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Hoarding Clutter Rating Scale Handout Sheets

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With Dr Gavin Heron, Fergus Reid and Professor Feng Dong

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Generative AI, critical thinking and social work practice

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This Insight provides some introductory information on AI and its use in social work contexts, and explores the limited literature in this area while presenting research on the impact of AI on critical thinking and professional curiosity.

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Adult Support and Protection (ASP) National Minimum Dataset, 2024-25 – Technical Report

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Technical report accompanying publication Adult Support and Protection (ASP) National Minimum Dataset, 2024-25 for Scotland and provides more detailed information on the background and methodology used to produce the statistics, as well as notes on data quality and a glossary of terms used.

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Multi Agency Adult Support and Protection Case Conferences (IRISS Video Resource)

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Multi Agency Adult Support and Protection Case Conferences (IRISS Video Resource)

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Great 1 hour video giving lived experience and multi agency perspectives on how what and how a multi agency case conference should run

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Multi-Agency Adult Support and Protection Case Conferences

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An Iriss Bitesize video introduction to multi-agency Adult Support and Protection meetings (Case Conferences) in Scotland…

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What is the Role of a Mental Health officer

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What is the Role of a Mental Health officer

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Short learning video produced by the Mental Health Officer Team in Dundee

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Learning Resources on the Adults with Incapacity Act in Scotland - produced by our Dundee City Council Mental Health Officer Team

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Your Tube recording from MHO Team in Dundee on Power of Attorney

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New Guidance in Dundee supporting 16/17 year olds

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New Guidance in Dundee supporting 16/17 year olds

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Book - A Pragmatic Approach to Chronic Disorganisation and Hoarding — hoarding academy

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An estimated 1 in every 40 adults has experienced problematic hoarding, yet there are few resources dedicated to understanding and supporting people with Hoarding Disorder. This book gives practitioners much-needed practical guidance on how to help those affected by extreme clutter, chronic disorga

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ASP Independent Advocacy Best Practice Guidance 2024 Final 

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Guidance & advice | Mental Welfare Commission for Scotland

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Here you can find all the good practice guides and advice notes we have produced relating to key themes.

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Information and directories of support in Dundee and Tayside

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Our aim is to provide high-quality mental health and wellbeing services within GP Practices across Dundee so that you can access the right support for your mental health and wellbeing when you need it.

We offer a multi-disciplinary team approach alongside our community partners, third sector and specialist services.

Mental Health and wellbeing issues are a common reason for people seeking care and support. If you are looking for support for yourself or a loved one, please read through these pages and follow the referral guidance for the resource required. We have included other places you can go to for support and digital options that you may find useful.

What We Offer

Our multi-disciplinary team includes general practitioners, link workers, mental health nurses, support workers, welfare advisors and volunteers. These make up five distinct services that are offered at GP practices or nearby.

You can find out more about these services, what they do and how you can access them in the page below.

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Themes of race , power and disability and coercive control

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Tell Them You Love Me Doc Tells the Complicated True Story of Anna Stubblefield

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The film about the woman and her nonverbal student, Derrick Johnson, explores disability rights.

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Steven's Story - A personal experience of Cuckooing

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It can be easy when talking about nude image sharing to lean hard on it being illegal to send or receive nude images under 18 but this can make young people hesitant to speak up if they are victim of sextortion or another form of intimate image abuse.

If you are talking about the Law, please consider adding that even if they do send images under the age of 18, it's not ok for those images to be used to blackmail or control them and that there is non-judgement support available to them.

Whilst it's illegal to send, share and receive nude images of someone under 18, if they've been tricked, threatened or pressured into doing it- like in a sextortion case - they will not face charges or blame.

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Empower youth and enhance community safety with Fearless Scotland by CrimeStoppers UK. Explore tailored resources and initiatives for professionals committed to making a positive impact on the lives of young individuals. Join a collaborative effort to create safer environments and foster resilience.

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Responding to Human Trafficking guidance and resource pack from Scottish Borders Council

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Responding to Human Trafficking guidance and resource pack from Scottish Borders Council

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Improving our Response to Human Trafficking – resource pack 2 (1)

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ASPire 2024: Introduction to Adult Support and Protection (webinar)

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This is an ASPire webinar from June 2024. It is a short, general introduction to Adult Support and Protection. It includes a clear description of what ASP is, types of harm, what to do if you have a concern, and examples to support learning.

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Quarriers Digital Financial Inclusion report

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Introduction

The LGBTQ+ Older Adult Social Care Assessment (LOASCA) study provided detailed knowledge of how adult social care workers consider sexual orientation and gender identity when assessing older people and how older LGBTQ+ people experience assessments.

Funded by the National Institute for Health and Care Research School for Social Care Research (NIHR SSCR), the project was undertaken by the University of Birmingham in collaboration with the University of Manchester, University of Bristol, and Opening Doors, a nation-wide charity offering services to older LGBTQ+ people.

The project team consists of:

Dr Jason Schaub (project lead, University of Birmingham)

Dr Paul Willis (University of Bristol)

Dr Stephen Hicks (University of Manchester)

Professor Ben Thomas (Opening Doors)

Dr Dora Jandrić (research fellow, University of Birmingham).

About the LOASCA study

The study used a collaborative process that included eight co-researchers, older LGBTQ+ people with lived experience of social care. These co-researchers undertook a range of research tasks and contributed across the project including: project design, data collection, data analysis, and dissemination, as well as ensuring the project findings were relevant and applicable.

This cross-sectional mixed-methods study used a multiple site case study design to understand:

A) How social care workers engage with issues of SOGI when assessing older LGBTQ+ people with care and support needs.

B) How these service users experience and receive assessments.

Webinar: Understanding how social care assesses older LGBTQ+ people for support

Project outputs

The CIRCLE project

The CIRCLE research project, led by Dr Jolie Keemink at the University of Kent in collaboration with The Applied Research Collaboration Kent Surrey Sussex, involves various partners such as universities, local authorities in Kent, Surrey, and Sussex, and LGBTQ+ voluntary organi szations like Opening Doors and Switchboard. Funded by the NIHR ARC KSS, the study spanned from October 2022 to September 20234. Its objective is to enhance inclusivity for LGBTQ+ (lesbian, gay, bisexual, trans, queer) residents in residential care facilities catering to individuals aged 50 and above.

Skills for Care LGBTQ+ learning framework

This framework for supporting LGBTQ+ individuals in their later years is designed to establish a foundation for recognising the insights, knowledge, understanding, and skills essential for the social care workforce. The goal is to enable them to engage affirmatively, inclusively, and effectively with people from gender and sexually diverse communities. Dr. Trish Hafford-Letchfield of the University of Strathclyde spearheaded the development of this project in collaboration with the LGBT Foundation, with funding provided by Skills for Care.

The framework describes core knowledge and skills, common and transferable across different types of service provision. It outlined four domains: LGBTQ+ awareness and affirming practice; health and wellbeing in later life; personalised care and support; and leadership, education and service development.

Resources

Short film: Fran's story

This animated video uses the LOASCA study findings to create a fictional case scenario in which we can observe the impact of hetero/cisnormativity on older LGBTQ+ people's social care assessments. This video is particularly relevant to social workers, encouraging them to reflect on their own practice. In the video we describe a range of assessment responses to 'Fran' an older adult being assessed in her home, and the impact of the social worker's approaches.

The video depicts a truncated version of a visit to allow for easier viewing. While in a real assessment there would be much more detailed engagements, particularly around some of the issues that Fran raised, this video considers those elements that support LGBTQ+ identities, and not the wider social care issues.

Graphic novel

The LOASCA project sought to understand how social care workers ask about sexual orientation and gender identity in adult social care assessments, hoping to improve social care for older lesbian, gay, bisexual, trans, and queer (LGBTQ+) people. This graphic novel presents some of the stories told by older LGBTQ+ people in the LOASCA study. The graphic novel contains three stories drawn from findings in the study and show how social care workers can help or hinder engagement of older LGBTQ+ people.

About the artist: Domenique Brouwers is a Belgian illustrator based in the north of England. Their work often focuses on bringing overlooked aspects of the human experience to the forefront.

Podcast series

This three-part podcast series looks at collaborative social work research of older people. They are led by Professor Paul Willis from Cardiff University. In the podcasts we hear from older people who have contributed to the LOASCA study and the Social Work with Older People (SWOP) project.

The first episode looks at why we should embark on collaborative research of older people and some of the benefits it brings.

The second episode explores how collaborative research with older people strengthens research.

The third episode considers what makes good, inclusive practice in social work.

LGBT History Month

Older LGBT People and Social Care 2024 conference

The first LGBT History Month Conference took place on 23 February 2024, at The Exchange in Birmingham. The was the first of many in the years to come, showcasing a range of research on the LGBTQ+ community, ethnic minority LGBTQ+ adults, and their experience with social care and residential care.

The Conference brought together academics, practitioners, senior professional leaders, policy makers and older LGBTQ+ people who had been involved in the research studies. The day was dedicated to fostering understanding, awareness, and acceptance of the LGBTQ+ community. This year's (2024) theme was 'older LGBTQ+ adults and social care' and it guided discussions about the progress made, challenges faced, and the road ahead.

Included here are the slides from three of the Conference presentations.

LOASCA

LOASCA is a mixed-method two-and-a-half-year study, funded by the National Institute for Health and Care Research, School for Social Care Research, conducted at the University of Birmingham, and in collaboration with the University of Manchester, Bristol, and Opening Doors. The study investigated the ways social care professionals engage with sexual orientation and gender identity (SOGI) when assessing the care and support needs of older LGBTQ+ people.

CIRCLE

CIRCLE is a two-year research study funded by the National Institute for Health and Care research. The study aims to answer the question 'how can residential care providers be best supported to provide LGBTQ+ inclusive care?' by exploring and evaluating three different ways of supporting residential care providers to improve their LGBTQ+ inclusive care offer: pride in care, community of practice, and co-designed resource.

The social care needs of older ethnic minority lesbian, gay, bisexual, trans and queer people

This scoping review of social care needs of older ethnic minority LGBTQ people was carried out by a team of researchers at the University of Manchester. The review was funded by the NIHR School for Social Care Research.

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Charity No. 1092778
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SCIE, Isosceles Head Office
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Tel: 0203 8404040
Email: info@scie.org.uk

© Social Care Institute for Excellence.
All rights reserved

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LOASCA - LGBTQ+ Older Adults and Social Care Assessment

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Older LGBTQ+ people and social care assessment

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Is Psychiatry working BBC sounds episodes

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Is Psychiatry working BBC sounds episodes

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BBC Radio 4 - Is Psychiatry Working? - Episode guide

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Friends Against Scams online awareness training

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Friends Against Scams online awareness training

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Margaret Fleming was a vulnerable young woman who vanished without trace - and no-one raised the alarm for almost 17 years.
She was 19 years old when she was last seen by anyone other than Edward Cairney and Avril Jones.

Her disappearance was so mysterious that at one point police asked the couple, who were meant to be Margaret's carers, if she even existed.

Their version of her life was stranger than fiction.

They claimed that Margaret, who had learning difficulties, ran off with a traveller, then went on to become a gangmaster who travelled Europe, and a drug dealer with several aliases.

Precisely what happened may never be known, but a jury found the pair guilty of murdering Margaret within three weeks of that final sighting on 17 December 1999. Her body has never been found.

During the seven-week trial, the prosecution painted a bleak picture of Margaret's life before she disappeared.

Early challenges

An only child, she was brought up in the town of Port Glasgow, Inverclyde, and faced challenges from an early age.

At Slaemuir Primary School, Margaret struggled with reading and writing, and she continued to require additional support as a pupil at Port Glasgow High.

But two defining events ultimately led her into the care of her killers.

A rare letter of praise

In a 1995 report, teacher Elizabeth Brown wrote: "Margaret Fleming has moderate learning difficulties. She works fairly well to her ability but needs written instructions set out simply and gone over verbally."

In evidence she said: "If you left Margaret on her own she would do very little. You had to prod her to do the work. Her marks were all at the very bottom end of the school."

On one rare occasion another teacher put on record her gratitude to the teenager for helping her with registration.

'A rather lonely, isolated girl'

His condition had deteriorated by 20 October 1995, when his ex-wife took Margaret to Inverclyde Council's social work office.

The meeting was arranged to discuss her behavioural problems, which included arguing with her grandparents.

The referral said: "Margaret does not know why her father is in hospital and is afraid it is something serious."

It also noted the child was always with her father and felt "rejected" by her mother.

The report continued: "I feel like Margaret is a rather lonely, isolated girl who is living with elderly grandparents.

"Margaret appears to be surrounded by a great deal of uncertainty and ill health."

Five days after the meeting, Mr Fleming lost his battle with cancer.

His death not only devastated Margaret but proved to be the catalyst for her eventual move from Port Glasgow to Inverkip, 10 miles along the Clyde coast.

A strained relationship

A month after Mr Fleming's death, Margaret and her mother met Inverclyde Council social worker Denise Munro in a bid to secure support from the additional needs team.

Ms Munro recalled: "She was quite a naïve girl, quite vulnerable, quiet, lonely, sad and did not have many friends."

She said there had been a strained relationship between mother and daughter.

Giving evidence, she added: "When I went to their house to pick up Margaret I would have a conversation with her mum, who found it difficult.

"She had lived on her own and had an adolescent girl who was missing her dad."

All ties between mother and daughter were finally severed after a chilling confrontation on 26 November, 1997.

Ms Cruickshanks told the jury she was attacked by Cairney after travelling to Inverkip to tell him she wanted her daughter to come home.

She said Margaret, who struggled with her weight, was then brought downstairs from her attic bedroom and asked where she wanted to live.

Ms Cruickshanks said: "I think she was a bit nervous and she turned round and said she wanted to stay there. There was nothing I could do about it."

She later called the police who went to check on Margaret.

'I didn't visit any more'

Memories of that night reduced her to tears in the witness box as she recalled: "The police came back to say she was alright. As far as I knew that was where she was living.

"I didn't visit any more. I got a letter. It said she didn't want to see me any more."

In the months that followed, Margaret became more reclusive and Cairney told the jury he tried to stop the teenager self-harming by putting cardboard tubes on her arms.

In October 1999, Margaret saw her GP, Dr James Farrell, for the last time.

He told the court she had "quite significant learning difficulties" and said she might have had Sotos syndrome from birth - although a definitive diagnosis of the rare disorder was never made.

The GP also said she was "socially and educationally" isolated and referred her to a psychologist.

Dr Alan Smith visited Seacroft before Christmas but all attempts to contact Margaret to arrange another appointment came to nothing.

Last confirmed sighting

The three-week timeframe during which detectives believe Margaret was murdered was narrowed down by the testimony of Avril Jones' brother, Richard, and mother, Florence.

The last confirmed sighting of Margaret was at Richard Jones' new home in Inverkip on 17 December 1999.

Florence Jones remembered Margaret as a "very, very quiet girl" who was unable to look after herself due to her learning difficulties.

The 79-year-old played a key role in the chronology of the case.

Her most recent memory of Margaret was at her ruby wedding celebrations in March 1999, and a photograph from that night is the last known image of the teenager.

Crucially, Mrs Jones had no recollection of Margaret joining the family at Mr Jones' house for Christmas dinner in 1999.

There was also no sign of her in the photos taken that day.

On 5 January, 2000 Mrs Jones spoke to her daughter on the phone.

The pensioner told the court: "She said Margaret had left with a traveller. I wasn't sure what had happened. It was up to them."

As the months turned to years, memories faded and not one person saw fit to report that a teenage girl had simply disappeared off the face of the earth.

Indeed it was not until October 2016 that a missed appointment for a benefits review finally led police to Seacroft.

Covering their tracks

The couple's attempts to cover their tracks, while Avril Jones fraudulently claimed £182,000 in benefits, included producing letters which were said to be from Margaret.

One was said to be from Carlisle on 9 January 2000 and the other two were from the Regent Palace Hotel in Piccadilly Circus, London, on 13 January, 2000.

As part of the complex investigation that followed detectives showed the typed letters to Jacqueline Cahill, who taught Margaret standard grade English at Port Glasgow High between 1994 and 1996.

She told the court the teenager would not have been capable of writing them.

Ms Cahill said: "She had literacy difficulties.

"She struggled to put pen to paper. She struggled to read, and read at about the level of an eight-year-old."

But despite her struggles in the classroom, the teacher told BBC Scotland Margaret had the potential to hold down a job that did not require some numeracy and literacy skills.

She added: "If she had stayed in Port Glasgow, she would have stayed in touch with her friends, but moving to Inverkip probably made it easier for Margaret to slip off the radar.

"I don't even want to imagine what her life was like when she was living in Inverkip."

'This wee girl was forgotten'

Watch Now on BBC iPlayer: Murder Trial: The disappearance of Margaret Fleming

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Margaret Fleming: The teenager who was forgotten for 17 years

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Margaret Fleming was last seen in 1999 but was not reported missing until 2016.

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Changing the way we think about Hoarding 

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Changing the way we think about Hoarding 

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Changing The Way, We Think About Hoarding - 15/05/24

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On the 22 February 2024, ASPire took place at The Barracks in Stirling. Featuring keynote speakers with specialisms across adult support and protection.

Opening Conference - Elaine Torrance (ASP Convenors Scotland Chair) and Brenda Walker (National Adult Support and Protection Coordinator)

Sextortion Scame - Ross Jackson and Katarzyna Owczare (Police Scotland)

Case of AB - Paula John and Moira Connolly (Mental welfare Commission for Scotland)

Undue Pressure - Nairn Young (Solicitor & Author)

ASP Learning Reviews - Mike Harkin and Winnie Burke (Care Inspectorate)

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On the 22 February 2024, ASPire took place at The Barracks in Stirling. Featuring keynote speakers with specialisms across adult support and protection.

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Sextortion Part 2 (Have you met Jess) (cyber-enabled blackmail) (youtube.com)

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Sextortion Part 2 (Have you met Jess) (cyber-enabled blackmail) (youtube.com)

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Sextortion reaction film  - Have you met Jess?

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Sextortion Scams are a rapidly growing concern. It is a form of blackmail where victims are threatened with sexual information, photos or videos about themselves, and are coerced into doing something against their will.

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Mark and Ros Dowey said their 'world has been shattered' since losing their son to suicide in December 2023, as Digital Producer Sam Leader reports Play Brightcove video
When Murray Dowey left his parents watching television downstairs to go up to his bedroom he was a happy sixteen-year-old boy.

Just hours later, Murray had taken his own life, having become the latest victim of a surge of sextortion cases in the UK.

Murray, 16, from Dunblane was contacted on social media by someone claiming to be a young girl but was actually a scammer, who tricked him into sending an intimate image and then blackmailed him with it.

Speaking for the first time about their son's case, Murray's parents told ITV News their "whole world has been shattered".

At Murray's local football club, Stirling Albion, where he spent every weekend with his friends, Mark and Ros Dowey said they "don't want this to happen to any other family" and called on social media platforms to up the safeguarding for teenagers "immediately".

They share their story as ITV News are given exclusive stats that reveal the UK's only helpline dedicated to helping victims of intimate image abuse received 54% more sextortion reports in 2023, than the previous year.

Sextortion, is when intimate images and/or videos are recorded and used for financial exploitation and coercion; It is mostly committed by organised criminal gangs overseas.
'The next thing I heard was Ros screaming, screams like I've never heard in my life before'
Reports to The Revenge Porn Helpline doubled last year reaching nearly 19,000, but sextortion made up over a third of those reports, and is the main form of intimate image abuse reported to the helpline - 93% of those cases were reported by men.

Mark and Ros Dowey said there 'world has been shattered' since losing their son

Murray had been enjoying festive celebrations last year with his parents and his two brothers, before going up to his room as normal, but his family "never for a minute thought that was the last time [they] were going to see him."

Ros Dowey, Murray's mother, said: "That evening we were just chatting and watching rubbish on telly... We were just a normal family of five.

"To the next morning, we're down to four people with a huge Murray-shaped gap that's never going to go away.

"He's my little boy. To think of my little boy in such distress and not to reach out for help, it's awful."

Murray took his own life on December 30, 2023, just hours after he was blackmailed by a scammer.

Mark Dowey, Murray's father, said he was "sitting watching the football, next thing I heard was Ros screaming, screams like I've never heard in my life before... it was horrendous."

"He was a very normal, easygoing, helpful boy, had a great sense of humour... I can't believe he's gone.
'We thought we were dealing with suicide... [it was] absolute torture'
"One of the reasons it is so devastating as it comes into your house, exactly where Murray should have been safest in his room, asleep. So there's very little you can do to protect them."

For two weeks, before police confirmed that Murray had been a victim of sextortion, Mark and Ros were left questioning everything they knew about their son's mental wellbeing.

Murray was a season ticket holder at his local club Stirling Albion Credit: Family handout

Ros told us: "He was a normal, happy teenager... he had plans. He had everything to look forward to... he was talking about saving up for a summer holiday with his friends.

"The panic and terror he must have been in for however long this went on, whether it was minutes or hours, I'm devastated for him, that he was just obviously in such a state that he thought taking his life was the only thing he could do.

"We'd had lots of conversations with our boys about online safety [and] social media... you'd never, ever imagine it's going to hit you because you're just a 'normal family' and these things don't happen."Mark said: "We thought we were dealing with suicide... [it was] absolute torture... indeed he did take his own life but he was very much taken to that point by these criminals."

"As parents, were very good at telling kids what not to do, but maybe not so good at telling them what to do if they do do it.
'I just think they're evil...those criminals killed our son.'
"I think that's something we really need to take away from this, that you need to give them that information, that if they do step over that line, don't panic. Don't do what Murray did."

Police Scotland are working with authorities in Nigeria to find the perpetrator responsible and to get justice for Murray.

Murray's parents, Mark and Ros, stand next to his seat at Stirling Albion FC

Sextortion scams can be perpetrated by individuals but the majority are committed by organised crime groups operating overseas, who often target young men with fake images, before blackmailing them for money.

Ros Dowey said: "I just think they're evil...those criminals killed our son. they can't just be anonymous people behind the keyboard thousands of miles away.

"There has to be consequences and there has to be consequences to deter others from doing this."

Mark said: "That demographic has been chosen very specifically by these criminals for their vulnerability to this crime."

In a statement to ITV News, Superintendent Joanne McEwan, from Police Scotland's Partnerships, Prevention and Community Wellbeing Department said: "We are experiencing an increase in the number of sextortion incidents being reported and organised crime gangs based overseas are often responsible, although individuals are also involved.
'It just breaks your heart that that's what his last moments on earth were... just that terror'
"People shouldn't panic, there is support available from policing and from third party organisations. We encourage victims to come forward. They will be treated with respect and dignity and the circumstances investigated professionally."

Not only do Murray's family now face a battle to get justice for their son, they want to put pressure on social media platforms to do more for young peoples safety, and ensure no other family loses a child under these circumstances.

Mark Dowey said: "I think the the platforms that these criminals are using need to up the safeguarding, up the protection for young people immediately. I think they know exactly how they could do that. It's been mooted by many an expert, but nothing's been done about it.

"We're starting to see a lot of young people dying through this crime."

Mark added: "I would very much like to say to young people if this is happening to you, that is your absolute route out of it, just switch the phone off and walk away from it. Get help. Go and get help."

Ros Dowey said: "There's all sorts of technologies they can be using because these criminals have a real pattern of behaviour... But I also think the [social media] platforms need to make it easier for children to report a scam and then they act on it really quickly.

"More needs to be done in schools and other forms of education to raise awareness to young people that that this can happen and this is what you do when this happens...

Murray's parents described him as the 'peacemaker' and the 'glue' between his two brothers Credit: Family Handout

"And for parents to be aware of it and to not sit there and think it's some abstract thing that couldn't happen, you know, it can happen to anybody."

Ros now wants other young people to know that if they do become a victim to sextortion, that "nothing is that bad, that it's worth taking your own life".

She added: Murray "hated being the centre of attention, so the thought that they were going to share this with all his contacts would have felt like the end of his world, but it wouldn't have been.
Revenge Porn Helpline's Amanda Dashwood explains what to do if you are a victim of sextortion
"We'd have gotten over it. We'd have helped him through it... rather than what we have now which is no Murray, and we have to live with that for the rest of our lives."

(Campaign Against Living Miserably) - Helpline: 0800 58 58 58

provides to empower anyone experiencing a mental health problem. Information line: 0300 123 3393

is an organisation offering confidential support for people experiencing feelings of distress or despair. Phone 116 123 (a free 24 hour helpline).

How to get help if you have been affected by the issues mentioned in this article:

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'They killed our son': The devastating impact of sextortion scams as cases soar | ITV News

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Murray Dowey, a 16-year-old from Dunblane, took his own life after he was "sextorted" by a scammer. | ITV National News

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This report explores working with 16 and 17 year olds, who might be eligible for support through Adult Support and Protection (ASP) legislation and Child Protection (CP) guidance.

The report provides a Guidance and Legislation table, as a practical tool for social workers of all levels, and other professionals working with 16 and 17 year olds, to view the policy and guidance options available to them. This is complemented by a discussion of the tensions and challenges around supporting 16 and 17 year olds, through a qualitative understanding of some of the experiences practitioners encounter in their work with this age group.

Together, the table and the discussion begin an analysis on what the overlap in ASP and CP means for 16 and 17 year olds, and the practitioners supporting them.

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Understanding age in Child Protection guidance and Adult Support and Protection legislation

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This report explores working with 16 and 17 year olds, who might be eligible for support through Adult Support and Protection (ASP) legislation and Child Protection (CP) guidance.

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Skip to content

Self-neglect is an extreme lack of self-care, it is sometimes associated with hoarding and may be a result of other issues such as addictions. Practitioners in the community, from housing officers to social workers, police and health professionals can find working with people who self-neglect extremely challenging. The important thing is to try to engage with people, to offer all the support we are able to without causing distress, and to understand the limitations to our interventions if the person does not wish to engage.

What is self-neglect?

Lack of self-care to an extent that it threatens personal health and safety

Neglecting to care for one's personal hygiene, health or surroundings

Inability to avoid harm as a result of self-neglect

Failure to seek help or access services to meet health and social care needs

Inability or unwillingness to manage one's personal affairs

What causes self-neglect?

It is not always possible to establish a root cause for self-neglecting behaviours. Self-neglect can be a result of:

Sometimes self-neglect is related to deteriorating health and ability in older age and the term 'Diogenes syndrome' may be used to describe this. People with mental health problems may display self-neglecting behaviours. There is often an assumption that self-neglecting behaviours indicate a mental health problem but there is no direct correlation.

Hoarding is now widely considered as a mental health disorder and appears in the US 'Diagnostic and statistical manual of mental disorders' (5th Edition). Hoarding can sometimes relate to obsessive compulsive disorder but hoarding and self-neglect do not always appear together and one does not necessarily cause the other.

a person's brain injury, dementia or other mental disorder

obsessive compulsive disorder or hoarding disorder

physical illness which has an effect on abilities, energy levels, attention span, organisational skills or motivation

reduced motivation as a side effect of medication

addictions

traumatic life change.

Self-neglect: what are the issues?

People who neglect themselves often decline help from others; in many cases they do not feel that they need it. Family or neighbours can sometimes be critical of professionals because they don't do anything to improve the situation of the individual. But there are limitations to what others can do if the adult has mental capacity to make their own decisions about how they live. Sometimes, even when all agencies have done everything in their power to support an individual, they may die or suffer significant harm as a result of their own action or inaction. It is therefore vital that all efforts to engage with and support an individual are clearly recorded.

The inclusion of self-neglect in the Care Act statutory guidance with regard to safeguarding focused attention on the issue and led local authorities to develop new approaches to working with people. In some cases, where the adult has care and support needs, safeguarding responses may be appropriate. However, the inclusion of self-neglect in statutory guidance does not mean that everyone who self-neglects needs to be safeguarded.

Safeguarding duties will apply where the adult has care and support needs (many people who self-neglect do not), and they are at risk of self-neglect and they are unable to protect themselves because of their care and support needs. In most cases, the intervention should seek to minimise the risk while respecting the individual's choices. It is rare that a total transformation will take place and positive change should be seen as a long-term, incremental process.

Barriers to good practice

Working with people who self-neglect can be alarming and very challenging.

People who self-neglect may refuse support or fail to acknowledge the problem.

The risks associated with self-neglect can be high and the options for intervention are limited.

There can be pressure on professionals to take action, but often very little they can do.

There is often a lack of clarity about who should take responsibility for supporting people who self-neglect.

Work patterns and resources don't support long-term, relationship-based work.

Individuals don't always have care and support needs - so safeguarding responses may not be appropriate.

Where the Safeguarding Adults Board isn't appropriate there may be no alternative decision-making forum.

Information sharing is sometimes problematic, particularly when the person refuses help.

Limited legal literacy - professionals may not have a good understanding of the law that can be utilised in relation to self-neglect.

Application of the Mental Capacity Act can be very complex in relation to self-neglect.

Lack of resources can prevent appropriate service responses.

Relevant legislation

The Care Act (2014) statutory guidance - self-neglect is included as a category under adult safeguarding.

Article 8 of the Human Rights Act 1998 gives us a right to respect for private and family life. However, this is not an absolute right and there may be justification to override it, for example, protection of health, prevention of crime, protection of the rights and freedoms of others.

Mental Health Act (2007) s.135 - if a person is believed to have a mental disorder and they are living alone and unable to care for themselves, a magistrate's court can authorise entry to remove them to a place of safety.

Mental Capacity Act (2005) s.16(2)(a) - the Court of Protection has the power to make an order regarding a decision on behalf of an individual. The court's decision about the welfare of an individual who is self-neglecting may include allowing access to assess capacity.

Public Health Act (1984) s.31-32 - local authority environmental health could use powers to clean and disinfect premises but only for the prevention of infectious diseases.

The Housing Act 1988 - a landlord may have grounds to evict a tenant due to breaches of the tenancy agreement.

A strategy for good practice

Local authorities should work with partners to ensure:

strategic and operational infrastructure and coordinated interdisciplinary involvement overseen by the Safeguarding Adults Board or equivalent

there is agreed policy and guidance on self-neglect that includes clear referral routes and strategy for dispute resolution

a multi-agency approach from strategic level to work on the ground, including shared ownership, risk assessment and management

the Mental Capacity Act is well understood and implemented in the context of self-neglect; making sure that the presence of mental capacity is not used as a justification for inaction

a clear record is made of interventions, decisions and rationale

relationship-based working and time for long-term work is supported

pressure from others (agencies/family/neighbours/media) is managed

training, supervision and support for staff dealing with people who self-neglect to help them understand the complexities of this area of work, the possibilities for intervention and the limitations.

Positive engagement and best practice

The research on self-neglect suggests beneficial approaches and a range of options, levers and practical measures that could help engagement with individuals.

Approach

In the past we may have intervened in ways that prioritised the views of others rather than trying to work from the perspective of the individual. Research has shown that those who self-neglect may be deeply upset and even traumatised by interventions such as 'blitz' or 'deep cleaning'. When developing an approach it is important to try to understand the individual and what may be driving their behaviour. There are some general pointers for an effective approach:

Multi-agency - work with partners to ensure the right approach for each individual

Person centred - respect the views and the perspective of the individual, listen to them and work towards the outcomes they want

Acceptance - good risk management may be the best achievable outcome, it may not be possible to change the person's lifestyle or behaviour

Analytical - it may be possible to identify underlying causes that help to address the issue

Non-judgemental - it isn't helpful for practitioners to make judgements about cleanliness or lifestyle; everyone is different

Empathy - it is difficult to empathise with behaviours we cannot understand, but it is helpful to try

Patience and time - short interventions are unlikely to be successful, practitioners should be enabled to take a long-term approach

Trust - try to build trust and agree small steps

Reassurance - the person may fear losing control, it is important to allay such fears

Bargaining - making agreements to achieve progress can be helpful but it is important that this approach remains respectful

Exploring alternatives - fear of change may be an issue so explaining that there are alternative ways forward may encourage the person to engage

Always go back - regular, encouraging engagement and gentle persistence may help with progress and risk management

Practical tasks

Risk assessment - have effective, multi-agency approaches to assessing and monitoring risk

Assess capacity - ensure staff are competent in applying the Mental Capacity Act in cases of self-neglect

Mental health assessment - it may, in a minority of cases, be appropriate to refer an individual for Mental Health Assessment

Signpost - with a multi-agency approach people can be signposted to effective sources of support

Contact family - with the person's consent, try to engage family or friends to provide additional support

Decluttering and cleaning services - where a person cannot face the scale of the task but is willing to make progress, offer to provide practical help

Utilise local partners - those who may be able to help include the RSPCA, the fire service, environmental health, housing, voluntary organisations

Occupational therapy assessment - physical limitations that result in self-neglect can be addressed

Help with property management and repairs - people may benefit from help to arrange much needed maintenance to their home

Peer support - others who self-neglect may be able to assist with advice, understanding and insight

Counselling and therapies - some individuals may be helped by counselling or other therapies. Cognitive behaviour therapy, for example, may help people with obsessive compulsive disorder, hoarding disorder or addictions

Levers

Resorting to enforcement action should be a very last resort with people who self-neglect. There are some options that can be used in extreme circumstances but often the threat of enforcement can encourage and individual to accept help and support. Levers may include housing enforcement options based on tenancy or leasehold breaches and environmental health enforcement based on a public health risk. Local authorities also have powers relating to anti-social behaviour that may be relevant in a minority of cases.

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Skip to content Self-neglect is an extreme lack of self-care, it is sometimes associated with hoarding and may be a result of other issues such as addictions. Practitioners in the community, from housing officers to social workers, police and health professionals can find working with people who self-neglect extremely challenging.

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1.1.1 Advocacy must be offered according to the relevant legislation. The criteria for when and to whom to offer it are described in the:

1.1.2 Local authorities must make appropriate arrangements for independent advocacy services to provide assistance to people making or intending to make complaints as described in the Health and Social Care Act 2012.

For a summary, see box 1 on the legal entitlement to advocacy, as well as supporting information and resources on the Social Care Institute for Excellence's information on advocacy.

For more guidance on helping people to make complaints, see the NICE guidelines on patient experience in adult NHS services and service user experience in adult mental health.

Adapted from the Care Act 2014 statutory guidance, the Mental Capacity Act Code of Practice, the Mental Health Act 1983: Code of Practice and the Health and Social Care Act 2012.

Care Act 2014

From the point of first contact, the local authority must appoint an independent advocate if an adult would experience substantial difficulty in any of these 4 areas:

understanding the information provided

retaining the information

using or weighing up the information as part of the process of being involved

communicating the person's views, wishes or feelings.

And

There is thought to be no one appropriate and independent to support and represent the person, for the purpose of facilitating their involvement.

This applies to adults taking part in:

Care and Support (Independent Advocacy Support) (No. 2) Regulations 2014

The Care and Support (Independent Advocacy Support) (No. 2) Regulations is a Statutory Instrument, which adds to the Care Act 2014 section 67(2). It extends the circumstances in which a person is entitled to an independent advocate to where an assessment or plan is likely to result in a hospital stay of more than 28 days or a stay in a care home for more than 8 weeks (although there are some exceptions).

Mental Capacity Act 2005

An independent mental capacity advocate (IMCA) must be instructed, and then consulted, for people lacking capacity who have no one else to support them (other than paid staff), whenever:

And

An IMCA may be instructed to support someone who lacks capacity to make decisions concerning:

care reviews, if no one else is available to be consulted

adult protection cases, whether or not family, friends or others are involved.

Mental Health Act 1983

People are eligible for support from an independent mental health advocate, irrespective of their age, if they are:

detained under the Mental Health Act 1983 (excluding certain short-term sections)

liable to be detained even if not actually detained, including those who are currently on leave of absence from hospital or absent without leave, or those for whom an application or court order for admission has been completed

conditionally discharged restricted patients

subject to guardianship

subject to a community treatment order

being considered for treatment under section 57 of the Act or, for under‑18s, any treatment under section 58A.

Health and Social Care Act 2012

The 2012 Health and Social Care Act amendment to the 2007 Local Government and Public Involvement in Health Act.

The local authority must make arrangements for independent advocacy services to provide assistance to people making or intending to make a complaint:

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Advocacy services for adults with health and social care needs

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This guideline covers advocacy for people using health and social care services in all adult settings (including young people under 18 using adult services). It describes how to commission and deliver effective advocacy, as well as identifying who should be offered advocacy (including who is legally entitled to it).

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Readers of this evidence-informed, practical guide will develop an understanding of e-safety and online safeguarding and learn how to understand and identify risks for adults online, critically evaluate relevant online safeguarding issues on a case-by-case basis and develop practical and effective online safeguarding plans. Drawing on research, theory and practice examples, this guide covers a range of relevant topics including online gaming and gambling, online radicalisation, exploitation, bullying and crime. This is an essential guide for social work students and experienced practitioners, and any professional involved in safeguarding adults and older people, helping them to plan, mitigate and manage the effects and consequences of online safeguarding plans. No

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Adult Protection and the Law in Scotland is an authoritative resource for professionals trying to navigate the complex framework of adult protection law and practice. The third edition includes legislative developments arising from the Mental Health (Scotland) Act 2015 and the Self-directed support (Scotland) Act 2013. It covers the new revised Code of Practice being introduced to the Adult Support and Protection (Scotland) Act 2007. The purpose of which is to ensure Adult Support and Protection guidance takes account of policy and practice developments since the Act was introduced in 2007, and thus bring the guidance up to date with current legislation and relevant changes in policy. This title also covers Court Measures of Protection with practical information on preparation for adult protection hearings, drafting applications, addressing sheriffs, use of temporary orders, warrants for arrest and remedies for breach of orders including a new section on contempt of court.

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Adult Protection and the Law in Scotland

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Adult Protection and the Law in Scotland is an authoritative resource for professionals trying to navigate the complex framework of adult protection law and practice. The third edition includes legislative developments arising from the Mental Health (Scotland) Act 2015 and the Self-directed suppo...

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Social Care Institute for Excellence (SCIE)

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Scotland's Dementia Strategy - Everyone's Story

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Scotland's Dementia Strategy - Everyone's Story

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Ministerial Foreword

Foreword from the Minister for Social Care, Mental Wellbeing and Sport and the Health and Social Care Spokesperson, Convention of Scottish Local Authorities ( COSLA)

This strategy sets out a positive, shared vision for dementia in Scotland over the next 10 years. It makes clear the importance of a shared vision that is owned by all of us working together to deliver a better experience for people living with dementia, their families and carers. It builds on several years of globally-recognised public policy on dementia in Scotland and commits to ongoing reflection and learning, greater inclusion and delivery from the start.

It's called "Everyone's Story" because it belongs to all of us. How we understand, support and see dementia impacts everyone, regardless of gender, ethnicity, additional disability or age. Across all settings, at all stages we must embed and enable empowerment, inclusivity and citizenship. That will require us to listen and respond more to the needs of people from different communities and backgrounds across Scotland.

We know that people with dementia still face many challenges, which are often rooted in poor understanding, inequality or stigma. This strategy recognises the need to develop our collective understanding of dementia and build an understanding of brain health over time. That may challenge some attitudes on what dementia is and raise questions about the best ways to enable or deliver support, but it also creates opportunities for doing some things differently and making new connections. That has to include ways to address long waits experienced by some people needing a diagnosis, as well as ensuring more consistent access to good quality post diagnostic support, co-ordinated care that supports people to live the best life possible and access to palliative care. But over time it will also require a focus on ways to ensure dementia services and supports feel more integrated into systems and communities.

The best way to deliver better experiences for people is to include them in policy design and delivery. Scotland has a strong record of working closely with people with lived experience of dementia to inform policy and delivery. This strategy - its approach, design and focus takes this work further. Last year, Scottish Government established a National Dementia Lived Experience Panel, drawing membership from different backgrounds, experiences, and places. This Panel has worked alongside local and national government, and with wider partners, to develop this strategy. We are hugely grateful for the time, commitment and expertise shared to date and look forward to continuing to work with the panel as we move into delivery. This document is enriched by their experience and contribution.

Our sincere thanks also extend to the Strategy Advisory Group. Meetings brought together a wide range of people and organisations who helped to inform and agree this vision, alongside the Lived Experience Panel. The group included a range of different voices and expertise, some with differing perspectives but a commitment to collaborate, learn and innovate as we move forward, keeping people and their experiences to the fore. Again, we look forward to continuing to work with this wide range of partners as we embark on delivery.

That commitment to ensuring delivery is our most important priority. Our rolling 2-year delivery plans, which will be developed with national and local

oversight, will increase accountability and keep us focused on impact. The first delivery plan will be developed and agreed this year for implementation in 2024-25.

There is no doubt that agreeing and resourcing the first set of priorities for delivery will be challenging given the pressures being experienced across all parts of the system. Whilst the increased national and local investment in dementia in recent years demonstrates our shared commitment to improving people's experience, we know we must work with others to maximise the impact of existing spend. We must ensure investment is focussed in the right areas and delivering greatest impact on our priorities. We will make the most of opportunities to align and test improvement as part of wider health and social care reform where that's appropriate.

We have hard work ahead to deliver on the level of ambition set out in this document. We want to thank every individual and organisation across Scotland who participated in the engagement and development process that has led us to this point. We know that people gave their time and experiences with expectations that change will happen, and it will. We are confident that this 10-year strategy sets the right course for dementia policy in Scotland. The next step is agreeing our plans for delivery. The strategy is everyone's story, but it only changes things if we each take a role in its delivery.

Maree Todd MSP, Minister for Social Care, Mental Wellbeing and Sport

Councillor Paul Kelly, COSLA Spokesperson for Health and Social Care

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New dementia strategy for Scotland: Everyone's Story

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The new Dementia Strategy for Scotland is a 10-year vision for change. This strategy was developed in collaboration with people with lived experience and our wider partners. It is the culmination of eight months of engagement with people across Scotland, focussed on how we improve delivery

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Ellie Atkins Episode 3 What We Need To Do To End Rough Sleeping

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Adult safeguarding legislation: Navigating the borderlands between mental capacity, mental health and social care law and practice

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The murder of a young woman. A botched police inquiry. And the BBC Disclosure investigation that helped catch the killer.

The murder of a young woman. A botched police inquiry. And the BBC Disclosure investigation that helped catch the killer. As the man who murdered Emma Caldwell is finally brought to justice, reporter Samantha Poling reveals a catalogue of missed opportunities by police to catch him. The inside story on how this left Emma's murder unsolved for nearly two decades, while a dangerous predator was free to continue raping and assaulting other women.

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BBC Scotland - Catching a Killer: The Murder of Emma Caldwell

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The BBC Disclosure investigation that helped catch the killer of Emma Caldwell.

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Two-part documentary about the investigation and trial of two carers accused of murdering 35-year-old Margaret Fleming and claiming benefits in her name for 16 years.

A mystery disappearance, a suspected secret guarded for 16 years, a murder trial in search of answers - two-part documentary Murder Trial: The Disappearance of Margaret Fleming has unprecedented access to the investigation and subsequent trial of co-accused Edward Cairney and Avril Jones.

Filmed by Bafta Scotland award-winning director Matt Pinder, this groundbreaking documentary takes the audience into the very centre of the trial at Glasgow's High Court and beyond as carers Cairney and Jones face trial for the murder of 35-year-old Margaret Fleming.

Offering a compelling insight into the work of the police and prosecutors in bringing the two suspects to trial, the documentary also shines a light on the work of the defence teams representing the two accused of Margaret's murder.

In 2016, an application for a Personal Independence Payment raised suspicions. When authorities couldn't contact the applicant, the police were called, and it was discovered that a 35-year-old woman had seemingly vanished from a village on the west coast of Scotland. Margaret Fleming was a vulnerable adult understood by authorities to be in the full-time care of Cairney and Jones, living in a remote coastal property in the village of Inverkip. But when police started questioning Margaret's friends and family, they were told no-one had seen her since 1999. In the 2019 murder trial that unfolds, Cairney and Jones stand accused of killing her, disposing of her body and claiming benefits in her name for 16 years.

With remarkable in-court access to an unfolding trial that gripped Scotland, Murder Trial: The Disappearance of Margaret Fleming tells the story of a prosecution without a body and a community without answers.
Filmed both inside and outside of the courtroom, this case takes viewers deep into the inner workings of Scotland's justice system as a small community is coming to terms with the prospect of a potentially brutal and calculated crime occurring unnoticed in its midst.

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BBC Two - Murder Trial, The Disappearance of Margaret Fleming, Episode 1

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Two people face trial for the murder of 35-year-old Margaret Fleming.

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Foreword from the Minister for Mental Wellbeing and Social Care

Since the introduction of The Adult Support and Protection (Scotland) Act 2007 in 2008, and publication by the Scottish Government of the Adult Support and Protection Code of Practice in 2014, there have been a number of policy, legislative and practice developments, both in the overall context of adult support and protection and in day-to-day activity.

This revised version of the Code of Practice aims to capture these changes and inform the development of local and national multi-agency adult protection procedures, processes and training across Scotland. It will also help to support the care and protection of adults who may be at risk of harm. This Code is for all those who may know adults at risk of harm whether they work in the local authority, health, police, or the third sector. The approaches set out build on the culture and ethos of partners who believe, as I do, that while there are specific duties associated with certain professional roles and public bodies, adult support and protection is "everyone's business". We all have a part to play in supporting the care and protection of adults who may be at risk of harm and are unable to safeguard themselves.

I am pleased that the Code of Practice has been developed collaboratively, through engagement with stakeholder groups, practitioners and a wider public consultation. This has helped us to shape our understanding of best practice and 'what works' from a variety of sources, including practitioner and stakeholder experience, inspections, research and learning from Learning Reviews (previously referred to as Significant Case Reviews).

Finally, I would like to offer my thanks to everyone who contributed to the revised Code and especially to those working in this field, for your continued commitment and efforts to support and protect adults at risk of harm.

Kevin Stewart, MSP

Minister for Mental Wellbeing and Social Care

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Adult Support and Protection (Scotland) Act 2007: Code of Practice

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This revised Scottish Code of Practice aims to reflect the developments in policy, practice and legislation both in the overall context of adult support and protection and in day-to-day activity. It provides information and detail to support practical application of the 2007 Act.

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Key points

Supported decision making aims to protect a person's 'legal capacity', or their right to have their will and preferences upheld in relation to all aspects of their life, regardless of disability or mental health status.

Supported decision making is central to the reform of mental health and capacity legislation nationally and internationally, but the research evidence is limited and it is likely that forms of substitute decision making will need to be retained.

Supported decision making refers to a wide range of models and practices, including informal supports from friends and family, assistance from advocates and legally mandated supporters, advance directives, and communication tools, among others, which will vary depending on the particular needs and circumstances of the person.

Building effective relationships is a foundational element of supported decision making.

Training and education initiatives are required to ensure social workers and health care professionals develop appropriate knowledge and skills for supported decision making.

Introduction

Consider the last 'big' decision you made. Not the type of decision you make every day such as what to wear or what to eat for lunch, but the type that you had to think over carefully before finalising. Maybe it was moving to a new home, making a large purchase, accepting treatment for a health issue, or entering into a new relationship. When it came to making this decision, did you know what to do instantly without any additional information, or did you seek to understand the possible repercussions of your decision and discuss it over with people you trust? Chances are you, like most people, gathered information about your options and spoke to someone else before deciding.

This process of decision making is very normal. It's unusual to make big (or even small) decisions without some basic research and consideration, but as a society we tend to take it for granted that people can make decisions this way. For persons with certain limitations, such as an intellectual impairment, severe mental illness, or dementia, making decisions may not be so straightforward, yet they often have significant and wide-ranging implications for their lives, including the types of services they receive, who provides them and others that involve limitations on their freedoms.

When people are not able to seek out, understand, weigh-up, and/or retain information fully, their decision making ability, often referred to as their 'capacity' to make a decision, is affected. Historically for people with limited capacity, someone else has either informally assumed or been granted the authority to make decisions for them. This is referred to as 'substitute decision making'. In Scotland, there are several types of formal substitute decision making, including Power of Attorney, where an attorney or attorneys are appointed by the individual before they lose capacity, and Guardianship, where a guardian or guardians are appointed by the Court when the individual already lacks capacity. Both are provisions of the Adults with Incapacity (Scotland) Act 2000. In addition, the Mental Health (Care and Treatment) (Scotland) Act 2003 provides for substitute decision making in relation to care and treatment for mental health where a person's ability to do so is deemed to be significantly impaired.

Legislation which facilitates substitute decision making is common around the world, and most countries have 'safeguards' within these laws to protect people from abuse. However, in recent years there has been a push to promote the rights of Disabled people, including their right to make decisions about themselves. This is largely due to the introduction of the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD), which was adopted in 2006. The UNCRPD also reflects increasing evidence that legal 'safeguards' are not sufficiently understood or applied by professionals, often leading to significant infringements of peoples' human rights. For example, a recent Mental Welfare Commission for Scotland report (2021a) found a lack of understanding among professionals about the legal framework for moving adults who lacked capacity from hospital to care homes during the Covid-19 pandemic, and that some of these moves were illegal. Relatedly, there are concerns about inadequacies with 'capacity assessments' and the degree of subjectivity they afford professional assessors. In response to the UNCRPD and related rights-based activism and advocacy, academics, lawmakers, and practitioners are exploring how supported decision making can enable people to exercise their legal capacity on an equal basis with others by overcoming decision making challenges, moving away from substitute decision making and seeking to ensure their human rights, will and preferences are upheld.

What is supported decision making?

Supported decision making (hereafter SDM) is exactly what it sounds like; it is relying on support from others to make and enact informed decisions. As has been noted above, most people already utilise some degree of support to make decisions, but people with certain limitations require more specific and tailored support to achieve this.

In addition to human rights imperatives, the drive to formalise SDM is informed by the social model of disability and the feminist critique of individualism (Dixon and colleagues, 2022). The social model of disability is the simple idea that a person's individual impairment is not what disables them, rather it is structures within society which present barriers to their differences (Oliver, 2013). When viewing issues through the lens of the social model rather than the medical/individual model, the focus shifts away from the individual's impairments and on to adapting the social environment as a means of promoting equality. Framed in this way, in SDM, the primary focus of state and professional activity is enabling the person to exercise their rights, will and preferences. This requires a wholesale shift from the current focus on assessing levels of impairment or incapacity and 'looking beyond human rights simply in terms of limiting unwarranted interventions to the proactive removal of obstacles to full rights enjoyment and the creation of environments that respect and support such enjoyment' (Stavert, 2021, p1).

SDM can look different in different contexts, but the general guiding principles are the same. The aim of SDM is to 'help [the person] understand the situations and choices they face so they may make their own informed decisions' (Blanck and Martinis, 2015, p26). This ultimately helps to promote the person's autonomy and upholds their right to self-determination. In contrast, substitute decision making has been criticised for cancelling rights and enforcing paternalistic control, particularly when it is 'plenary', which means without any limitations (Arstein-Kerslake, 2016; Shogren, 2017). Additionally, SDM is distinct from 'shared decision making' in helping contexts because of its emphasis on shifting power from professionals to service users (Kokanović and colleagues, 2018).

In jurisdictions that endorse human rights, such as the countries of the UK, it may seem obvious that upholding a person's rights is preferable to cancelling them. So why, then, is SDM being discussed at all, rather than having already been implemented as the norm? Despite general agreement about the merits of SDM, the questions of if/when/how to implement it in practice remain contentious (Davidson and colleagues, 2015).

This Insight will provide an overview of the policy and legislative background to SDM as well as the changing landscape in Scotland and globally. It will then provide a brief summary of research evidence looking at how SDM may be approached within three key areas of intellectual impairment, mental health, and older age / dementia. Finally, implications for current and future social work practice are explored.

The policy and legal context

While SDM is a relatively new concept, it is already reshaping policy and legislation around the world. SDM is a tool which gives effect to a person's 'legal capacity', or the right to hold and exercise legal agency. This is an important concept that is often confused with 'mental capacity', which refers specifically to someone's 'functional decision-making ability' (Harding and Taşcıoğlu, 2018, p2). SDM in policy and legislation is aimed at protecting a person's legal capacity, even where there are limitations on their mental capacity.

Much of the recent legislation in this area is informed by two international treaties which uphold the rights of Disabled people - the European Convention on Human Rights (ECHR) and, particularly, the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD).

The ECHR dates back to 1953 and has helped shape policy and law formation in Europe since that time. In Scotland, the law states that the rights protected by ECHR must be reflected in any devolved legislation. This includes Article 5 (the right to liberty) and Article 8 (the right to private and family life), among others. While the ECHR does not explicitly protect a person's legal capacity, the principles of rights and equality provided many of the building blocks for subsequent legislation for Disabled people.

Following on from the ECHR, the UNCRPD, is an international human rights treaty which aims to protect the rights for all Disabled people. Since it was first adopted in 2006, it has gained 186 ratifications, representing broad agreement from the vast majority of UN member states. Unlike the ECHR, Article 12 of the UNCRPD (2006) explicitly recognises the right of all Disabled people to hold and exercise legal capacity on an equal basis with others, ie, regardless of the type or extent of disability or impairment, which is the first time this right has been made unequivocal. Further to this, General Comment No. 1 of the UN Committee on the Rights of Persons with Disabilities calls for the revocation of all substitute-decision making and the implementation of SDM alternatives. This 'paradigm shift' is influencing policy around the world, however no countries have fully eliminated the practice of substitute decision making and commentators argue that this is unlikely to be achieved (Kokanović and colleagues, 2018).

While the UK is party to the UNCRPD, legislation related to capacity, mental health treatment, and safeguarding does not yet align fully with the requirements as outlined by the UNCRPD Committee. Despite this, most of the laws in the UK rest on similar principles to those endorsed by the international treaties mentioned, although the specific approach taken and degree of alignment varies. In England and Wales, the Mental Capacity Act (2005) and the Mental Health Act (2007) dictate the parameters of professional intervention for those with mental impairment. The Mental Capacity Act (2005) provides the basis for assessing mental capacity and is built on five key principles, including the presumption of capacity and the need to support people to make their own decisions. And while this would appear to endorse SDM in all contexts, there is evidence that practitioners still default to the 'best interest' principle and substitute decision making for large and complex decisions (Harding and Tascıoglu, 2018). The Mental Health Act (2007) provides mechanisms for, and is still most often used for, providing compulsory treatment in hospital and the community (Davidson and colleagues, 2016).

Unlike England, Wales and Scotland, the recently implemented Mental Capacity Act (Northern Ireland) 2016 combines capacity law and mental health law using a 'fusion approach' (Campbell and colleagues, 2018). And while this Act still includes mechanisms for the deprivation of liberty and some other restrictive processes, it provides explicit instruction to offer all support necessary before utilising any substitute measures.

In Scotland, both the Adults with Incapacity (Scotland) Act 2000 and the Mental Health (Care and Treatment) (Scotland) Act 2003 were written and introduced prior to the UNCRPD; they do not provide an explicit presumption of legal capacity, but the underlying principles provide a great deal of recognition and protection for people to make their own choices regarding their lives. Similarly, there is no explicit requirement to utilise SDM before resorting to substitute measures, although the in-built principles provide a clear opportunity for this and there is an evident direction in practice guidance toward SDM (Mental Welfare Commission for Scotland, 2021b). The impact of the UNCRPD and the need for change can be seen in the recent review of mental health legislation in Scotland, whose proposals place SDM at the centre of a human rights approach and recognise the necessity of embedding it in professional health and social care practice (Scottish Mental Health Law Review, 2022).

Further afield, some countries have already reformed their laws to align more fully with the UNCRPD. While legislation exists that endorses SDM as an alternative to substitute measures in Canada (Browning and colleagues, 2020), Ireland (Donnelly, 2019), and Australia (Campbell and colleagues, 2018), many point out that further reform and evaluation is badly needed (Arstein-Kerslake, 2016; Callus, 2018).

Supported decision making: intellectual impairment

There are many ways that SDM can be utilised for all Disabled people, including those with intellectual impairment. This demographic is wide ranging and therefore has a variety of support needs, however there are some common themes which help to guide practice.

Shogren and colleagues (2017) completed a review of literature on SDM and included a thorough synopsis of some of the themes identified for working with Disabled persons with intellectual impairment. Their review identified that for this population, the relationship with the support provider was especially critical as it was shown to influence decisions. This was particularly noted where families of these individuals placed a greater emphasis on risk and protection, rather than on opportunities to take risks (Shogren and colleagues, 2017). Additionally, the authors discovered that Disabled persons with intellectual impairments were given more support for decision making when in community-based settings, as opposed to institutional care settings. Finally, the review evidenced that utilising a specific decision making aide helped significantly to increase their participation and engagement.

In Webb and colleagues' (2020) study with 41 Disabled adults with intellectual impairment and/or mental health problems, participants identified the positive impact of being able to make decisions for their sense of self and agency. Without support, however, the decision making experience could feel abstract and difficult, provoking fear related to not knowing 'how' to make a decision or of making the wrong one, and confusion when a quick decision was called for. The study underlined the requirement for tailored approaches to SDM to suit different needs but identified the main factors found to support decision making as: ensuring there is enough time; practical help, including having matters explained sufficiently and offered in accessible formats; emotional support; and having a range of options provided.

Because the support needs of Disabled people with intellectual impairment may be more static than those with poor mental health or dementia, there is a particular emphasis here on developing practical tools and theoretical models for implementation. One tangible decision making aide, Talking Mats, originated in Scotland but is now used around the globe. Talking Mats is a tool that utilises specially designed visual images to gain a better understanding of a person's views. Talking Mats has been shown to improve the quantity and quality of information communicated when used effectively with those with intellectual impairment (Murphy and Cameron, 2008).

Another example of a common SDM practice model is a 'support circle', which sees family, friends, or other close relations working to support individuals to make their own decisions (Devi, 2013). A support circle should ideally know the individual well and have a sense of their history, their communication style, and their general desires; they can help the person to understand information, communicate their wishes, and enact their decisions (Devi, 2013). In addition, the past decade has seen a growth internationally in the development of legally mandated and informal roles to support decision makers, with research highlighting the importance of providing education to facilitate effective and culturally sensitive SDM (Kileen, 2016). In their study with Disabled adults and their nominated supporters, Then and colleagues, (2022) found increased confidence and autonomy in the adults' decision making over time, together with a greater willingness for supporters to step-back from decision making and to seek more opportunities for the adult to participate. Alongside these formally nominated supported roles are found important contributions by independent advocacy workers. This includes 'non-instructed advocacy', where the advocate seeks to uphold the person's rights and wishes when they are unable to give a clear indication of their views (The Scottish Independent Advocacy Alliance, 2009).

Despite the apparent push to create and implement models and tools of SDM for Disabled persons with intellectual impairment, it has been noted that there remains a dearth of empirical research in this area (Webb and colleagues, 2020) which creates a risk that strategies employed could result in unintended harm (Kohn and Blumenthal, 2014). Areas for further exploration include SDM with people with 'severe or profound' intellectual impairment, with recent research highlighting the importance of relational approaches when planning life transitions for people in this demographic (Jacobs, 2021). In addition, Laurens and colleagues (2021) point to other intersectional factors, such as gender and cultural diversity, that need to be considered in order to address power differentials in how people are enabled to express autonomy over their lives.

Supported decision making: mental health

The challenges of achieving effective SDM in mental health contexts may be particularly marked, when considering the impact mental health symptoms can have on people's insight related to care and medical treatment, and how this may fluctuate in response to levels of mental distress/illness. Penzenstadler and colleagues (2020) cite the example of eating disorders, where skewed views about weight together with cognitive impairment caused by lack of nutrition directly impact decision making capacity. The experience of fluctuating capacity can also be exacerbated by factors such as substance use, potentially making SDM more difficult. In addition, concerns about risk to the person or others often necessitate making quick decisions, a process that does not lend itself to SDM. Like other care groups, however, the critical factor appears to be building trusting relationships. In their study with 90 mental health service users, family members and professionals, Kokanović and colleagues (2018) found that communication skills, empathy and attitudes among clinicians were key. Likewise, Knight and colleagues (2018, p2002) saw SDM as dependent upon 'sharing information and working toward consensus about treatment and life decisions'. In their study with 29 individuals diagnosed with a mental illness, they note that best practice in SDM doesn't guarantee service user engagement, which may be disrupted by histories of mistrust, but that a fundamental starting point is to understand the individual's unique perspective or 'narrative position' about SDM. They identified a range of narrative positions adopted by participants, ie, how they expect to be interacted with and supported by professionals. From one position, self-reliance and the degree to which clinicians showed respect to them as 'experts by experience' was key. In contrast, from another position, medical expertise and attention were seen as crucial and likened to 'being rescued', and fear was associated with this being taken away. A third position saw personal autonomy and support from others as equally valid, whereas a fourth placed emphasis on the social dimensions of illness and was more likely to accept interventions that promoted social inclusion and citizenship. The study found that people's narrative positions weren't fixed and changed in line with factors such as degree of illness/wellness. The authors conclude that effective SDM is predicated on the professional getting to know the individual's standpoint and adapting their approach to communication and support accordingly.

Theoretically, SDM is aligned with concepts of 'recovery' and 'citizenship' in mental health, in which helping efforts are directed at facilitating the person's engagement in support of their rights, will and preferences (Minkowitz, 2006). Key approaches include planning tools such as Wellness Recovery Action Plans (WRAPs) which enable the individual to explore and record in detail how they wish to live, and the kind of supports they wish to have in place (Knight and colleague, 2018). Relatedly, 'advance directives' (ADs), such as an 'advance statement' under the Mental Health (Care and Treatment) (Scotland) Act 2003, provide means of stipulating the types of treatments given during periods of illness. Criticisms of ADs relate to the degree to which medical opinion may override the person's views. While this is recognised as a difficult balancing act, there is a discernible trend towards strengthening the effects of ADs in the reform of mental health legislation in recognition of their importance for SDM (Department of Health, Victoria State Government, 2021; Mental Welfare Commission for Scotland, 2019; Kokanović and colleagues, 2018) by including both treatment related options and personal support choices (Lenagh-Glue and colleagues, 2022). Lenagh-Glue and colleagues' (2022) project developed a new AD called a 'Mental-health Advance Preferences Statement' highlighting the importance of the right support, prominently flagging it to clinicians and overcoming apathy among users and clinicians by identifying champions to promote it.

Nominated persons arrangements, including power of attorney, as well as advocacy schemes, including peer advocacy (Penzenstadler and colleagues, 2020) feature increasingly in mental health legislation as ways of supporting decision-making. Advocacy schemes show potential to avoid 'risk aversion' and 'best interests' recommendations by professionals and families (Simmons and Gooding, 2017). Penzenstadler and colleagues (2020), however, note the potential for 'undue coercive influence' to shape any support for decision making. There has also been growing interest in more collaborative approaches to SDM, including Family Group Decision-Making (FGDM) (also known as Family Group Conferencing) which shares features with the above-mentioned circles of support and in which the 'resources' of the individual's family and social network are marshalled to give effect to the person's will and preferences. While the research evidence for FGDM in adult mental health context is small, it does illustrate its ability to equalise power differentials and to arrive at decisions and outcomes that support adults' autonomy (de Jong, Schout and Abma, 2018; de Jong and Schout, 2011). Relatedly, there is a growing body of research on 'Open Dialogue' in mental health, which originated in Finland and is described as 'a consistent family and social network approach where all treatment is carried out via a whole system / network meeting, which always include the patient' (NELFT NHS Foundation Trust, 2022 [online]). There is good research evidence for its effectiveness, with a recent NHS study concluding, 'participants experienced unique therapeutic benefits when engaging with the open dialogue service', which was facilitated by qualities of 'openness, inclusivity and mutuality' (Hendy and Person, 2020, p101).

Supported decision making: older age and dementia

Providing support for decision making is challenging in every context, but it may be especially complex when it comes to supporting those in later life. The global population is ageing at a rapid pace (WHO, 2022), and societies around the world are scrambling as they attempt to adjust to the complex needs of this shifting demographic. Older age presents a number of challenges to services, including a higher prevalence of multi-morbidity and dementia.

Dementia is an umbrella term to describe a group of symptoms including memory loss, confusion, and changes to understanding and behaviour (Alzheimer's Scotland, 2022). Dementia is not a normal part of the ageing process, but it is more prevalent for people over the age of 65 (Alzheimer's Scotland, 2022); albeit it can also affect people in younger age groups. Dementia can be a devastating disorder for individuals and families; among many other things, it impairs someone's capacity to make their own decisions in areas where they previously had full autonomy. In these cases, many jurisdictions, including Scotland, rely on pre-appointed substitute decision making in the form of Power of Attorney, or where this is not in place prior to losing capacity to make specific decisions, a Guardianship Order.

Given the prevalence of substitute decision making for people with dementia, there is growing interest in developing SDM practice frameworks. However, this area is not well researched (Sinclair and colleagues, 2018) and the challenges of SDM with this demographic are different than in other areas. One of the unique challenges of supporting those with dementia is that prior to the onset of the condition they will have formed set views informed by their moral, political, and social perspectives (Donnelly, 2019). And while these previous views can and should be taken into consideration (Dixon and colleagues, 2022), they may be at odds with the person's expressed wishes following the onset of dementia. When this occurs, it becomes difficult to navigate which views to honour, particularly as the UNCRPD Committee seems to emphasise 'the prioritisation at all points of a person's immediately identifiable wishes and feelings' (Ruck Keene and colleagues., 2017, p 138). Dixon and colleagues (2022) point out this is especially problematic where such decisions are placing the individual at risk and safeguarding is necessary. Szmukler (2017) offers the concept of 'subjective best interests', as a way through, based on the premise that a person's will and preferences that have been established over a long period of time are a more reliable guide than those seen to be more transient.

So, what does the limited research base say about how SDM may be provided to those with dementia? Wied and colleagues (2019) conducted a systematic review of existing literature and identified only 11 studies which looked specifically at this question. The review indicated that modifying information to increase understanding and the application of support tools could be successful strategies (Wied and colleagues, 2019). One tool, DecideGuide, was specifically designed to support those with dementia and their wider networks with decision making in the Netherlands and has been received favourably so far by users (Span and colleagues, 2015). Scotland's Talking Mats, as described above, has also been evidenced as an effective tool for supporting those with dementia (Murphy and colleagues, 2010).

As an alternative to practical tools for simplifying information or collecting a person's views, some have proposed a 'spectrum approach' for people living with dementia, which aims to maintain the individual's involvement wherever possible, but allows for an increasing amount of support and eventual representation as cognitive impairment progresses (Sinclair and colleagues, 2018). This flexible model was devised after those living with dementia and their families described the relational nature of decision making in the context of a progressive illness, rather than viewing it as a solely individual responsibility (Sinclair and colleagues, 2018). Writing in the context of safeguarding adults with dementia, Dixon and colleagues (2022) propose an holistic approach to SDM, which includes a focus on providing clear and accessible communication, being flexible with timescales and building effective relationships. These themes are echoed in Donnelly and colleagues' (2021) study with health and social care professionals in acute hospital, which identified enablers and barriers to SDM with older people with dementia, including: building meaningful engagement with the person and their family, including ensuring the older person's attendance at family/professional meetings; effective interprofessional collaboration, which require culture shifts in knowledge about SDM; and addressing the ward environment, in particular, providing quiet and private spaces to facilitate communication.

Looking ahead

The view expressed by people living with dementia that decision making is a relational and shared process brings us full circle to the original point about decision making - it is very rarely an isolated process for most of us. This highlights one of the many debates around SDM and its implementation. While there is broad agreement that the 'traditional' approach to substitute decision making should be challenged and that legal capacity should be presumed, there is concern about the practicalities and ethical implications involved in prioritising an individual's will and preferences above all else. Many have raised that this could place vulnerable individuals at risk of harm, and others have noted that there will inevitably be situations where it is not possible to ascertain someone's desires at all. Nonetheless, SDM holds the potential to make the paradigm shift sought by the UNCRPD happen; a shift from achieving 'protection' by restricting a person's autonomy to make decisions, towards the protection of their human rights, which necessitates a more enabling approach.

When it comes to working out these ethical and practical dilemmas, social workers have a critical voice. Social workers are faced with complex and difficult decisions regularly; it is part of their values and skillset to manage competing demands, assess risks, and uphold the law, all while promoting the rights of individuals. As practitioners, they will be familiar with the tensions presented 'in the real world' and can offer valuable ideas for navigating such dilemmas. They are also orientated as a professional group to the social model of disability, on which SDM is founded. Social workers, therefore, should not shy away from engaging with these critical debates, particularly as so many laws and policies involving SDM are currently being formulated and therefore may be shaped by social work perspectives. As indicated, this includes the recommendations of the Scottish Mental Health Law Review, which place SDM at the centre of transforming current legislation relating to mental health, capacity and adult safeguarding so that they become human rights compliant (Scottish Mental Health Law Review, 2022). However, the Scottish Mental Health Law Review and the broader literature recognise that as well as additional empirical research, social workers and health professionals need dedicated training on SDM. This is required to enable them to deepen knowledge of its nuances, such as how it differs from shared decision making, and to adopt approaches that are congruent with principles of respect for autonomy and can stand up to the competing resource and time constraints of frontline practice (Knight and colleagues, 2018).

Conclusion

SDM has become a core organising concept for the objective of upholding people's legal capacity and honouring their will and preferences. It is key to large-scale reform of national and international law on mental health and capacity, driven by recognition that current statutes and policies are too deficit-based and aligned with substitute decision making principles and frameworks. SDM comprises a series of models, tools and practices designed to maximise a person's understanding about the decisions they need to make, and to give effect to their views and wishes. These include communication aids and approaches (eg support circles, 'open dialogue', family group decision making, Talking Mats, etc) advance directives, informal and legally mandated supporters, among others. SDM should be tailored to a person's specific needs and circumstances, including factors that affect their health and development. This Insight has provided an overview of legal and policy developments, and research in SDM in relation to people with intellectual impairment, mental health problems and dementia. It has identified that SDM is complex and necessitates navigating ethical, professional knowledge and skills, and resourcing barriers. It has, however, established that building effective relationships is at the heart of SDM and that decision making is an inherently relational process; it therefore takes time and is built on trust. This summary finds that SDM aligns with the social work profession's social model perspective and social workers are ideally placed in terms of values, knowledge and skills to lead in the development of progressive SDM initiatives, in line with recommendations regarding law reform (Scottish Mental Health Law Review, 2022). It also concludes that significantly more empirical research is needed into what effective SDM looks like, as well as educational and training schemes to embed SDM in professional social work and interprofessional practice.

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About the authors

Lauren Gillespie is a registered social worker and PhD student at the University of Edinburgh. Lauren practised in adult care and justice settings before starting her PhD, which is exploring supported decision making in care transitions with older adults who lack capacity and is funded by the University's Advanced Care and Research Centre. This study aims to add to the research evidence on SDM and provide insight into how it might be facilitated in the context of practice challenges.

Dr Pearse McCusker is a registered social worker and Senior Lecturer in Social Work at the University of Edinburgh. His teaching and research focuses on mental health, including the ethical use of mental health, capacity and safeguarding legislation, and ways of improving mental health and wellbeing, such as mindfulness. He also explores initiatives to improve opportunities for practitioner-based research and develop participatory methodologies to increase involvement in research and education for people with lived experience.

Acknowledgements

This Insight was reviewed by Helen Allbutt (NHS Education for Scotland), Sam Cairns (Equal Say), Andy Miller (SCLD), Jill Stavert (Edinburgh Napier University), Brenda Walker (National Adult Support and Protection Coordinator) and Scottish Government colleagues (Adult Support and Protection, Directorate for Social Care and National Care Service Development).

Comments represent the views of reviewers and do not necessarily represent those of their organisations. Iriss would like to thank the reviewers for taking the time to reflect and provide feedback on this publication.

Credits

Series Coordinator: Kerry Musselbrook

Commissioning Editor: Kerry Musselbrook

Copy Editor: Stuart Muirhead

Designer: Ian Phillip

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Our one-to-one support and group activities help build connections and confidence, and we run courses to give people the skills to understand and manage their mental health. By sharing knowledge, experience, space and resources, we enable people to take control in their own lives, and make a difference for others.

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Supporting intimacy and relationships in later life: Practice Tool (2023)

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Social Care Institute for Excellence (SCIE)

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Published August 2021

Introduction

This report from Social Care Institute for Excellence (SCIE) aims to explore resident-to-resident harm in care homes, also referred to as resident-to-resident abuse. However, there is an important distinction to be made between harm and abuse as abuse occurs within relationships where there is the expectation of trust. That expectation cannot be applied to the relationship between residents. Having highlighted this key distinction, this report reflects the literature and so refers to resident-to-resident abuse (RRA) throughout.

SCIE provides adult safeguarding training to a wide range of organisations across sectors. When working with care home providers, including those providing care in secure accommodation for people sectioned under the Mental Health Act, the issue of resident-to-resident harm is frequently raised as an issue of concern. Staff have highlighted the difficulties of managing residents with high-level needs and behaviours that may cause risk to others that are often caused by cognitive impairment. These issues are exacerbated where many such people are housed in the same service. Staff working with these challenging issues have reported the difficulties it causes for them as social care practitioners, causing anxiety and stress for individuals who are expected to manage sometimes volatile situations.

This led SCIE to look at the research evidence to establish what techniques and practices might be considered best practice in this area of work. Unfortunately, the research review found little in the way of evidence to support good practice in this area.

Specifically, this report aims to identify current research, policy and practice about resident-to-resident abuse in care homes. The report explores:

Definitions and types of resident-to-resident abuse

Prevalence of resident-to-resident abuse

Risk factors for resident-to-resident abuse

Prevention of and interventions for resident-to-resident abuse

Research gaps

Potential case studies

Whilst this report focuses on care homes, we recognise that harm can occur between people who use services in other settings such as day services.

Key messages

There is very little UK literature on resident-to-resident abuse or harm, with most being from the US. Of the UK literature that is available, much of it is policy or practice documents rather than empirical research.

The focus of literature on resident-to-resident harm has been on older adults, with less available about people with learning disabilities and other groups.

Types of resident-to-resident abuse included: verbal (yelling, screaming), physical (hitting, kicking, pushing, throwing things), sexual (inappropriate touch, exposing themselves), violation of privacy and taking/damaging another's belongings. Linked to this was bullying, mainly highlighted in 'senior living facilities'.

Abusive behaviour was rarely documented or reported in some settings, with evidence that some care managers consider it an inevitable or predictable part of living in a residential setting. Some services allow harmful behaviours to be accepted and unchallenged.

Research regarding the prevalence of resident-to-resident abuse is limited, yet information from a variety of sources suggests it occurs fairly frequently. Prevalence data is hard to compare across studies and settings due to very different methods being used.

Resident characteristics that are a risk factor for resident-to-resident abuse include dementia, mental illness, behavioural symptoms that may disrupt others and a history of aggressive or negative interactions with others.

Environmental characteristics that are risk factors for resident-to-resident harm include a crowded environment, inadequate staffing levels, lack of staff training, high numbers of residents with dementia, a lack of meaningful activities, crowded common areas and excessive noise.

Many incidents of resident-to-resident harm are not witnessed by staff.

There is significant overlap between interventions to prevent staff-to-resident abuse as for resident-to-resident harm. These include professional training, development of person-centred care practices, and the use of a multidisciplinary approach.

Interventions to reduce resident-to-resident harm include both environmental considerations (such as reducing crowding, noise and clutter, and prompting meaningful activities) and care practices (including care plans, staff training, identifying risk factors, consistent staffing to build relationships)

There is a paucity of research into resident-to-resident harm, including prevalence data, detailed identification of perpetrator and victim characteristic, developing/assessing environmental interventions, developing/assessing staff training interventions

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Full version: Resident-to-resident harm in care homes and other residential settings

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Resident-to-resident harm in care homes and residential settings

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This report from SCIE aims to identify current research, policy and practice about resident-to-resident abuse in care homes.

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Home - Self-Harm Network Scotland Penumbra

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What is self-harm? Self-harm is any non-accidental behaviour which causes, or has the potential to cause, harm to a person. Self-harm is where someone hurts themselves as a way of coping with difficult, distressing or overwhelming feelings or experiences. While we know that self-harm and suicide are linked, we also know that self-harm is often [...]

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Key points

The unique factors which contribute to suicide actions in later life are often more difficult to recognise than contributing factors in younger individuals.

Suicide thought may be passively expressed and can be triggered by the experience of existential loneliness or a sense of a 'completed life'. This can give rise to self-neglect, particularly of one's own health, and death hastening behaviour such as the voluntary stopping of eating and drinking, as well as more purposive suicide acts.

Taking a life course including a trauma-informed approach can help practitioners identify contributory risk and protection factors.

Ageism and stigma can mean that suicidal thought and action are less likely to be recognised in later life.

Existing suicide prevention interventions are not sufficiently nuanced for older people.

Practitioner skills and knowledge on how to screen, approach and discuss the topic of suicide in later life should draw on principles of time, space, and compassion.

Introduction

Suicide prevention is a priority for public health. The United Nations and the World Health Organization have coordinated a global response to suicide prevention (WHO, 2014). In the UK, suicide prevention strategies are developed by its four devolved governments. Documentary analysis of sampled strategies, however, revealed that these strategies say relatively little about people in later life (Hafford-Letchfield and colleagues, 2021).

Suicide rates in many countries are higher among older people in comparison with other age groups (Shah and colleagues, 2016). An analysis of trends in deaths by suicide over the past five years in Scotland shows that rates of suicide have fallen for most age groups, except for those aged 45-54 years and in females aged 55-64 years (Barry and colleagues, 2022). More recently, age related data on completed suicide in Scotland shows an increasing trend over the age of 65 since 2020 (NRS, 2022). High rates of suicide among older adults are thought to be a consequence of the ageing population demonstrating more determined and planned suicide acts, coupled with fewer warnings, or detection of suicidal intent. For instance, self-harm and suicide behaviour in older people is more likely to result in death, compared to younger age groups (Monforte-Royo and colleagues, 2011; Wand and colleagues, 2018).

The prevalence of suicide in later life may also be under-estimated and under-recorded due to its unique presentation. Deaths in older people that result from more passive acts of suicide, such as the voluntary stopping of eating and drinking (VSED) and refusing medication, are unlikely to be formally investigated as potential suicide deaths and are, therefore, less likely to be recorded (Deuter and colleagues, 2016). Such acts may be considered a rational decision, or interpreted as a legitimate exit, when people experience dramatic changes in social status and role (Berniere and colleagues, 2020; Hafford-Letchfield, 2022a).

Ageism in society has also been identified as a barrier to people seeking help and getting support (Ayalon and Shiovitz-Ezra, 2011). Structural ageism and internalised stigma can promote views that poor physical and mental health is a normal part of ageing, which may in turn not be routinely investigated or treated (Stanley and colleagues, 2016).

The field faces challenges in relation to how suicide thought and behaviour in later life is recognised, and whether a specific model for late life suicide can provide an enhanced understanding of the ageing experience (Van Orden and Conwell, 2016). An emerging body of evidence articulated in this guide describes how aetiology, epidemiology and presentation of suicide thought and actions during later life is a different phenomenon from that experienced in other times of the lifecourse.

Aims

This Insight is targeted at:

Practitioners who work with older people and may want to know more about how to address suicidal thought and behaviour in this population

Specialist suicide prevention providers who are interested in tailoring their existing services for people in later life (by 'later life' we mean people aged 65 years or older)

It summarises the key messages from the research evidence and emerging themes on how to improve recognition, responsiveness, and access to support.

The policy context

The Scottish Government and the Convention of Scottish Local Authorities (COSLA) developed Scotland's Suicide Prevention Plan (2022-2025), Creating hope together. This makes specific reference to older adults in outcome three and action area five. It calls for a compassionate response and to develop new approaches to prevent suicidal behaviour in older adults, with a focus on delivering action in key settings. This includes engaging with people with lived experience; reviewing and synthesising the evidence around the needs, risk and protective factors; effective responses; and implementing learning from reviews of suicide deaths in older adults.

While the plan addresses the suicide prevention needs of the whole population - especially where there are known risk factors, such as poverty, or being from marginalised or minority groups - there is less research and fewer interventions aimed at suicide prevention skills specific to people in later life. A fairer Scotland for older people (Scottish Government, 2019) aims to address barriers and deliver improvement that tackles inequalities for people in later life that are also known to impact on suicide. There are resources available to enhance the capacity of the workforce in this area through building skills and knowledge (NHS Scotland and Public Health Scotland, 2022).

Overview of the body of evidence

Research suggests that there are a range of unique factors that contribute to suicide thought and behaviour in later life. These include increased social isolation, childhood and/or life-long trauma(s), cumulative loss and complicated bereavement experiences, financial distress, material disadvantage, feeling like a burden and deteriorating health that can increase with age (De Leo, 2022; Hafford-Letchfield and colleagues, 2022b).

There have been several reviews exploring ageing in relation to suicidal behaviours. Some have focussed on exploring this topic from a theoretical point of view (Stanley and colleagues, 2016), while others have focussed on specific risk factors such as socioeconomic status (Ju and colleagues, 2016), the social determinants of health (Carvalho and colleagues, 2020; Dautovitch and colleagues, 2021) and gender (Heisel and colleagues, 2020).

A conceptual framework for suicide-related expression in later life

Hafford-Letchfield and colleagues (2022b) developed a conceptual framework from a scoping review of the literature which describes how we might better understand the pathways to suicide in later life. This framework captures the complexity of terminology used to describe suicide related behaviours and presentations unique to ageing. This provides a first step in helping policy makers, researchers, professionals, and people who work and live with older adults to progress towards identifying more tailored preventive measures and early interventions targeting suicide-related behaviours that are unique to, but common in, later life. The remainder of this Insight draws on this conceptual framework to summarise some of the key themes from this body of work.

Four key concepts on suicide expression in later life, the relationship between each, and factors that protect against their development are described in Figure 1 (below).

Viewing life as 'completed'

Behaviour that hastens death

Self-destructive behaviour

Protective factors: social connectedness; satisfaction in one's social life; high level of purpose; perceived control over one's life; low levels of perceived burdensomeness and/or hopelessness; low levels of functional disability.

Figure 1. A conceptual model of the 'grey areas' of suicide-related expression in later life (Hafford-Letchfield and colleagues, 2022b)

The four concepts are:

1. Completed life and existential loneliness (including feeling 'tired of life')

2. Death wishes, thoughts, and ideation

3. Death hastening behaviours and advanced directives (eg, voluntary stopping of eating or drinking)

4. Self-destructive or self-injurious behaviours (including self-neglectful behaviours).

Based on the identified protective factors, we recommend that those working in social care and social work aim to develop an enhanced understanding of older individuals' conditions or attributes (living environment, conditions, skills, strengths, resources, personal character, support networks or coping strategies). This will aid strategies designed to enhance protective factors, as well as inform the development of any psychosocial or peer-led interventions to prevent the development of the identified suicide expressions.

Viewing life as completed

Richards (2017) described a 'sense of a completed life' as feeling unable or unwilling to connect or feeling disconnected with life. A major theme was the person's anxiety about further loss of self-determination and self-sufficiency in their future. Existential loneliness has been differentiated from other types of loneliness where people feel isolated and acutely aware of their own mortality. A synthesis of studies (Bolmsjö and colleagues, 2019) revealed that failure to have needs met in a crisis and lack of authentic communication gave rise to overwhelming negative feelings, emotion or moods including sadness, hopelessness, grief, meaninglessness and anguish.

Developing a wish to die

Monforte-Royo and colleagues (2011) talk about the lack of terminological and conceptual precision in defining the construct of death ideation in later life, and the need to distinguish between a generic wish to die, the explicit expression of a wish to die, and a request for euthanasia or physician-assisted suicide.

Further differentiation between thoughts, wishes and intentions has been associated with a diagnosis of depression (Raue and colleagues, 2010) which is significantly associated with increased mortality. However, Fässberg and colleagues (2012) found that most of their participants (77.4%) who reported thinking about their own death at least once per month were not diagnosed as depressed.

Studies exploring why a wish to die in later life develops, point to feelings of being a burden and hopelessness (Guidry and Cukrowicz, 2016); a dissatisfaction in one's social life (Bernier and colleagues, 2020); viewing one's life as having no purpose; and perceiving a lack of control over one's life (Bonnewyn and colleagues, 2014). Changes in health that impact day to day functioning (Fässberg and colleagues, 2016), problematic drug and alcohol use (Cavalcante and Minayo, 2015) and personal experience of violence, and abandonment in earlier life, are also associated with the wish to die.

These findings suggest that a wish to die by suicide is expressed in highly complex ways through an older person's life course. Personal character, coping strategies and social support play a role in the way that individuals deal with challenging events or situations (Rurup and colleagues, 2011). Balancing positive and negative feelings towards living and dying was important in whether the person went on to complete suicide (Van Wijngaarden and colleagues, 2016).

Behaviours that hasten death

Actions that hasten death may include voluntary and or/deliberate stopping of eating and drinking (VSED), which highlight ethical debates and considerations (Rodríguez-Prat and colleagues, 2018). Advanced directives, for example, can be extremely complex where the person is living with dementia (Steinbock and Menzel, 2018; Trowse, 2020).

Stängle and colleagues (2019) attempted to distinguish between different forms of VSED, its cause and associated intentions. Exploring meaning in the wish to hasten death in patients with advanced illness indicated that VSED may be a response to physical, psychological and/or spiritual suffering; a means of taking control and a deliberate expression of personal autonomy (Rodríguez-Prat and colleagues, 2018). The research indicates the importance of exploring all possible areas of distress to include existential and social aspects, as well as the legal context.

In England, care staff participating in a study by Hafford-Letchfield, and colleagues (2020) described a sense of helplessness in not knowing what to do when care home residents 'gave up' (ie, engaged in death hastening behaviours). Staff expressed tensions in providing the right support and creating spaces to respond to such challenging situations. Person-centred care helped to alleviate personal stressors, as did investment in relationships within which the resident could confide and express themselves. Building a team around them required appropriate expertise and indicated a need for improved training. Engaging residents in expressing their wishes around dying, care and safety planning particularly when transitioning into more dependent care was recommended in supporting older people living their final years in care home settings.

Self-destructive behaviour

This can include self-harm, indirect and direct self-destructive or self-injury through purposive actions. A review of the prevalence, risk factors and characteristics of self-harm in later life (Troya and colleagues, 2019) found moderate evidence that a previous history of self-harm, previous and current psychiatric treatment, and sociodemographic factors (single, living alone and younger older adults aged 60-74 years old) were significant risk factors for repletion of self-harm. Alcohol/drug use, female gender, psychiatric history, and a diagnosis of musculoskeletal conditions such as arthritis were also associated with repetition of self-harm.

One review looked at self-injurious behaviour in people with dementia living in nursing homes (Mahgoub and colleagues, 2011). The most common direct self-injurious behaviour included self-pinching, scratching, and banging one's fist against objects or less commonly, pulling one's own hair and self-hitting. Wand and colleagues (2018) examined the reasons why older people have self-harmed and suggested that both active and passive self-harm should be considered as distinct entities as the underlying motivations and intentions differ. They also observed that for some older people self-neglect may reflect impaired coping skills or cognitive impairment.

Older adults who self-harm have a sixty-seven times higher risk of suicide compared with younger populations (Murphy and colleagues, 2012). There is increased risk of repetition in those with a previous history (Troya and colleagues, 2019). Socio-demographic factors including being single, living alone and being a younger older adult (60-74 years old), were more strongly associated with its repetition. Time spent in hospital with self-harm is longer and medical complications are more likely. As most studies are based in hospital settings, our knowledge of self-harm is not representative. It does not consider self-harm that does not result in hospital admission.

Troya and colleagues' (2019) study focussed specifically on self-poisoning which they found to be distinctive in later life compared with other populations. This is possibly due to increased access to prescribed medication for complex health problems and antidepressants (Hedna and colleagues, 2020).

Screening, assessment and help-seeking

A key feature in preventing suicide is to accurately and routinely assess and screen for suicide ideation. There is a need for more age-specific screening and diagnostic measures (Gleeson and colleagues, 2021).

Currently, there is little consensus as to how best to screen for suicide ideation in older people and how to assess wider factors described earlier. This points to the need for holistic psychosocial assessment. Professionals may lack training in how older people express concerns about their mental health, or in recognising the subtle clues that suggest more passive expressions of suicide.

Screening of suicide ideation in older people is not routine across settings, especially outside of health (Gleeson and colleagues, 2021). Numerous studies have highlighted a reluctance to speak openly about mental health among this generation (eg, Hafford-Letchfield and colleagues, 2022a). In contrast, there is a preference for talking therapies among older people given that those over 85 years are up to a third more likely to be prescribed antidepressants compared to those between 55 and 85 years (Frost and colleagues, 2020).

Older people, however, may not be offered talking therapies. They may be reluctant to discuss psychological or emotional distress with care professionals, have low expectations and experience self-stigma (Hafford-Letchfield and colleagues, 2022a). Many older people who die by suicide have been shown to have visited a GP in the previous 30 days where they discussed problems that were somatic in nature rather than psychological (Neufeld and O'Rourke, 2009). Additionally, GPs report that they do not always have the time and sensitivity needed to properly uncover and respond to these issues (Frost and colleagues, 2018).

Suicide screening may also decrease with increasing age. Wider screening for suicide ideation in older people, across a range of social care settings, may be indicated. Screening and assessment could take more account of protective factors by asking questions about social connections and support and to ensure cultural sensitivity towards marginalised groups (Gleeson and colleagues, 2021). Helping people to identify risk reduction interventions, such as therapeutic support and collaborative safety planning, could lead to enhanced safety and quality of care, which is more acceptable to people. It promotes a sense of hope and agency (McLaren and colleagues, 2022) by identifying and encouraging an individual's own psychological resources and resilience in working towards their own goals when challenges arise. A study of lay perspectives on suicide thought in later life (Hafford-Letchfield and colleagues, 2022) identified that relationship and language are key in enabling discussion and the importance of professionals learning to identify implicit/passive suicidal expressions in later life and being willing to take up opportunities to address it.

Bereavement by suicide

While there is some work to explore suicide bereavement support (McDonnell and colleagues, 2020; Scottish Government, 2022) there is limited work focussing on the experiences of suicide bereavement of those aged 60 years old and over. Only two studies have specifically explored age related factors on the impact of a suicide and how people re-orientate their later lives after such a devastating loss (Hyboldt and colleagues, 2020; Hafford-Letchfield and colleagues, 2021).

The absence of suicide bereavement support at any stage in life, contributes to a person's lack of self-care, and for some, leads to extreme post-traumatic stress. For example, the loss of a significant person by suicide can heighten the awareness of growing older alone and developing a fear of becoming more vulnerable (Hafford-Letchfield and colleagues, 2021; Hyboldt and colleagues, 2020). Experiencing a bereavement by suicide can also increase the likelihood of subsequent suicidal behaviours for the bereaved (Hafford-Letchfield and colleagues, 2021).

The practice implications of these findings point to asking about history of suicide bereavement and how this experience has affected the person's life and their current wellbeing.

Summary

Early detection of expression of these different areas is crucial. Expressions of living a completed life may transition to a desire to die or attempts to hasten death (Hafford-Letchfield and colleagues, 2020), and appear to precede direct suicide attempts (Kjølseth and colleagues, 2010). Being able to differentiate these from a broader acceptance by people that their lives are coming to an end or the sense of a completed life, is important as a wish to die can manifest independently of diagnosed depression. There are also wider narratives on the value of some people's lives over others, and tensions with desires for agency and control. These are reflected in the debates on euthanasia and assisted dying (Scottish Parliament, 2019).

More importantly, the belief that life is not worth living is likely to represent dissatisfaction with quality of life and is essential to discuss with individuals facing such circumstances - as are wishes to die/suicide ideation. This calls for closer examination of the impact of service culture and service quality on people's experiences.

Implications for the social services workforce

Adopt the right approach

Practitioners supporting or caring for older people need the right language, confidence, and skills to discuss issues concerning suicide thought and actions in later life. This is required for them to take the initiative and articulate their concerns when these are observed. It includes knowing where and when to sensitively seek appropriate and expert advice and support, and being able to access learning resources to enhance the capacity of the workforce in this area through building skills and knowledge (NHS Scotland and Public Health Scotland, 2022).

Develop early intervention strategies

The development of early intervention and prevention strategies in response to early expression could focus on protective factors that addresses the range of issues that contribute to suicide thought and behaviour such as promoting participation, autonomy and person-centred support.

Undertake training

Given the risk of suicide in later life, and some of the unique ways in which it may be expressed (existential loneliness, wish to die, self-neglect), all staff working with people in later life should be trained to recognise and improve awareness at the everyday level. This is where subtle interactions take place, such as in personal care or in the person's own home environment. Interdisciplinary work can encourage ethical reflexivity in relation to improving the quality of life of people who prefer to die than to continue living.

Encourage participation

Involve people and their carers in discussing mental health and wellbeing in later life. Consider community asset-based approaches that compliment medical interventions to address common issues such as loneliness, and that tackle the interpersonal and structural impacts of ageism.

Normalise discussion about completed life

Recognise the impact of service culture and service quality on people's experiences. Make active use of tools that promote end of life planning and advanced directives. Normalise opportunities to talk, review and express people's thoughts and fears about their completed life without being silenced or accused of being morbid, and use care plans to revisit and review any concerns about mental health and suicide ideation.

Be trauma informed

Adopt a trauma-informed approach to service delivery, acknowledging the importance of adopting a non-pathologizing and strengths-based approach to help prevent possible re-traumatisation of older adults within practices.

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Van Wijngaarden E, Leget C and Goossensen A (2016) Caught between intending and doing: older people ideating on a self-chosen death. BMJ Open, 6, 1, e009895

Wand APF, Peisah C, Draper B et al (2018) Understanding self-harm in older people: a systematic review of qualitative studies. Aging & Mental Health, 22, 289-298

World Health Organization (WHO) (2014) Preventing suicide: a global imperative. Geneva: WHO

Acknowledgements

This Insight was reviewed by Barbara Billings (retired social worker and peer researcher); Naresh Mall (registered social worker); Merrick Pope (Royal Edinburgh Hospital); and Maria Dale, Gillian Davies and Suzanne Crooks (NHS Education Scotland).

Comments represent the views of reviewers and do not necessarily represent those of their organisations. Iriss would like to thank the reviewers for taking the time to reflect and provide feedback on this publication.

About the authors

Dr Trish Hafford-Letchfield is Professor of Social Work at the University of Strathclyde. She is a qualified nurse and social worker. Her research engages with the experience of ageing in marginalised communities. Trish has more than 100 publications in the field of leadership, management, LGBTQ+ issues in health and social care, feminism, lifelong learning, mental health and problematic substance use.

Dr Toby Ellmers is a Wellcome Trust Sir Henry Wellcome Fellow, at Imperial College London. His research investigates psychological functioning and physical wellbeing in older adults, particularly with respect to anxiety, fear of falling and physical frailty.

Dr Helen Gleeson is a Research Fellow in Social Work/Social Policy at Middlesex University. Her PhD in psychology explored the relationships between young people and the police in Ireland. Her research focuses on young people's experiences in the criminal justice system, substance use treatment service experiences of minority groups, suicide ideation in older people, and social work interventions for children on the edge of care. Her research broadly works across a range of projects within social work and mental health that have a specific focus on socially and economically marginalised groups.

Dr Nicola Cogan joined the University of Strathclyde in October 2017 having previously worked as a consultant clinical psychologist and clinical lead in mental health services in the NHS. She has over 15 years NHS experience working as a practitioner clinical psychologist in mental health services. She retains an honorary consultant clinical psychologist post in NHS Lanarkshire. She has a strong interest in mental health research and the use of participatory methods.

Dr Susan Rasmussen is a chartered health psychologist with many years' experience of conducting research to understand the reasons why people develop suicidal thoughts, and how these thoughts are at times translated into behaviours. She is a senior lecturer in the School of Psychological Sciences and Health at the University of Strathclyde where she is also a Centre for Health Policy Fellow. She is currently part of the academic advisory team which supports the leadership group responsible for the development and implementation of the Scottish Government's suicide prevention strategy. She also chairs the Research Ethics Committee for the Samaritans.

Jolie Goodman is an artist who has worked from a survivor perspective in mental health for over two decades. Before going freelance last year, she was Programmes Manager for Empowerment & Later Life for the Mental Health Foundation. Jolie's daily drawing practice can be seen on Instagram @jolie.goodman.

Dr Jeffrey R Hanna is a Research Associate at the Institute of Nursing and Health Research, Ulster University. His research interests and profile include cancer care, bereavement, suicide prevention and positive mental health outcomes. Alongside this, he is undertaking an MSc in Professional Nursing at Queen's University Belfast.

Credits

Series Coordinator: Kerry Musselbrook

Commissioning Editor: Kerry Musselbrook

Copy Editor: Michelle Drumm

Designer: Ian Phillip

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Suicide thoughts and behaviour in later life

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A summary for practitioners and suicide prevention providers who work with older people.

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This resource has been designed to assist professionals and practitioners who will be interacting with victims of scams, this includes but is not limited to; social workers, community nurses, volunteers and befrienders.

This e-learning will give you:

An understanding of the scale of the problem of scams

Insights into the behaviour of the criminals behind scams

Practical advice on how best to support a victim of scams

An understanding of the legislation that can be used to support scam victims and to prosecute the criminals behind scams

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Practitioner E‑Learning | Friends Against Scams

# data[].attributes.attachment_link.description
This E-Learning has been designed to assist professionals/practitioners interacting with victims of scams such as social workers, community nurses, volunteers.

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National Adult Support and Protection Coordinator

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Video animation about dealing with tricky friendships

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To celebrate Scotland's National Adult Support and Protection Awareness Day 2022 we want to make sure that adults in Scotland are as safe as possible, year round, because staying safe matters every day. You can help to keep yourself and others safe by thinking about the friendships you and they may have.

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National Adult Support and Protection Coordinator

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Carer/Family Member experience Powerful video detailing a family members experience of the ASP and other related processes.

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Working together in adult support and protection

A course supporting professionals to put the voice of adults and carers at the centre of their experience in Adult Support and Protection.

Learning objectives/outcomes

To understand the key principles of participation

To develop the skills and knowledge that supports effective participation of adults and carers in Adult Support and Protection

To understand how tools and visual methods can aid participation

This course was created in partnership by Iriss and NASPC. We are grateful to all who contributed to its development.

We encourage those undertaking this resource to record their learning in the the SSSC MyLearning app.

Duration

Category

Modules

8 hours

Adult support and protection

6

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Working together in adult support and protection

# data[].attributes.attachment_link.description
Working together in adult support and protection A course supporting professionals to put the voice of adults and carers at the centre of their experience in Adult Support and Protection.

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Multi Agency Adult Support and Protection Protocol

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Multi Agency Adult Support and Protection Protocol

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Unfortunately, your browser is too old to work on this website. Please upgrade your browser

How has Scotland fared on health and health inequalities in the two decades since devolution? This report - part of the most comprehensive review of its kind since devolution began - looks at the evidence.

A healthy population is one of Scotland's most important assets. It is a vital input into people's wellbeing and a thriving society and economy.

This report suggests that progress in building a healthier and fairer nation is possible. But it also highlights that despite undoubted policy ambition, implementation barriers have enabled inequalities to persist. Worse still, they are growing.

The most glaring predicament revealed by the review is that the health of people living in the most deprived local areas is being left behind the rest of society. The report also identifies three areas of particular concern: the prevalence of drug-related deaths; inequalities in the health and experiences of infants and children; and health and socioeconomic outcomes among young and middle-aged men.

With a tight fiscal settlement for public services, identifying the barriers to successful policy delivery and enacting reform will be critical to improving Scotland's future health. Resources do exist but must be used more effectively. Change will require action and collaboration across all parts of the delivery system and from the public.

For that change to have lasting impact it must be developed and owned by Scotland. Taking action and making progress is possible and can be achieved within existing powers - and by maximising their use - for a healthier and more equal society.

Rooted in Scotland and informed by Scottish experts, this report brings together evidence of trends in health inequalities and wider determinants of health since devolution.
The two decades since devolution in Scotland have seen major external shocks which have changed the underlying social and economic context and created new challenges for tackling health inequalities. These shocks include the 2008 financial crisis and, more recently, the COVID-19 pandemic and alarming rises in the cost of living.

Against this backdrop, the story of Scotland's health has been mixed. Since the 1950s, Scotland has had the lowest life expectancy of UK nations and in recent decades its position relative to other western European countries has deteriorated. Inequalities in life expectancy between people living in the most and least deprived areas widened in the years prior to the pandemic - with the gap growing to 13.3 years for men, and to 9.8 years for women by 2017-19.

This report provides a picture of past and present health and inequalities to inform future efforts to improve both. It draws on perceptions of the barriers to progress from relevant stakeholders and concludes by considering how Scotland can build on strong policy intent to reduce stubbornly high inequalities and close the gap in health outcomes.

The scale of health inequalities in Scotland is not inevitable. The pandemic demonstrated that agility in policy delivery and local practice is possible and the need to act at pace presents an opportunity for change and renewal. Yet for that change to have lasting impact it must be developed and owned by Scotland. Taking action and making progress is possible and can be achieved within existing powers, and by maximising their use. For Scotland, the human and economic cost of inaction is simply too high.

Further reading

In this webinar, we explored the findings of the independent review and discussed the 'so what now?'...

An independent review of health and health inequalities in Scotland over the past two decades.

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Rooted in Scotland and informed by Scottish experts, this report brings together evidence of trends in health inequalities and wider determinants of health in the two decades since devolution.

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A rapid health impact assessment was conducted to identify and, where possible, quantify the pathways through which the rising cost of living might affect health in Scotland. The aim of the health impact assessment is to inform policy responses.

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Population health impacts of the rising cost of living in Scotland - A rapid health impact assessment

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A rapid health impact assessment was conducted to identify and, where possible, quantify the pathways through which the rising cost of living might affect health in Scotland. The aim of the health impact assessment is to inform policy responses.

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Trauma and Supporting those living with Learning Difficulties

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Trauma and Supporting those living with Learning Difficulties

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Once for NES : Learning Disabilities | Turas | Learn (nhs.scot)

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Once for Scotland : Learning Disabilities

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Please refer to the page sub-headings to direct you to your topic of interest. Selecting each heading will direct you to relevant resources and information to help enhance your knowledge and skills for supporting adults with learning disabilities, their families, and carers.

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Transform Toolkit Supporting those with Learning Disabilities Experiencing Domestic Abuse

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Transform Toolkit Supporting those with Learning Disabilities Experiencing Domestic Abuse

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Adult Support and Protection: everyone's business | Iriss

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Adult Support and Protection (ASP) is designed to support and protect adults who are unable to safeguard themselves, their property and their rights. The Adult Support and Protection (Scotland) Act 2007 (ASPA) both defines and provides the legislation framework for all of this work.

This report aims to raise awareness of ASP and its important role and contribution in keeping 'adults at risk' safe. It should be of interest to all stakeholders, whether they work in local authorities, health, police, fire and rescue, or the third sector; or the public themselves. This report will:

Introduce readers to key ASP definitions, duties, processes and stakeholders. This will begin with ASP's origin story, providing the rationale for the introduction of the Adult Support and Protection (Scotland) Act (2007) which gives ASP its name and legislative framework, and places it within a wider legislative context.

Share what we know about adults at risk of harm, who they are and what harms they are experiencing, highlighting any significant trends and possible contributing factors, including COVID-19.

Highlight key issues to consider when supporting and protecting adults at risk of harm and live issues going forward in a changing environment, with future implications for various sectors.

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Adult Support and Protection: everyone's business

# data[].attributes.attachment_link.description
Adult Support and Protection (ASP) is designed to support and protect adults who are unable to safeguard themselves, their property and their rights. The Adult Support and Protection (Scotland) Act 2007 (ASPA) both defines and provides the legislation framework for all of this work.

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Brené Brown: Focus on guilt instead of shame

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The body keeps the score - mind, brain and body in the transformation of Trauma

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The body keeps the score - mind, brain and body in the transformation of Trauma

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The Body Keeps the Score: Mind, Brain and Body in the Transformation of Trauma

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Buy The Body Keeps the Score: Mind, Brain and Body in the Transformation of Trauma 01 by Kolk, Bessel van der (ISBN: 9780141978611) from Amazon's Book Store. Everyday low prices and free delivery on eligible orders.