Risk vs safety – decisions, decisions!

There has been a lot in the news recently about the expected rise in the cost of our energy bill. The Guardian quotes the Resolution Foundation which forecasts that ‘energy bills will become unaffordable for 27% of households when the [energy] price cap rises to about £2,000 a year’ see ‘Why is no one up in arms?’ Six householders on the menace of fuel poverty, The Guardian, Wed 2 February.

I have been thinking about this and what steps I could take to improve insulation at home. My house was built in the early 1900s, a mid-terrace with solid walls. I started researching the options - to insulate the external walls on the inside or outside? I now have a number of decisions to make.

This led me on to think about the decision-making process. More specifically, the capacity to decide.

We make a lot of decisions very day. Some studies suggest that an adult makes about 35,000 remotely conscious decisions each day (in contrast a child makes about 3,000) (Sahakian et al; Labuzetta, 2013). Cornell University (Wansink and Sobal, 2007) propose we make 226.7 decisions each day about food alone. And the more responsibility we have, the greater the range of our choices and consequently the more decisions we have to make.

The interface between the ability to make a decision for yourself (mental capacity) and safeguarding is a critical area of practice. It continues to challenge us across our safeguarding ‘ecosystem’ (see December 2021 blog - Wanted: safeguarding ‘ecosystem’ builders). NSAB has identified this interface as a priority.

The greatest test of a practitioner’s judgement is choice versus control, risk versus safety, writes Ruth Hardy. Decisions which are seen as ‘unwise’, particularly in a safeguarding context, can be very hard to work through. Hardy said:

‘One of the five main principles of the Mental Capacity Act 2005 is that an individual has the right to make an unwise decision – this doesn’t mean that they lack mental capacity to make decisions. I recently stayed up until 1am reading the latest Philip Pullman book. This felt like a not very wise thing to have done when my alarm went off at 6:30. But it doesn’t mean that I need someone else to make my decisions for me.’

‘The issue comes when there is a concern over someone’s safety. For instance, self-neglect is a notoriously difficult area of practice, for this reason. If a person has capacity, and seems to be choosing to live in a situation where their personal safety is at risk, can and should social workers intervene? Where does the right to choose stop and the duty of care start?’
See Safeguarding adults who have mental capacity: key principles

Considering mental capacity is crucial at all stages of the safeguarding adults procedure. It provides a framework for decision making to balance independence and protection. For example, this could mean determining the capability of an adult (who has a range of vulnerabilities in their life) to make lifestyle choices, such as choosing to remain in a situation where they risk abuse; deciding whether a particular act or transaction is abusive or consensual; or determining how much the individual can be involved in making decisions in a given situation.

This is why this interface is a key piece of work for Norfolk. We have areas of strong practice and areas and sectors where we are less confident.

There is nothing in the Care Act that replaces or undermines the Mental Capacity Act (MCA) when it comes to making decisions with or on behalf of adults who lack capacity. The principles of the MCA remain as important as ever, see Section 2 MCA Code of Practice.

So, what is the plan to address this? Our Prevention, Managing & Responding and Learning Lessons (PML) subgroup are developing a 4-step campaign for this year (possibly running into next year too) to support the workforce:

Step 1
Survey the workforce, particularly those less-skilled practitioners, asking them what would be most helpful to them to improve their skills and confidence with using mental capacity: what people would like and in what format?. Keep a look out for the survey, fill it in and encourage your colleagues to do the same.

Step 2
Run a series (2 or 3) face to face workshops for frontline workers - where the trainer could tease out some of those things that people are uncertain about. This would include a communication campaign on key messages.

Step 3
Build assets / a package of resources (including downloadable material from the NSAB website for phones or other digital devices) and run training in support of the workforce.

Step 4
Evaluation at the end of the training which would provide useful feedback.

In the meantime, I am keen to flag the great resources we have on the mental capacity & safeguarding page on the NSAB website. These include a link to a new website called:

• Capacity Guide | Guidance for clinicians and social care professionals on the assessment of capacity. What is so good about this resource is that it gives information, linked back to case law, on how to approach situations which seem challenging (e.g. the person seems to say one thing and to do another) or seem risky.

Also checkout the:

• MCA Toolkit launched by Bournemouth University and funded through the Burdett Trust for Nursing. It’s a learning tool to support nurses and other practitioners in their understanding and duties under the Human Rights Act and MCA.

The next time you need to make a difficult decision, why not use it as a prompt to refresh your knowledge on mental capacity and safeguarding?

Thank you.
Walter Lloyd-Smith
NSAB Board Manager

Email: [email protected]

Monday 14 February 2022