Improving collaborative inter-agency systems and practice in self-neglect: a realist review and interview study

Self-neglect can have serious consequences for individuals' self-care, health and well-being, and requires collaboration between many practitioners, from adult social care, health, fire and rescue, environmental protection and other organisations. Yet practice reviews highlight repeated failings in working together. This National Institute for Health and Care Research-funded study aimed to identify what problems arise in interagency and interprofessional practice with self-neglect within relevant contexts, and develop realist theory describing how they might be addressed.

A realist review of 41 international research publications, 273 Safeguarding Adults Reviews (local statutory reviews of interagency safeguarding practice cases where it is felt there are 'lessons to be learnt') from England, and 85 Safeguarding Adults Board policies and procedures was undertaken to map evidence on collaborative working with self-neglect. Interviews were undertaken with 69 practitioners and managers from relevant agencies, 16 people with lived experience of self-neglect and 2 family carers about their experiences of collaborative working. A selection of 100 Safeguarding Adults Reviews featuring self-neglect was analysed as a set of case studies to estimate the use of services, and costs to agencies of support. Three focus groups were held with seven practitioners to coproduce research translation for use by services from the findings. Four workshops took place to pilot this research translation with practitioners; 73 participants responded to a post-workshop survey. Follow-up interviews with nine practitioners took place to further validate the study's conclusions.

The study proposes four principal programme theories of interagency dynamics with self-neglect: policies, procedures and interfaces; mutual interagency understanding of roles and task; keeping a collective focus on the person experiencing self-neglect; and management support and monitoring. Practically oriented policies and procedures are needed to support a common understanding and coherent response to self-neglect among different agencies. Mutual interagency understanding of roles and the self-neglect task should be supported through shared spaces for consultation, better understanding of each other's legal powers, careful monitoring of mismatched expectations over referral, and expectations of interprofessional 'devil's advocacy' (presenting an opposing viewpoint, whether or not held with conviction, to ensure that all objections are considered). Where mutual understanding is lacking, communication and co-operation between services is impaired. Keeping a collective focus on the person experiencing self-neglect becomes harder to do when practitioners' attention is absorbed by interagency processes and barriers. Practitioner networks need to achieve a shared approach, informed by a trauma-aware perspective, if they are not to undermine each other's work. Management support and monitoring is needed to provide the time and flexibility that self-neglect support often needs.

Professional curiosity in safeguarding must be complemented by greater 'interprofessional curiosity', supported structurally, procedurally and managerially, if interagency working is to fulfil its potential contribution to improving the lives of people experiencing self-neglect.

This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR133885.