range of local agencies, and they stay in touch with people after they have been referred to other services. (Author abstract)
Crisp, AP (2015) Understanding best practice: the emergency response to mental illness - an exploratory report. London: Winston Churchill Memorial Trust (pdf)
The aim of this research was to learn more about some of the more established, coordinated responses to mental health emergency incidents. It examines the emergency response to mental illness with funding to visit areas of best practice internationally.
This report outlines the findings from international site visits with police services and their partner agencies who specialise in addressing the emergency response to mental illness. Key findings include:
- There is a complex and necessary role that police have in supporting and dealing with mental ill health in the community setting
- The need for mental health training for police professionals has importance and needs investment in order to improve outcomes
- Partnership co-response models can be an efficient and effective method of dealing with community and organisational demand
It includes several recommendations based on observations of practice from the US, Canada and Australia.
Home Office (2015) Supporting vulnerable people who encounter the police: a strategic guide for police forces and their partners. London, UK: Home Office (pdf)
This guide is intended to provide a strategic overview of the range of approaches available to provide effective help to people with mental ill-health, learning disabilities or substance misuse problems. It is primarily intended for police forces in England and Wales to use in conjunction with their partner agencies (including the voluntary and community sector) with responsibility for helping them respond to vulnerable people. It may also be of use in shaping appropriate local responses to others that may be deemed vulnerable.
Examples of approaches used in the UK
Dumfries and Galloway Police Division (2017) Local policing plan 2017-20 (pdf)
In Dumfries and Galloway, a Multi Agency Safeguarding Hub (MASH) was implemented to support the process of screening and responding to Adult Support and Protection referrals enabling a multiagency discussion with regard to risk at the earliest of opportunities. This involved the co-location of Police, NHS and Social Work staff to work out of premises at Police HQ, Dumfries.
The key principles of the MASH include:
- Safeguarding adults who may be at risk of harm
- Single point of entry for screening referrals on adults at risk
- Assessment and Sharing of information
- Consider Interim Safety Plan
- Identifying patterns of vulnerability in our community
- Identifying / Assessing Risk to adults at risk
- Provide performance information and outcomes
Dyer, W and Biddle, P (2016) Enhanced support for high intensity users of the criminal justice system – an evaluation of mental health nurse input into Integrated Offender Management Services in the North East of England. Social Policy and Society, 15 (1) pp.43-55 (paywalled or author repository copy)
This article reports on the findings of an evaluation of a new Integrated Offender Management-Mental Health (IOM-MH) service developed in the North East of England. The initiative aims to provide support for repeat offenders with mental health problems who frequently come into contact with the Criminal Justice System (CJS). It discusses the potential benefits of co-locating mental health nurses.
Edinburgh, Lothians and Borders Executive Group Public Protection (ELBEG-PP) (2013) Multi-agency guidelines (pdf)
This updated version of the multi-agency Adult Support and Protection guidelines replaces the guidelines that were initially published in January 2010. The new guidelines take account of further changes to legislation; changes to agency structures and nomenclature, experiences of practitioners over the last two years and feedback from users of the guidelines on a number of issues. These issues include new information on protection orders; risk assessments and transition of users from Child Protection to Adult Support and Protection.
Hampshire, Isle of Wight, Portsmouth and Southampton (2016) Safeguarding adults: multi-agency policy, guidance and toolkit (pdf)
This policy, guidance and toolkit was first published in May 2015 by the Local Safeguarding Adults Boards (4LSAB) covering Hampshire and the Isle of Wight (including Portsmouth and Southampton) to meet the requirements of the Care Act 2014 and the Department of Health Statutory Guidance published in October 2014. This 2nd edition of the policy reflects the changes introduced in the revised Care Act 2014 statutory guidance published in 2016 as well as other legislative changes. It is designed to support current good practice in adult safeguarding and outlines the arrangements which apply to the whole of the 4LSAB area.
The document includes a section on guidance on statutory safeguarding enquiries (section 2) which outlines the process that should be followed when responding to concerns raised about a person with care and support needs who is experiencing or is at risk of abuse, neglect or exploitation and reflects the new statutory safeguarding duties introduced under the Care Act 2014. This includes guidance on what safeguarding responses should look like (outcome focused, inclusive, proportionate, timely, structured, flexible, effective and formative). It introduces the stages of the safeguarding process, factors to consider when raising a safeguarding concern, and good practice for information gathering and record-keeping.
Inverclyde Council (no date) West of Scotland inter-agency adult support and protection practice guidance (pdf)
This document aims to:
- Assist in the prevention of harm occurring to adults who may be at risk of harm in the West of Scotland through building on good practice and a common understanding of the issues;
- Support adults who may be at risk of harm through having a joint understanding across each agency of:
- Their roles and responsibilities in responding to reports of criminality or identified concerns involving adults at risk
- The duty of cooperation of public bodies
- Ensuring links between Child, Adult and public protection guidance
- Better understanding of the lead role of social work in adult protection and the integral part that partner agencies play in the protection of adults who may be at risk
- Identify the role of each council where cross-boundary issues arise
- Support existing local operating procedures by providing a framework of the overall interagency response in terms of referrals, inquiries, investigations, actions and the monitoring and review of outcomes
- Provide Procedural Forms (Appendix 1, 2, 3) which can be used by all agencies across the West of Scotland
- Explain the role of Chief Officers Group and Adult Protection Committee
- Provide an understanding of the legal basis for intervention
- Provide an understanding of the terminology used in adult protection
- Share the principles of good practice in adult protection
Irvine, AL et al. (2016) Evaluation of the Scarborough, Whitby and Ryedale Street Triage Service: research report. Department for Social Policy and Social Work, University of York (pdf)
This evaluation used qualitative and quantitative methods within a co-production framework to explore the impact of the Scarborough, Whitby and Ryedale (SWR) Street Triage service was funded for 12 months by the Department of Health as one of nine pilots in England. Street triage was introduced to bridge a gap between police and NHS mental health services, and to help reduce the number of detentions under s.136 Mental Health Act 1983. Among the findings, the authors identified that the intervention helped to de-escalate crisis situations and find non-custodial options for people experiencing mental distress. It freed up police officers to attend other incidents and signposted people towards other more appropriate services which could provide suitable help.
McKenna, B et al. (2015) Police and mental health clinician partnership in response to mental health crisis: a qualitative study. International Journal of Mental Health Nursing, 24(5), pp.386-393 (paywalled)
This paper discusses the introduction of the Northern Police and Clinician Emergency Response (NPACER), in which police and mental health clinicians work collaboratively to "reduce behavioural escalation and provide better outcomes for people with mental health needs through diversion to appropriate mental health and community services". The authors report on collaborative strengths, including communication, information sharing, and knowledge/skill development. Improved outcomes reported include emergency department diversion, direct access to inpatient mental health services, reduced police officer 'down‐time', improved interagency collaboration and knowledge transfer, and improvements in service utilization and transition.
Norrie, C et al. (2017) The advantages and disadvantages of different models of organising adult safeguarding. British Journal of Social Work, 47(4), pp.1205-1223 (paywalled or author repository copy)
This paper identifies a typology of different models of adult safeguarding and compares their advantages and disadvantages. The four models are termed:
- Dispersed-generic
- Dispersed-specialist
- Partly-centralised-specialist
- Fully-centralised-specialist
The authors describe the characteristics of these models and examples of where across the UK they are used. The advantages and disadvantages discussed include practice around identifying concerns, multi-agency working, prioritisation, case handovers, tensions, confidence and deskilling, performance management and auditing, and feedback on safeguarding services.
Ogloff J, et al. (2013) Policing services with mentally ill people: developing greater understanding and best practice. Australian Psychologist, 48(1), pp.57–68 (paywalled)
This article provides an overview of some of the key findings from a programme of research undertaken in Victoria to further understand and develop a best practice model at this interface for people with mental illnesses in the criminal justice system.
Some suggested strategies may be drawn from the research. A key focus of the authors is the impact of procedural justice (the process by which people are dealt with by the law) in improving outcomes for individuals:
Some suggested strategies may be drawn from the research that the police may use to validate the victim's experiences, improve their outcomes, and reduce some of the sequelae that come with being victims. First, police need to ensure that they treat the victim as a person—not a case or statistic. At the same time, though, police should acknowledge that the wrong happened and should emphasise the unacceptance of the crime. In their interactions with victims, they need to ensure that they do not display attitudes that the victims might perceive as being blamed for their victimisation. They also need to employ empathic listening skills in their work with victims.
Perth and Kinross (2015) Adult Support and Protection (Scotland)
Act 2007 Perth and Kinross Multi-Agency Guidelines (pdf)
This Multi-Agency Operational Guidance represents the commitment of agencies in Perth and Kinross to:
- Unite in the prevention of and protection from harm, mistreatment and neglect of adults at risk aged 16 years and over
- Ensure situations of actual or suspected harm, exploitation, mistreatment and neglect are identified, recorded and investigated
This multi-agency guidance has been adopted by Perth & Kinross Council as the Council's Adult Support and Protection Operational Guidance. This Guidance is designed to ensure that there is common practice across Tayside and is consistent with the ethos of the Tayside Protocol.
Renfrewshire Adult Protection Committee (2017) Inter-agency adult support and protection guidance and procedures (pdf)
This set of guidance and procedures have been produced on behalf of Renfrewshire Adult Protection Committee. It is based on the revised West of Scotland inter-agency Adult Support and Protection Practice Guidance. It is intended to provide a framework to enable all agencies to work together effectively to ensure that adults at risk of harm receive support and protection. It includes context for partnership working, outlines roles and responsibilities of partner agencies, provides guidance for staff from all partner agencies with regard to key questions and issues, and identifies cross-agency issues.
Forthcoming events
Healthcare Conferences UK. Caldicott Principles & Information Sharing in Adult Safeguarding. Friday 30 November 2018, De Vere West One Conference Centre, London (£365-£594)
This conference will focus on developing your role in improving communication and information sharing in adult safeguarding whilst ensuring patient confidentiality. Case studies will focus on applying the Caldicott Principles in Adult Safeguarding, Domestic Violence, working with the Police, working with homeless people and working with Vulnerable Adults in Mental Health services.
Learning outcomes include:
- Understand and reflect on decision making around information sharing
- Update your knowledge on ethical decision making principles and frameworks and how you can implement these in decision making practice
- Understand when information can be shared with relatives, other professionals and services, and when it cannot
References
Allen Consulting Group (2012) Police, Ambulance and Clinical Early Response (PACER) Evaluation final report (pdf)
Anderson, S (2011) Complex Responses - understanding poor frontline responses to adults with multiple needs: a review of the literature and analysis of contributing factors. Revolving Doors (pdf)
Braye, S (2015) Serious case review findings on the challenges of self-neglect: indicators for good practice. The Journal of Adult Protection, 17(2), pp.75-87 (paywalled or author repository copy)
Cantrill, P (2012) Independent multi-agency review report in respect of: Miss G. NHS Doncaster (pdf)
Crisp, AP (2015) Understanding best practice: the emergency response to mental illness - an exploratory report. London: Winston Churchill Memorial Trust (pdf)
Department of Health and Concordat signatories (2014) Improving outcomes for people experiencing mental health crisis. London: HM Government (pdf)
Dorset Safeguarding Adults Board (2011) Executive summary of serious case review in respect of an adult female who died on 28 February 2011 (pdf)
Dumfries and Galloway Police Division (2017) Local policing plan 2017-20 (pdf)
Durcan, D (2014) Keys to diversion: best practice for offenders with multiple needs. London: Centre for Mental Health (website)
Dyer, W and Biddle, P (2016) Enhanced support for high intensity users of the criminal justice system – an evaluation of mental health nurse input into Integrated Offender Management Services in the North East of England. Social Policy and Society, 15 (1) pp.43-55 (paywalled or author repository copy)
Edinburgh, Lothians and Borders Executive Group Public Protection (ELBEG-PP) (2013) Multi-agency guidelines (pdf)
Grace, J (2015) Better information sharing, or 'share or be damned'? Journal of Adult Protection, 17(5), pp.308–320 (paywalled or author copy)
Hampshire, Isle of Wight, Portsmouth and Southampton (2016) Safeguarding adults: multi-agency policy, guidance and toolkit (pdf)
Herrington, V (2012) Inter-agency co-operation and joined-up working in police responses to persons with a mental illness: lessons from New South Wales. Policing, 6(4), pp.388–97 ([paywalled] or [open access])
HM Government (2018) Information sharing: advice for practitioners providing safeguarding services services to children, young people, parents and carers (pdf)
Hollander, Y et al. (2012) Challenges relating to the interface between crisis mental health clinicians and police when engaging with people with a mental illness. Psychiatry, Psychology and Law, 19(3) pp.402-411 (paywalled)
Home Office (2015) Supporting vulnerable people who encounter the police: a strategic guide for police forces and their partners. London, UK: Home Office (pdf)
Home Office (2014) Multi-agency working and information sharing project: final report. London, UK (pdf)
Hughes-Morley, A et al. (2017) What models or mechanisms for inter-agency collaboration between the police or law enforcement and other statutory agencies for people with mental problems have been evaluated, and what evidence is available on their effectiveness? A systematic scoping review (open access)
Inverclyde Council (no date) West of Scotland inter-agency adult support and protection practice guidance (pdf)
Irvine, AL et al. (2016) Evaluation of the Scarborough, Whitby and Ryedale Street Triage Service: research report. Department for Social Policy and Social Work, University of York (pdf)
Kane, E et al. (2017) Effectiveness of current policing-related mental health interventions in England and Wales and Crisis Intervention Teams as a future potential model: a systematic review. Systematic Reviews, 6(85), pp.1-7 (open access)
Krayer, A et al. (2018) Exploration of joint working practices on anti-social behaviour between criminal justice, mental health and social care agencies: a qualitative study. Health & Social Care in the Community, 26(3), pp.431–441 (open access)
Lennox, C et al. (2012) Information sharing between the National Health Service and criminal justice system in the United Kingdom. Journal of Forensic Nursing, 8(3), pp. 131–137 (paywalled)
McGregor et al. (2018) Multidisciplinary working: moving beyond rhetoric. In MacIntyre, G et al. (Eds) Safeguarding adults: key themes and issues (book - available through NHS libraries)
McKenna, B et al. (2015) Police and mental health clinician partnership in response to mental health crisis: a qualitative study. International Journal of Mental Health Nursing, 24(5), pp.386–93 (paywalled)
National Police Chief's Council et al. (2018) Policing, health and social care consensus: working together to protect and prevent harm to vulnerable people (pdf)
Nilson, C (2017) Collaborative risk-driven intervention : research supporting technology-enabled opportunities for upstream virtual services in rural and remote communities. Journal of Community Safety and Wellbeing, 2(3), pp.76–86 (open access)
Norrie, C et al. (2017) The advantages and disadvantages of different models of organising adult safeguarding. British Journal of Social Work, 47(4), pp.1205-1223 (paywalled or author repository copy)
Ogloff J, et al. (2013) Policing services with mentally ill people: developing greater understanding and best practice. Australian Psychologist, 48(1), pp.57–68 (paywalled)
Parker, A et al. (2018) Interagency collaboration models for people with mental ill health in contact with the police: a systematic scoping review. BMJ Open, 8:e019312 (open access)
Paton, F et al. (2016) Improving outcomes for people in mental health crisis: a rapid synthesis of the evidence for available models of care. Health Technology Assessment, 20(3) (open access)
Perth and Kinross (2015) Adult Support and Protection (Scotland)
Act 2007 Perth and Kinross Multi-Agency Guidelines (pdf)
Reid, P (2014) Mental health and criminal justice: What can we learn from liaison and diversion in the USA and Canada? (pdf)
Renfrewshire Adult Protection Committee (2017) Inter-agency adult support and protection guidance and procedures (pdf)
Scottish Institute for Policing Research (2015) Interagency adult support and protection practice of police and health and social care professionals: a realistic evaluation approach (pdf)
Skubby, D et al. (2013) Crisis Intervention Team (CIT) programs in rural communities: a focus group study. Community Mental Health Journal, 49(6), pp.756–764 (paywalled or author copy)
Social Care Institute for Excellence (2015) Sharing information barriers and solutions - adult safeguarding: sharing information (website)
Stevens, E (2013) Safeguarding vulnerable adults: exploring the challenges to best practice across multi-agency settings. The Journal of Adult Protection, 15(2), pp.85-95 (paywalled or author manuscript)
South Lanarkshire Adult Protection Committee (no date) When is an adult at risk? (website)
West Lothian CHCP (2013) Adult support and protection: ensuring rights and preventing harm. Multi-agency guidelines (pdf)
Winters, S et al. (2015) Interprofessional collaboration in mental health crisis response systems: a scoping review. Disability and Rehabilitation, 37(23), pp.2212-2224 (paywalled)
Wood, JD and Watson, AC (2016) Improving police interventions during mental health-related encounters: past, present and future. Policing and Society, 27(3), pp.289–299 (paywalled or author manuscript)
