Memorandum by Help the Aged (EA20)
SUMMARY OF
COMMENTS AND
RECOMMENDATIONS
— Research suggest that approximately
half a million older people are being abused in the UK at any
one time, but the true extent of abuse is likely to be much greater
due to under-reporting.
— In comparison to that in care homes,
little is known about the abuse of people receiving domiciliary
care.
— Help the Aged believes that victims
may experience more than one type of abuse, with a cumulative
effect on the individuals concerned.
— Contrary to popular opinion, few
incidents of abuse are committed by loving, supportive people,
who have lashed out as a consequence of their caring responsibilities.
Potential abusers include paid workers, friends and extended family
members, who exploit the opportunities provided by their contact
with the person, and the trusted relationship they have with that
person. More must be done to limit these opportunities.
— Help the Aged believes that in some
cases the cultural and financial environment prevalent within
older people's services can actually constitute abuse by neglect.
Abuse cannot solely be blamed upon the failure of individual care
workers.
— The social isolation of the older
person; extent of formal or informal monitoring and supervision
of the worker or relative; and the extent to which the older person
is dependent on the carer or able to challenge, report or escape
from the abuser are all factors which affect the likelihood of
abuse occurring.
— The role of management and leadership
in promoting good practice, empowering staff and in reacting to
complaints and concerns is crucial in preventing abuse within
care settings.
— It is unrealistic to expect older
people themselves to "whistle blow" and highlight abuse.
The development of a comprehensive, and fully funded, network
of advocates for older people must be a priority.
— Every professional who has regular
contact with older people should go through mandatory multi-disciplinary
training on elder abuse.
— The Government should give serious
consideration to making it a statutory offence for an individual
to fail to act when witnessing neglect or abuse.
— The POVA register must be introduced
as a priority, to ensure that anyone found guilty of mistreating
an older person in care can not be re-employed in the care industry.
Consideration must be given to extending CRB checks to all volunteers
or care givers who have one-to-one contact with older people.
— All local authorities should be required
to establish a multi-disciplinary management committee, locally
agreed protocols regarding sharing of confidential information
when there is an older person at risk, and sufficiently staffed
and resourced adult protection teams to provide an in depth monitoring
of all local adult protection investigations.
— Government resources should be targeted
on implementation of the "No Secrets" guidance.
— The Government has a responsibility
to inform older people and the wider population about their rights,
to empower them, and those who care about them, to take action
when these rights are being undermined. The new Commission for
Human Rights should be specifically tasked with protecting the
rights of older people.
Help the Aged warmly welcomes the opportunity
to provide evidence to the Health Committee inquiry on Elder Abuse.
Elder abuse is a very serious issue that has repeatedly failed
to get the attention it deserves. We hope that the Committee's
enquiry will contribute to raising the general level of awareness
about the reality and prevalence of this problem.
HOW PREVALENT
IS ELDER
ABUSE?
Is there adequate research data on the extent
of abuse of older people? How robust is the evidence, and what
are its shortcomings? Have specific issues, such as abuse in black
and minority ethnic communities been neglected? Which types of
abuse are most prevalent?
Help the Aged strongly believes that there is
a need for further research into the incidence and prevalence
of elder abuse. The latest comprehensive research was completed
in 1992[74],
and concluded that approximately half a million older people were
abused in the UK at any one time. With fluctuating population
dynamics and a greater understanding of elder abuse, this research
is too outdated to provide the statistics required to understand
the true scale of the problem. Further research is essential if
elder abuse is to obtain the attention it deserves.
However, ultimately it is doubtful whether research
could ever capture the full extent of abuse, due to the very "hidden"
nature of much of the abuse that occurs. The lack of general awareness
of what constitutes abuse, and considerable pressures inhibiting
people from talking about what is happening, mean considerable
under-reporting is likely. Older people are often fearful of the
consequences of talking openly about abuse. They may have been
"punished" for speaking openly on a previous occasion,
be conscious of how dependent on the perpetrator they are, have
emotional ties to the perpetrator, or be unable to communicate
what is happening to them.
Further specific research is needed to enhance
our understanding of what characteristics of the older person's
situation make them vulnerable to abuse. A clearer understanding
of what can be done to prevent abuse needs to be developed. There
is a particular need for research into the abuse of people receiving
domiciliary care. In comparison with other, more institutional
settings such as care homes, little is known about abuse of those
receiving domicilary care, despite the greater numbers of older
people living at home. It is possible that the current level of
known abuse is only the tip of the iceberg.
Studies highlighted financial abuse as being
the most prevalent form[75].
In addition abuse cases were often multi-faceted, for example
it was common for gross physical neglect to be linked to financial
abuse. Phone calls to the Action on Elder Abuse Helpline (hereafter
"the Helpline") registered psychological abuse as being
the most prevalent, with financial and physical abuse the most
significant types after that.[76]
But when surveyed workers highlighted physical abuse as the major
problem. Help the Aged believes it is not always helpful to break
the issue of abuse into such separate categories, we believe that
victims of abuse experience many types of abuse, with cumulative
effect on the individual concerned.
WHAT ARE
THE CAUSES
OF ELDER
ABUSE?
Who are the abusers? What is their relationship
to the victim? What are the triggers for abuse? Do factors such
as age, illness, race and gender affect the incidence of abuse?
Help the Aged believes that historically there
has been too great an emphasis on "carer stress" in
relation to the issue of elder abuse. Indeed, despite high levels
of anxiety amongst carers that they will "snap" under
pressure, few incidents of abuse are committed by loving, supportive
people, who have lashed out as a consequence of the burden of
their caring responsibilities. Our understanding of elder abuse
needs to change. It has been too easy to be distracted by responding
to carers' own worries about the stress they are under (hence
workers' preoccupation with physical abuse rather than financial
abuse) and avoid the harsh reality that paid workers, professionals,
unqualified carers, and extended family members could all possibly
be abusers. Very few callers to the Helpline identified the abuser
as the principal carer (only 1.9%); 46.5%, however, identified
a relative who wasn't the principal carer as the abuser[77].
We must recognise that abusers are those who
exploit the opportunities provided by their contact with the person,
and the trusted relationship or position they have with that person.
Inevitably within any profession, as within informal networks
of support, there are some people who will abuse the positions
of trust and power that are bestowed upon them. Paid workers were
the next most significant group of abusers, after a relative,
highlighted by the Helpline (29.4%)[78]
and within this group nurses and care workers have been identified
as most likely to be the perpetrators. This may be due to the
comparatively large numbers working in regular intimate contact
with older people on a one-to-one basis and no professional ought
to be above suspicion whether solicitor, social worker, police
officer or doctor.
Help the Aged feels that it is not only individuals
who should be highlighted as perpetrators. It is impossible to
ignore the extent to which the cultural and financial environment
within older people's service not just facilitate the opportunities
for individuals to abuse older people but also contribute to abuse
by neglect. When services are organised in a way that does not
enable paid workers to provide quality care—because of staff
shortages, inadequate resources or poor training and support—it
is not the individual worker who is to blame. The investigation
by CHI into the "forgotten" ward in Manchester Mental
Health Services[79]
highlights that without effective monitoring, intervention and
leadership, a culture of bad practice and neglect can become self-perpetuating.
Abuse does not just take the form of one off
incidents. Within some families there are long-standing patterns
of abusive relationships that do not stop when one family member
becomes older. When the statistics on abuse by family members
who are not the main carers are broken down, they show that the
majority of perpetrators are the adult child of the victim.[80]
This highlights the complex nature of the relationships surrounding
many incidents of abuse and demonstrates why older people will
often need considerable support if they are to be able to consider
change or escape from abuse.
THE SETTINGS
OF ELDER
ABUSE?
Are there differences between abuse committed
in a domiciliary or family setting and abuse in an institutional
setting? Are there institutional factors that help create an abusive
environment or are the risks greater in the domestic setting where
care workers are more likely to work alone?
Given the fact that the majority of older people
live in their own homes, Help the Aged feels that it is likely
that this is where the majority of abuse occurs. Care at home
is more likely to offer the paid worker or the relative unsupervised
contact with the older person and therefore greater opportunity
to abuse them without ever being detected. Two-thirds of calls
to the Helpline relate to abuse in the person's own home.[81]
And a report by the Community and District Nursing Association,
whose members have a unique opportunity to see behind closed doors,
found that 88% have encountered elder abuse at work and that for
12% of respondents this was on a daily, weekly or monthly basis.[82]
For potential abusers, the environment in which
contact with the older person occurs is likely to be a crucial
determinant of the perpetrator's ability exploit this contact.
Key considerations will be whether they are left alone with the
older person, and whether their contact is likely to be monitored
or reviewed—in essence whether they are able to get away
with it. In situations where there is little monitoring the older
person will be less likely to be able to highlight the problem,
challenge the abuse or escape from it.
If an older person has a physical illness, especially
one which effects general levels of mobility or functioning, concentration
or memory, communication skills or comprehension they are also
likely to be vulnerable. Furthermore the degree to which the older
person is isolated from the wider community, whether they are
living in their own home or in a care home or sheltered scheme,
is relevant. Strong networks of support can act as a deterrent
as it increases the likelihood of detection. Support networks
can also help older people in accessing formal complaint procedures.
Isolation and loneliness can also make older people more reluctant
to leave an abusive situation, as it can create a greater physical
and emotional dependence.
There are considerable institutional factors
which can contribute to a culture of abuse. Issues of loyalty,
peer pressure, fear, intimidation, cutting corners, and inequitable
power dynamics are all potential minefields that can foster abusive
attitudes, or at least permissive attitudes in which it is acceptable
to "turn a blind eye".[83]
The aforementioned CHI report into the forgotten ward in Manchester
clearly illustrates the crucial role of management, resources
and culture in terms of challenging bad practice and promoting
good.[84]
As discussed earlier, in some cases under-resourced
care settings can create abuse. Older people in care homes are
all too often neglected by the medical profession, who fail to
review the medication that they take and in the worst cases medication
is used as a form of restraint—with older people with a
reputation for challenging behaviour are kept semi-conscious using
anti-psychotic medication. In December 2001 Paul Burstow MP published
a report which calculated that as many as 88,500 elderly people
in nursing and residential homes were kept in a state of sedation
for no medical reason. Further to this are issues of inappropriate
restraint, lack of stimulation or even basic communication.
WHAT CAN
BE DONE
ABOUT IT?
What interventions are successful in preventing
elder abuse? What more can be done to protect older people?
INFORMAL CARERS
Which organisation should take the lead in cases
of abuse by informal carers? Can older people be encouraged to
come forward and report abuse? Are adequate systems in place to
detect abuse opportunistically? What more can be done to support
and protect informal carers?
While Help the Aged believes that Social Services
Departments should be the lead agency in cases of abuse by informal
carers as they are already developing adult protection frameworks.
However this should not be at the exclusion of other agencies,
in particular, where appropriate, the police. Help the Aged recommends
that all local authorities should be required to establish a fully
multi-disciplinary management committee, locally agreed protocols
regarding sharing of confidential information when there is an
older person at risk, and sufficiently staffed and resourced adult
protection teams to provide an in depth monitoring of all local
adult protection investigations, to ensure they comply with the
guidance.
It is unrealistic to expect older people themselves
to "whistle blow" and raise the alarm when they experience
or witness an incident of abuse. Frequently the perpetrator of
the abuse will be in a position of power over the older person
and so the consequences of complaining, as well as the fear of
the consequences are strong inhibitors for older people. Victims
of abuse in their own homes may also be fear losing their home
or their family by speaking up. Research found that victims of
abuse frequently remained in abusive situations because they did
not know how and where to get the practical advice and the information
they needed to leave.[85]
Older people therefore need support from a fully independent third
party to overcome these fears. There is also a very clear need
to develop post-abuse support services for all victims of abuse.
This is an area of need that has been consistently overlooked.
Help the Aged is concerned that not enough is
being done to encourage the opportunistic detection of abuse by
other professionals. Professionals are unclear about what they
are witnessing and have little knowledge about how to act if they
do suspect elder abuse. Community and District nurses are often
in an ideal position to detect abuse yet in a survey only 35%
felt equipped to deal with the problem. Help the Aged is concerned
that this would be similar for GPs or A&E staff who are all
important points of contact for older people. Every professional
who has regular contact with older people should go through mandatory
multi-disciplinary training on elder abuse. There is a clear model
for this already amongst professionals working with children and
99% of nurses, responding to the survey by the Community and District
Nursing Association, felt that training would be beneficial.[86]
FORMAL CARERS
Are clinical and care guidelines (eg NSFs, NICE
etc) adequate? Are effective performance management systems in
place? Is the new regulatory framework adequate or do other institutional
structures need to be in place? What is the role of CHI/CHAI,
the NCSC and other regulatory bodies in the protection of vulnerable
elders and should their roles be strengthened? What is the role
of inspections?
What is the role of staff training? What restrictions
can be introduced or improved on the recruitment and monitoring
of staff? Are arrangements for the Protection of Vulnerable Adults
adequate? Are there particular concerns about older people making
use of Direct Payments to employ care workers?
Help the Aged believes there are steps that
can be taken to limit the opportunity for perpetrators to abuse
older people who receive care: where possible staff should work
in teams, limiting the amount of unsupervised, one to one contact;
regular supervision, and challenging of "bad practice"
or corner cutting should be central to good management practice;
clear review procedures including confidential feedback from the
older person, facilitated by independent support should be in
place; and there should be a clear system of spot checks to promote
good practice.
Bad practice founded upon a lack of understanding
amongst staff is not acceptable, but a culture of blame rather
than support is unhelpful. Help the Aged is concerned that currently
staff are insufficiently supported and empowered in their role
of promoting good practice and challenging abusive or bad practice.
Whistle blowing or challenging powerful people directly is no
easy matter, especially when your career could be on the line.
Reform of the present criminal record bureau
check system is vital to make it affordable and swiftly accessible
for all care providers. Consideration must be given to extending
CRB checks to all volunteers or care givers who have one-to-one
contact with older people but presently do not meet the requirements
for a CRB check. It is equally as important to introduce the long
awaited POVA register, to ensure that anyone found guilty of mistreating
an older person in care cannot be re-employed in any situation
that will give them direct access to older people again.
Older people's services must be regularly reviewed
and monitored, and confidential feedback sought often and acted
upon, from both the older person and the carer. Older people should
have a more direct involvement in the reviewing, monitoring, commissioning
and inspection processes—expanding their role as lay assessors.
Inspection reports should include user feedback and be easily
accessible to all prospective new users of the service.
The introduction of Direct Payments creates
complex issues as a requirement for CRB checks or NVQ trained
personal assistants would undermine the basis of the system. Older
people who choose Direct Payments should be able to choose who
they employ, but support should be given to those who are not
able to employ personal assistants who they already know and trust.
Accessible, cost-free CRB checks should be available to older
people receiving Direct Payments, there should be locally registered
approved personal assistants for older people to contact, and
there should be support for personal assistants to access NVQ
training programs while they are in post.
Further consideration also needs to be given
to support staff employed by supported living schemes who may
also not have to register with the NCSC inspection team and thus
may not be CRB checked or receive NVQ training.
RECOMMENDATIONS FOR
NATIONAL AND
LOCAL STRATEGY
How can the Government's strategy be improved?
Are existing government standards and guidelines adequate? What
are the policy options? What are the priorities for action?
Older people's human rights are consistently
being ignored or abused. The Government has a responsibility to
inform older people and the wider population about their rights,
to empower them and also those who care about them to take action
in any situation in which their rights are being undermined. However
at present this is not happening—while 98% of local authorities
had met their statutory responsibilities to develop multi-agency
adult protection policies, less than 2% of them had actually told
their communities that such protection existed.[87]
Older people and their carers need to know what levels of help
exist for them and Help the Aged therefore believes that the new
Commission for Human Rights should be specifically tasked with
promoting older people's rights.
The Government must make it a priority to develop
a comprehensive, and fully funded, network of advocates for older
people, who should be encouraged to make themselves available
to older people who are particularly isolated and without other
sources of support. Advocacy can help to ensure older people are
able to consider their options in an informed manner and can ensure
investigations into abuse are carried out with the older person
and in accordance with their wishes and best interests.
Given the additional vulnerability to elder
abuse of older people with limited or fluctuating capacity there
is a clear need for the Government to enact the Mental Incapacity
Bill. Help the Aged would like this Bill to include a guarantee
of access to advocacy support and for much stronger links to made
with the "No Secrets" guidance and various local procedures
for adult protection.
Help the Aged strongly believes that the legal
dimension of elder abuse cannot continue to be ignored. Case law
does exist but rarely gets instigated due to its low profile.
The Government should give serious consideration to considerably
strengthening this by making it a statutory offence for an individual
to fail to act when witnessing neglect or abuse. Help the Aged
is concerned at the apparent lack of interest shown by the police
force in situations of elder abuse, and believes that new legislation
would help raise awareness of the grave nature of elder abuse.
This should be accompanied by a national publicity campaign to
raise the profile amongst the general public of their roles, responsibilities
and rights to intervene to protect older people.
Implementing the "No Secrets" Guidance
is a demanding requirement that at present has not attracted any
targeted government funding. Local Authorities are struggling
to find sufficient resources to commit to it and only 23% of authorities
report having a designated budget for adult protection[88].
Help the Aged would like to see Government resources targeted
to enable implementation of the "No Secrets" guidance,
and compliance made a key performance indicator.
Help the Aged would like to see a much stronger
focus on prevention of elder abuse. Vital to achieving this will
be providing sufficient funding to care providers to enable them
to provide a quality service. In 2002 Laing estimated "that
an additional £1 billion per annum might have to be found
to fund a stable care home sector which is fully compliant with
all national minimum physical standards".[89]
There has been additional funding to Local Authorities in more
recent years but this has not been sufficient to address the chronic
underfunding of the care industry. Service providers must be supported
and enabled to provide well resourced, quality care.
Older people's position within the wider community
needs to be reviewed. Help the Aged would like to see older people
as valued and active members of a community, no longer considered
as helpless dependants, but as people with ongoing skills to give.
If perpetrators choose their victims on the basis of isolation
and opportunity, then more needs to be done to ensure that older
people are still an integrated part of their community.
November 2003
74 "Elder Abuse in Britain", J Ogg and G
Bennett, British Medical Journal vol. 305: 1992. Back
75
"The Needs of Older Women: Services for Victims of Elder
Abuse and Other Abuse", Jacki Pritchard, Joseph Rowntree
Foundation, May 2000 and "Male Victims of Elder Abuse: Their
Experiences and Needs", Jacki Pritchard, Joseph Rowntree
Foundation, March 2002. Back
76
"Listening Is Not Enough", G Jenkins, Z Asif and G
Bennett, Action on Elder Abuse, The Journal of Adult Protection,
vol 2 Issue 1: February 2000. Back
77
ibid. Back
78
ibid. Back
79
"Investigation into Matters Arising from Care on Rowan Ward,
Manchester Mental Health and Social Care Trust", Commission
for Health Improvement, Department of Health: September 2003. Back
80
"Listening Is Not Enough", G Jenkins, Z Asif and G
Bennett, Action on Elder Abuse, The Journal of Adult Protection,
vol 2 Issue 1: February 2000. Back
81
ibid. Back
82
"Responding to Elder Abuse", Community and District
Nursing Association: September 2003. Back
83
"Care Betrayed: A Discussion of the Issues Which Give Rise
to Abuse in Homes", Les Bright, Counsel and Care: December
1995. Back
84
"Investigation into Matters Arising from Care on Rowan Ward,
Manchester Mental Health and Social Care Trust", Commission
for Health Improvement, Department of Health: September 2003. Back
85
"The Needs of Older Women: Services for Victims of Elder
Abuse and Other Abuse", Jacki Pritchard, Joseph Rowntree
Foundation: May 2000. Back
86
"Responding to Elder Abuse", Community and District
Nursing Association: September 2003. Back
87
Report by the Centre for Policy Studies on Ageing quoted in "Silent
Screams", G Fitzgerald, British Institute of Human Rights
Brief: Summer 2003. Back
88
"The Response To No Secrets" D Matthew, H Brown, P
Kingston, C McCreadie and J Askham, The Journal of Adult Protection,
vol 4, Issue 1: February 2004. Back
89
"Calculating A Fair Price For Care", William Laing,
Joseph Rowntree Foundation: June 2002. Back
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