Examination of Witnesses (Questions 20-39)
MR GARY
FITZGERALD, MS
TESSA HARDING,
MR JONATHAN
COE AND
MRS JENNY
POTTER
11 DECEMBER 2003
Q20 Dr Taylor: Any comments, any others?
Mr Fitzgerald: I would say to
you that what we are actually talking about is one of the mechanisms
to make culture change within service provision and certainly
we have evidence from the USA and Britain that good-quality provision
of training reduces the potential for abuse, and staffing ratios
reduce the potential for abuse. We are talking of institutional
settings now, domiciliary care, but we are fundamentally talking
about culture change and I think that is partly about the degree
to which we invest in service provision and perhaps I can suggest
to you that there are two sides to this coin. One is about a lot
of what the Government has already done and that is about the
establishment of standards, inspection and the adult protection
legislation that I was talking about. I understand that the Minister
this morning has announced that the POVA list is now going to
be enacted in July of next year.
Q21 Chairman: This was announced when?
Mr Fitzgerald: This was announced
this morning.
Chairman: That is a coincidence!
Q22 Mr Bradley: He knew we were going
to ask about it!
Mr Fitzgerald: I also say that
it is something that is very welcome because again not only is
it a mechanism to weed out repeat abusers, but it is a mechanism
that sends a clear message to service provision that abuse is
not going to be tolerated. All of those mechanisms are very much
about imposing from the outside and I think what we have not invested
enough in is the support mechanisms for providers and there is
a real issue in terms of domiciliary care and care homes about
how much this will actually cost them and how achievable it is
to provide the quality training that is needed and the staffing
ratios that are needed and I think we do have an issue there.
That is a double-sided coin and I think our problem is that we
have not as a society invested in that and I keep bringing you
back to that is about the perception we have got of older people.
We do invest in other groups and we do not tend to for older people.
It is a long-winded answer, but I think you take the point.
Q23 Dr Taylor: And the same point, training
and supervision, would go for people being looked after in their
own home, that they need the support just as much?
Mrs Potter: Yes. There are a lot
of private agencies now in the community caring for people in
their own homes and the staff there get no training at all.
Ms Harding: And that is an area
of very considerable concern because that can be a one-to-one
situation behind closed doors, no other parties involved and that
older person is entirely dependent on the district nurse or the
care worker or both who come into their home. I would like to
emphasise though the point that Gary has been making about the
need for clear messages, very clear messages that this is abuse
and this is wrong, not just through training, multi-disciplinary
training to all staff who are in contact with older people, including
people in accident and emergency departments, GPs and so on, but
also a message to the public that this is abuse and this is wrong.
If you think how much more the public knows now about child abuse
or about domestic violence than it knew 20 years ago, we need
to travel that same journey as far as elder abuse is concerned
only rather more quickly perhaps. When elder abuse hits the press,
it is almost always in terms of somebody mugged at a bus stop
or by someone who has come into their home or whatever. In other
words, it is sort of equivalent to the stranger danger that children
are warned about, but we know full well that that is not where
children are most at risk, and the same is the case as far as
older people are concerned. I think we need a very clear message
to the public as well and to try and influence the press and to
make a clear distinction between what is bad practice and what
is a criminal act and a violation of somebody's human rights.
Q24 Mr Burstow: I have two quick points,
one picking up this issue mentioned just now about training and
the effect that can have on levels of abuse. It really is an area
where there was a slight difference in the evidence we have had
from the witnesses we have today. I think in the evidence we had
from Mr Coe, the implication was that abuse was particularly concentrated
around professionals and I wonder whether that is solely on the
basis of his organisation's perspective that he made that statement
or whether he thinks that is a more general applicable statement
to the issue of elder abuse. On the other hand, Mrs Potter's submission
made the opposite point, which was that there was a very important
need for training because it was a way of reducing levels of abuse
because it tended to be confined around less trained staff. Can
I just unpick that so we are clear that we are all on the same
hymn sheet or whether there are two different hymn sheets and,
if so, what?
Mr Coe: You are right in your
assertion there, but our organisation is solely concerned with
abuse by professionals, so the information that we have provided
here is necessarily about that group and it is not at all about
informal carers.
Q25 Mr Burstow: Generally speaking, you
would accept the assertion others have made that the problem is
particularly acute around untrained staff and, therefore, training
is a key factor?
Mr Coe: Absolutely and I think
one of the recommendations that we make here is that formal professional
training and induction training by care providers should cover
awareness and prevention of abuse, reporting concerns and whistle-blowing
and I think that needs to be systematically introduced for all
kinds of professional training and it is very, very ad hoc at
the moment.
Q26 Mr Burstow: That is very helpful.
The other thing I wanted to ask Ms Harding was regarding this
point about messages. What message do you think care-home providers
might take from differential standards being set for care homes
for the elderly compared to other groups?
Ms Harding: Well, it confirms
the different value attached to older people as against younger
adults.
Q27 Chairman: Can I push you further
on that point. This strikes me frequently when we are talking
about child abuse and elderly abuse and the interesting contrast
in society, that why is it at a time when we have been moving
away from institutional care of children, we have moved wholly
towards the institutional care of older people? The numbers of
elderly people in institutional care seem to have increased since
1981 and we have privatised that care and when countries like
Denmark have completely moved away from that, why have we as a
country seen the institutional model as being the answer to the
problems of older people?
Ms Harding: Well, there have clearly
been efforts by government to shift the balance away from residential
care to providing greater support to older people in the community,
but I think we are all very well aware of the extent to which
those services are under-funded, how very tightly rationed they
are, the eligibility criteria for access to social care services
of any kind by older people getting tighter and tighter year by
year, and when you look at unit costs, the expenditure by social
services departments on older people per head is considerably
lower than it is for younger adult groups, so there is a huge
shortfall, if you like, in the funding of social care for older
people which affects both people's access to it and the quality
of that care because local authorities are then having to stretch
those resources to cover increasing numbers of older people. We
all know about the demographic shift and those over 80 being the
fastest-growing segment of the population. Those demands are going
to increase and I think that at the moment the level of care provided,
the time that is allocated to each individual is very, very tightly
stretched indeed.
Q28 John Austin: You have answered part
of the question I was going to raise about the risks of care.
You have indicated that people are at greater risk because domiciliary
care staff were unsupervised, on their own, it is a one-to-one
relationship, are often poorly trained and obviously you have
expressed concern about that. In that sense, it is not surprising
that the reported cases are those which take place in institutional
care. Have any of you done any assessment of the extent to which
the undetected cases of abuse take place within the home?
Mr Fitzgerald: I think the reality
is that it is the very nature of abuse being behind closed doors
and in a one-to-one situation that it is likely to be almost impossible
to get a good feel on what the issue is. The Care Standards Commission
right at this moment remain unclear as to exactly how many domiciliary
care agencies are actually there and we have a problem with registering
domiciliary care agencies and knowing they exist and I think that
goes back to the question which was asked earlier about the nature
of what have we done. We introduced a social care market ten years
ago that was supposed to get good costs and improve quality and
I think by any yardstick we have to say that that social care
market has failed and it has created a provider service that does
very much feel under siege and does very much feel under pressure
both within domiciliary care and care homes and to some extent
that does then create a culture of denial, "We don't have
a problem", or, "If we do have a problem, it is a very
small problem", or, "It's an unusual problem",
when our experience would be that it is probably far more prevalent
than any of us would like to believe. We have got to change that
culture and I personally do not think we have succeeded in that
by relying exclusively on market forces to do that. What I am
saying is that it is almost impossible to ascertain and quantify
the percentage. What I can say to you is that 66%, two-thirds
of what comes through to us is about abuse within someone's own
home. Conversely, 20%, 21% is about institutions where less than
5% of older people actually live. There may be many reasons why
we are getting that. That could well be that it is easier to report
that type of abuse, to identify that type of abuse than it is
in a one-to-one situation.
Ms Harding: Can I just add that
in addition to the sort of, "We will get better information
when there is somewhere for people to go with that information",
in addition to the clear messages to the public and to the professionals
involved, I think we need independent local advocacy schemes where
people can report their concerns, their anxieties and which have
links with the regulatory bodies so that they can feed in, if
you like, the collective information. Until people are clear where
they should go with this information and what will be done about
it and that it will be treated in confidence and with respect,
but action will be taken, I think that would help us to have a
much better developed understanding of what is actually going
on at the local level.
Q29 Mr Burstow: I wanted to move on to
another aspect of care of elderly people, particularly being cared
for in the community and the issue of direct payments and how
that also cuts across some of the concerns you are raising with
us today. In the circumstances of direct payments, people commission
their own care. They purchase and buy in the support they need.
The people they employ are not covered by any of the existing
framework of regulation. Does that give you any cause for concern?
Do you think, for example, there might be a role for the General
Social Care Council in respect of people that are taking on personal
care assistant roles?
Mrs Potter: I think this is a
real Pandora's box and we are going to have a lot of problems
with this, people who have been employed by agencies who are now
taking on private care for people in their own home, and we have
problems where abuse then starts to take place on a large scale,
especially financial abuse.
Q30 Mr Burstow: So an agency that is
providing staff with direct payments will not necessarily have
to be registered with the Commission as a domiciliary care agency,
for example?
Mrs Potter: These are staff who
had been working for agencies and have now terminated their employment
to work privately for people in the community.
Q31 Mr Burstow: So it is a way of perhaps
avoiding those regulations?
Mrs Potter: That is right.
Q32 Mr Burstow: How widespread do you
think that is as a practice?
Mrs Potter: Well, most of the
direct payments at the moment are done by the more vulnerable
rather than the elderly, although the elderly will start to take
this up in larger numbers soon and there are quite a few concerns
about that.
Q33 Mr Burstow: Does anybody want to
add to this point about direct payments?
Mr Coe: There is more about the
regulatory framework which you mentioned. I think our view is
that really anybody who is working with people who are in need
of care services needs to be properly accountable and there need
to be clear, comprehensive frameworks for accountability. Of course
what that means in practice is that they need to be regulated
and they also need to be subject to Criminal Records Bureau checks
and that needs to be absolutely routine, I think. I find it incredible
that people are allowed to work with very vulnerable people with
none of these checks and with no framework of accountability.
People can walk into these jobs often with a very kind of tokenistic
reference check, if that, and suddenly they are allowed to go
into the homes of people who are extremely dependent on them.
Ms Harding: I do think that it
is entirely possible for individuals, whether they are disabled
adults, younger or older, if they are using direct payments, they
need a support system, and there are independent agencies in some
local areas, to take on the responsibilities as an employer and
no person presumably would willingly wish to employ somebody who
was going to abuse. Provided that the CRB checks and the POVA
register and so on are available to those individuals as employers,
then they are in as good a position as any, with the support of
an independent agency, to monitor that.
Q34 Mr Burstow: Can I move on to the
General Social Care Council briefly and its role in registering
staff. There are about 1.2 million people in the social care workforce
across public, private and voluntary sectors. The current priorities
for registration have been published around care managers and
social workers. What is your view about the priorities that have
currently been set and what would be your next priority group
amongst the social care workforce for registration?
Mr Fitzgerald: I have to say that
in looking at what the General Social Care Council are doing as
an organisation, I am quite impressed with the structures and
systems they are putting up. In terms of the priorities, I do
have grave concerns. It would make more sense to us that the initial
registration process is focused on care staff within residential
and nursing homes and domiciliary workers rather than social workers
for a number of reasons. Firstly, it is apparent to us through
the helpline that that is where the greatest issue of abuse for
us is, and, secondly, to touch back on the point you were making
in terms of training, social workers have gone through quite substantial
training and whilst that does not stop abuse, we are looking at
a situation where with care workers in nursing homes or domiciliary
care, the training, if we call it training, is actually vocational
qualifications. It actually is not training, but it is about assessing
somebody's skills and looking at those skills rather than equipping
them to be trained. For example, a lot of the work we are looking
at with professional workers is providing theoretical training,
but what do we say to a nurse who says to us, "But I have
not actually been taught physically how to care for somebody.
I have the theory, but no one has actually equipped me with the
practical skills to care for somebody", so I think there
are issues for us within that. My priority very clearly would
be that large group of people who have not had investment down
the decades and where we do not have the rigid structures that
we have got in other fields, and that has got to be care workers
and domiciliary workers.
Q35 Mr Burstow: My final area, if I may,
very quickly is around No Secrets which has been touched
on several times. We have received some evidence from various
contributors about how it has been rolled out now it is being
implemented. There has been reference already made to the issues
around data collection and the fact that has not been used as
a means to classify data so far. Could each of the witnesses perhaps
give us their view on the current state of play within local authorities
in terms of actually implementing it and is the system now in
place to provide adequate safeguarding of vulnerable adults in
terms of the ability to have, as I think Ms Harding said just
now, somewhere where people know they can go? Does that currently
exist in every part of England and Wales and, if not, why not?
Mrs Potter: I do not think it
does. It is not consistent throughout the country. No Secrets
did come out, but there was no money to follow it and social services
departments are very over-stretched now, so it went to the bottom
of the pile. Some areas have wound it out and it is a very efficient
policy and it is joint working between health and social services.
In some areas it has been rolled out and it is just social services
alone and health have not had any input. A closer working relationship
between health and social services would help to eliminate some
of the abuse, I think.
Mr Coe: In some areas there is
a now a potential unit that is well staffed, well publicised and
they pull together information and have a good role, but because
no resources followed No Secrets in other areas, there
may be a written policy, but an adult protection officer may just
have that added on to their job description and actually they
are doing other things. I do not think the figures for it have
worked across the board.
Ms Harding: My understanding is
similar, that it is fairly patchy, but I would also say that alongside
finding out more about the extent of elder abuse, we do need to
consider the kind of support that is actually offered to older
people who are subject to abuse and long-term continuing support,
and I think that is a dimension which needs to be strengthened
and emphasised and they are in a very similar situation, for example,
to the position of women in a domestic violence situation. It
is a complex, painful, difficult family situation and the support
for the older person needs to be there and that also requires
resources.
Mr Fitzgerald: I would use that
dreadful phrase of a "postcode lottery" in terms of
whether or not you can access quality adult protection. What we
have clearly seen are some excellent local authorities who have
invested quite significantly in adult protection. They have advertised
it within their local area and they have adequately equipped it,
but I would say that those are in the minority.
Q36 Mr Burstow: Could you, perhaps not
now, but maybe subsequently, signpost some of those for us because
we might want to get some additional evidence?
Mr Fitzgerald: Yes.
Q37 Chairman: It would be very helpful.
Mr Fitzgerald: What I would say
to you is that we are seeing exactly what Jonathan has said, the
role being tacked on to someone else's already busy job or posts
created twelve months ago are now disappearing and when we look
and we talk to people, we are finding that nobody is replacing
that post. Now, perhaps I can also say to you that the Centre
for Policy Studies looked into this issue some time ago and one
of their conclusions was that less than 3 per cent of local authorities
had actually told their local area of the existence of these procedures
and systems. What value is a human right if you do not know you
have got it and what value is a human right if you cannot access
it? Unless we publicise and tell people and do what Tessa said,
which is to give people some place to go, there is not much point
in us having these things. One is resource and the other one is
very much about the status of No Secrets and In Safe
Hands. It is Section 7 guidance and it has not the same weight
as legislation. We clearly need a strong message of legislation
there backing up adult protection.
Q38 Mr Burstow: My final question is
to ask whether or not it would be helpful if the new Commission
for Healthcare Audit and Inspection and CSCI undertook an inspection
of this area as a way of seeing how No Secrets guidance
is being implemented on the ground?
Mr Fitzgerald: Yes.
Chairman: Everyone is nodding.
Q39 Mr Bradley: Presumably everyone will
nod when the Secretary of State says he knew I was going to ask
about POVA when he said it would be implemented in July! Do you
want to make any comment about what has been happening to date
without that provision in place and can I also link it very quickly
to a previous question about domiciliary care, particularly looking
at people with dementia, but who are still being able to be cared
for in the home? From some evidence I have had where social services
contract to an agency and then that agency often sub-contracts
it again to another agency, particularly at weekends where they
have difficulty recruiting staff, if someone has dementia, one
of the keys is to have some continuity of and familiarity with
that domiciliary care, but because of their dementia, often they
might not be very clear about, understandably, who is actually
responsible for their care at any particular time which may lead
to a hidden abuse which, under the current accountability for
those contracts down the line, is not being effectively monitored,
so maybe you could just comment on both of those points?
Mr Fitzgerald: I think, first
of all, I would say to you that looking at both the POVA list
and the Criminal Records Bureau situation, delaying the implementation
of criminal records checks for domiciliary workers, delaying the
POVA list clearly is totally unacceptable. As a society, if we
acknowledge and accept that there is a need to provide protection,
delaying it for whatever reason, whether that is resources or
an organisation needing more people involved in it, such as the
case with the CRB, it cannot be tolerable to know that there is
abuse taking place and to choose not to bring forward those processes.
We obviously welcome the introduction of the POVA list, and it
would be wrong not to. It is a partial implementation. It is coming
into social care first followed by health at a later date, but
nevertheless, it means that those abusers that we know are in
existence, that we know move to abuse and abuse again will finally
be squeezed out of our sectors and out of that provision. We would
obviously strongly welcome that, but it should happen sooner,
a lot sooner.
Mrs Potter: One problem with domiciliary
care, yes, it is sub-contracted out and at weekends and Bank Holidays,
there is no help available for these people and often health have
to pick it up because the district nursing service is the only
domiciliary service that do actually work weekends and Bank Holidays,
so we have found they have to go in then to pick up the care that
the private agencies are not picking up. You do find people who
are distressed because they are confused, they do not know who
is going in to help them, but with such poor pay in these areas,
they are looking at picking up anybody who actually will work
for them and there are no checks.
John Austin: There has been a great deal
of progress in training a whole range of professional workers
in recognising the tell-tale signs of physical and mental abuse
in children, and the Community and District Nursing Association
has recommended extending training to all nursing and care staff
in recognising abuse in elders. How practical is that as a suggestion
and what is the role of GPs and A&E departments in that? Are
they as geared up as they are perhaps in the area of child abuse?
Can I raise one other issue also, going back to the point that
some of us who were in local government before 1974—
Chairman: Great days!
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