Who would have thought that pressure ulcers would be one of the most contentious issues at Community Care’s conference on prevention in adult safeguarding this week?
The topic was raised by the first speaker, Claire Crawley, senior policy manager in adult safeguarding at the Department of Health, who, while outlining what we can expect in the imminent Care Act guidance, said: “Clinical issues remain clinical issues [rather than a safeguarding issue]. If I hear one more conference highlighting pressure ulcers as a safeguarding issue, I’ll shoot myself!”
Her comment sparked a debate that continued throughout the day about how far social workers intervene in cases of poor care in a safeguarding capacity.
In the question and answer session after Crawley’s presentation, one delegate queried her stance, questioning whether ulcers were purely clinical, however they occur. He argued that, as a patient safety issue, surely ulcers could become a safeguarding issue: if a plan is in place to prevent and manage ulcers and this isn’t followed through negligence then why is it not a safeguarding matter?
Crawley’s response was that ulcers were unlikely to lead to a safeguarding enquiry – as set out in section 42 of the Care Act – apart from in rare instances where actual abuse is present. However, this didn’t dispel some people’s apparent uneasiness at pushing the issue out of social workers’ safeguarding remit.
Paul Bedwell, business manager for the Essex safeguarding adults board, summed up the potential difficulties ahead for social workers acting in line with the new Care Act guidance when he said that there was a question around which alerts were about safeguarding and which were about quality of care issues. “There’s a fine line between quality of care and neglect, and it’s hard to define.”
Perhaps social workers and local authorities should take heart from Hertfordshire’s experience. The county moved away from social care staff having to investigate pressure ulcers through safeguarding because social workers “were on their knees” with the volume of referrals they were dealing with, according to Tracey Cooper, head of adult safeguarding at Herts Valleys Clinical Commissioning Group and NHS East and North Hertfordshire Clinical Commissioning Group.
Health and social care staff have been armed with specific guidance on how to make a decision about whether to refer an ulcer to adult safeguarding; a five-step procedure for determining if a pressure ulcer is due to neglect; and a screening tool. Now, if a pressure ulcer is believed to have been caused by neglect it is reported as an adult safeguarding alert; but, in other instances, the CCG as the commissioner investigates and providers (and GPs) are held to account.
The CCG has a range of sanctions it can use such as contract levers, including financial ones, and at the end of the day no provider wants that sort of bad publicity. The new approach is having a positive effect: in December 2013, East and North Hertfordshire NHS Trust had one month without a single, avoidable, hospital-acquired pressure ulcer in patients – the first time this has been achieved across the whole trust.
According to the Stop the Pressure campaign, 700,000 people are affected by pressure ulcers each year and each ulcer adds additional costs of care of over £4,000; 95% of ulcers are preventable using the five-step model SSKIN.
Social workers have enough to deal with when it comes to adult safeguarding, perhaps it’s time to take the pressure off and take heed of the Department of Health’s view that unless there is evidence that an ulcer is caused by neglect or abuse, it is a health concern.