Select Committee on Health Second Report

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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