3 The prevalence of elder abuse
15. The prevalence of elder abuse is difficult to
quantify for a number of reasons. Abuse is frequently hidden,
may not be obvious even to the victim, and is likely to be under-reported.
The Association of Directors of Social Services quoted research
to suggest that "reported alleged abuse is but a small proportion
of the overall experience."[11]
Moreover, a lack of staff awareness of what constitutes abuse
(including poor practice), and inadequate knowledge and training
in how to detect abuse can also lead to under-reporting of cases
of abuse. Overall therefore, robust evidence is very hard to obtain.[12]
16. Academic research examining the extent of such
abuse within England is very limited. Aside from the apparent
lack of funding for projects, there are also methodological difficulties
in undertaking and comparing research, such as the variability
in the definition of abuse and the need to ensure adequate response
rates that include physically and mentally frail people.[13]
17. Estimates of the prevalence of abuse have tended
to be based either on generalising from (often dated) research
studies, or from analysing cases reported to helplines, such as
that operated by AEA. A widely quoted figure, cited in several
submissions, of approximately half a million older people being
abused in the UK at any one time is derived from a representative
omnibus survey of approximately 2,000 people living in the community
conducted in 1992.[14]
The basis for the estimate needs to be understood. The study inquired
about older people's own experience of physical, verbal and financial
abuse from close family members and relatives, and found that
approximately 5% of older people (aged over 60) had experienced
psychological (verbal) abuse, and 2% reported physical or financial
forms of abuse. The researchers who analysed the survey acknowledged
that some of the behaviour reported "was probably not 'abusive'
in terms of severity and intensity." Nevertheless, the results
provided the "first systematic British evidence of elder
abuse in the domestic setting." The survey excluded the most
frail and vulnerable older people (living in residential provision)
who might be more at risk of abuse than the general older population.
18. In addition to asking almost 600 older people
about their experience of abuse within the family, the survey
also asked all adults within the sample who were in regular contact
with people of pensionable age whether they had recently found
themselves "shouting at, insulting or speaking roughly to
them or pushing, slapping, shoving or being rough with them in
any other way." The responses to this question indicated
a higher rate of verbal abuse (9%), but a lower rate of reported
physical abuse of older people (less than 1%). AEA argued that
if these proportions were applied to the older population, they
would indicate between 5-9% of older people were subject to verbal
abuse (equivalent to 500,000-900,000 people).
19. An analysis of abuse reported to the AEA helpline
provides an estimate of the distribution of abuse by type, as
indicated in Figure 1.Figure
1 - Abuse by type
Source: Action on Elder Abuse, Ev 15
20. We accept that the use and analysis of calls
to a helpline is bound to offer less than the total picture. Access
to a telephone is probably limited to the less frail; those who
do use it are self-selected; and reticence about personal experiences
will distort the true position. Nevertheless, in the absence of
better data, this estimate is a useful pointer.
21. A survey of community and district nurses, commissioned
by the Community and District Nursing Association last year, indicated
that the vast majority of respondents encountered elder abuse
at work (88%) and in 12% of cases this was on a monthly, or more
frequent basis.[15] The
Association recommended further research should be conducted to
"give greater detail into elder abuse" including: the
number and types of abusive incidents; the services involved;
the outcome of the incident; the consequences for the abused person;
the geographical distribution; and the incidence within black
and minority ethnic communities.[16]
22. We explored the issue of prevalence with our
witnesses. It became obvious that any estimates were closely linked
to the definition of abuse that was employed. The absence of clear
requirements for reporting and recording data on elder abuse added
to the difficulties in agreeing figures. Jonathan Coe, Chief Executive
of the Prevention of Professional Abuse Network told us: "What
we need is a really rigorous and systematic approach to recording
and reporting the whole spectrum of abuse and what we would like
to see is that made a requirement of both providers and regulators,
and the categories would be those used in No Secrets."[17]
Gary Fitzgerald, Chief Executive, AEA, observed that considerable
information already existed because of the operation of adult
protection procedures; however, he also noted the widespread variation
between authorities in the definitions used.[18]
23. Other witnesses also commented on the estimate
of "half a million" older people abused at any one time.
Both Bill McClimont, Chair of the UK Home Care Association, and
Sue Fiennes, National Lead for Older Peoples Services of ADSS,
suggested that the figure was an under-estimate. Mr McClimont
commented that it was likely that there was greater reporting
in the part of the care sector that was currently regulated. As
regulation spread to other parts of care, detection and reporting
were likely to rise.[19]
24. We agree that there is growing awareness of abuse
in the health and care system, in part through the reports from
the Commission for Health Improvement. However, it is important
not to confuse improved detection and reporting with an increased
prevalence of abuse. The difficulty is that because there have
been such poor data in the past, there is nothing reliable against
which to compare emerging findings and therefore trends in abuse
cannot be detected. Dame Deirdre Hine, Chairman of CHI, agreed
that accurate figures about the prevalence of abuse were difficult
to identify; however she noted:
All the evidence that we have and we can put
before you is that concerns about services for older people in
the NHS are one of the most frequent matters brought to our attention
... Of the 11 investigations into serious clinical failure that
we have completed and reported on, three of those involved cases
of serious abuse of older people.[20]
25. Anne Parker, Chair of the National Care Standards
Commission, suggested that the creation of the Commission (and,
from April 2004, of the successor bodies the Commission for Social
Care Inspection, and the Commission for Healthcare Audit and Inspection),
meant that evidence would increasingly become available.[21]
Moreover, as other witnesses also noted, the introduction of regulation
and national standards will, over time, bring about a process
of cultural change in institutional and community-based services
that should reduce the incidence of abuse.
26. We explored estimates of the prevalence of elder
abuse with the Minister, Dr Stephen Ladyman. He told us that there
was some disagreement over the figure of half a million older
people experiencing abuse, which he felt was perhaps an over-estimate:
We probably have a dispute over the number. I
do not dispute that it is a very significant problem and that
there is a very significant number of elderly people who are abused
… The figure of 500,000, because it is an extrapolation of
1992's figures assumes that nothing has been done since 1992 to
improve the situation. I would suggest the figure is probably
lower than 500,000, but I do not dispute that it is a very significant
problem.[22]
27. The Minister acknowledged that the picture was
a complex one in which it was very difficult to obtain reliable
figures and also made clear his Department had not made an estimate
of the extent of abuse.[23]
He also indicated that part of the difficulty concerned the definition
of abuse that underpinned such estimates:
The concern I have about those earlier definitions
is that they include things that can be as innocuous as raised
voices. There is a difference in my view, between a raised voice
when somebody loses their temper under stress and immediately
apologises, realises they have done things and the apology is
accepted. That should not be counted as abuse, in my view, unless
it is happening every day in a systematic way. Those broad definitions,
in terms of the realities of providing care to people, are not
helpful.[24]
28. We were somewhat surprised by this comment. We
agree that abuse can cover a range of situations and circumstances.
However, while some instances of verbal abuse may indeed be one-off
incidents as the Minister suggested, and as the omnibus survey
identified, in other cases this is far from true. The Minister
accepted that No Secrets provided the Government's definition
"of what really constitutes abuse", even going so far
as to suggest its major failing was in concentrating on abuse
in terms of outcomes rather than actions leading to such outcomes.[25]
Even as it stands, the definition in No Secrets seems to
be consistent with an inclusive approach that recognises the range
of circumstances that can be included under the heading of abuse.
As we have previously noted, the guidance states: "Abuse
may consist of a single act or repeated acts. It may be physical,
verbal or psychological, it may be an act of neglect or an omission
to act, or it may occur when a vulnerable person is persuaded
to enter into a financial or sexual transaction to which he or
she has not consented, or cannot consent. Abuse can occur in any
relationship and may result in significant harm to, or exploitation
of, the person subjected to it."[26]
No Secrets also acknowledges that isolated incidents of
poor or unsatisfactory professional practice occupy one end of
the spectrum of abuse, while pervasive ill treatment or gross
misconduct occupies the other.[27]
The Minister's own view of what constitutes abuse appears therefore
to contradict the clear definition stated in the No Secrets
guidance.
29. We recommend that multi-disciplinary research
into the subject of elder abuse should be commissioned by the
Department of Health to clarify the full extent of elder abuse
and to allow the Department for the first time to ascertain the
extent of this problem within society.
30. At present there exist no performance indicators
which allow the measurement of the quantity and quality of work
in adult protection. We recommend that performance indicators
be established as soon as possible to enable accurate measurement
to be undertaken. In addition we recommend that the Department
uses No Secrets as a baseline to enable progress to be
determined in tackling the issue of elder abuse.
31. The figure of at least half a million older people
experiencing some form of abuse at any point in time appears to
offer the only estimate that is currently available. We are disappointed
that the Department has not commissioned research to establish
a more precise figure. We recommend that data collection in this
area improves, and that the Department uses the definitions contained
in No Secrets as the basis for collecting and monitoring
data both on complaints of abuse and on proven incidents. We welcome
the news that the Department is to fund Action on Elder Abuse
for two years from financial year 2004-05 to establish a national
recording system for the incidence of adult abuse.
11 Ev 79 Back
12
Ev 166 Back
13
Ev 150 Back
14
Ogg J and Bennett G, "Elder Abuse in Britain", British
Medical Journal Vol 305 (1992), pp 998-9 Back
15
Ev 64 Back
16
Ev 65 Back
17
Q 11 Back
18
Q 12 Back
19
Q 58 Back
20
Q 100 Back
21
Q 101 Back
22
Q 146 Back
23
Q 157 Back
24
Q 152 Back
25
Q 156 Back
26
Department of Health, No Secrets, 2000, para 2.6. Back
27
Ibid, para 2.9. Back
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