Examination of Witnesses (Questions 46-59)
MR FRANK
URSELL, MS
SUE FIENNES,
MR BILL
MCMCCLIMONT
AND MRS
NADRA AHMED
11 DECEMBER 2003
Q46 Chairman: Can I welcome our second
group of witnesses and again express the Committee's thanks for
your co-operation with this inquiry, particularly with the written
submissions you have given us which have been very useful and
helpful. Can I say again this is a fairly brief session so I appeal
for short answers to what will be short questions, hopefully,
although I cannot guarantee it. Can I ask each of the witnesses
to briefly introduces themselves.
Mrs Ahmed: Nadra Ahmed, Chairman
of National Care Homes Association which represents the residential
and domiciliary care sector.
Mr Ursell: I am Frank Ursell,
the Chief Executive of the Registered Nursing Home Association.
We were formed 35 years ago. We focus on that part of the sector
which deals with what were nursing homes and they are now called
care homes providing nursing. I am also the owner of a nursing
home and have been since 1983.
Mr McClimont: Bill McClimont,
I am the Chair of the UK Home Care Association, an organisation
which is campaigning for improved developed standards in domiciliary
care.
Ms Fiennes: I am Sue Fiennes and
I am Director of Social Care and Strategic Housing in Herefordshire.
I am the lead director of social services nationally on adult
protection and that is partly because I set up the first adult
protection committee in Sheffield some years ago. I was on the
No Secrets Group to establish that particular guidance. I am very
concerned and interested, also, to see progress in this area.
I think enthusiasm and motivation are added to my background.
Q47 Mr Burns: Can we begin this session
as we did the previous session by just getting your view and perspective
on whether you believe it makes sense to talk about elder abuse
as distinct from the abuse of vulnerable adults?
Mrs Ahmed: I think for me vulnerable
people are vulnerable people and the distinction, although it
has been drawn, is that older people are different but I think
vulnerable people are vulnerable people at whatever age they are.
I think the needs of older people may be slightly different and,
therefore, there is a case for it to have some further dimensions
to it because of the protection issues which will be related to
their particular medical needs. That goes across the board so
I am not really convinced that it needs to be treated, especially
as inspectors throughout the country are inspecting the services.
Mr Ursell: I think we have the
same sort of attitude. There is a series of dichotomies. Does
it really matter that you differentiate between abuse on older
people as opposed to abuse on vulnerable adults if the abuse is
the same? What does matter, of course, within those dichotomies
is how you deal with it. If we create a difference and we deal
with it in a different matter then it is important and that is
where it focuses. If we still do them in the same way then, of
course, it will minimise the need for any difference. The fundamental
issue is that abuse should not be allowed to happen, whatever
it is.
Mr McClimont: Yes, I would support
that. The position is that we have created a difference between
older people and younger adults in a whole range of ways, not
least, as was pointed out in the last session, in the attitude
that society has towards older people that they are in some way
expendable or less important than others. While it is true that
everybody should be entitled to protection from abuse, equally
we have set ourselves a societal position where that is not true
and focus on the area where it is most in need, which is with
elderly people, is perfectly proper.
Ms Fiennes: I think that it is
important to retain a national framework in relation to the protection
of vulnerable adults. We had a long debate on this in the No Secrets
development, as you can imagine, both on definition and in terms
of being comprehensive across the vulnerable adults area. I do
think some of the earlier witnesses were right though in saying
that people's vulnerability is different at different stages of
their life and, therefore, how you respond to elder abuse is going
to be different from how you might respond individually or service
wise to younger adults. I would strongly in terms of legislation
and further guidance and in the developments that we need in this
area want to argue for an all embracing vulnerable adults position
because that is the widest protection that we can offer in the
legislative and policy framework.
Q48 Mr Burns: Getting on to the second
question I asked the earlier group as well, do you think the wide
range of situations covered by the term "elder abuse"
limits its value? For example, is there not a vast difference
between deliberate physical abuse and inadvertent neglect or discrimination?
Mrs Ahmed: I think systematic
abuse and neglect are two very different things, that is for sure,
but abuse is abuse. We have got to get the definition right I
think that is non negotiable. It is a no tolerance policy which
most associations representing providers would like to see. I
do not think it matters what form of abuse we are talking about.
Neglect can be just as detrimental as we heard. If it is systematic
and long term, it can have a more devastating effect than other
forms of abuse.
Mr Ursell: I have one or two issues
in answer to this question. Firstly why should we have a differential
and if it is simply to determine that this is (a) or (b) then
there is no point in it. If we look further than that, if we look
at what we can do about these things, one of our concerns—and
it is in our submission—is that with a very wide ranging
definition of abuse as soon as you use the word abuse you trigger
the defence mechanisms. Those things which are poor practice—knocking
on doors and things like that—will come in that technical
definition. If we start calling this abuse then we get a defence
mechanism, we do not want a defence mechanism. What we want is
we want to put them right, we want to be able to stop, whatever
it is called, whether it is poor practice or abuse, we want to
stop it quickly. I think from that context it is important that
we do differentiate between those things. In my previous life
as a policeman we always used to have to find a guilty mind then
a guilty act, actus reus and mens rea. If we can
find the bits without the mens rea, without the guilty
minds and try and treat these as poor practice so we can deal
with them quicker and more effectively then there is a value in
having a differentiation between the two.
Q49 Chairman: Can I ask you, you would
raise questions about some of the other witnesses who include
poor practice within the abuse framework, you would not be happy
with that approach?
Mr Ursell: It is not that I would
not be happy, it is just that I would be happier if we could have
some differentiation between the two so we can get a more effective
and quicker response to it. What we do not want is a long drawn
out inquiry into something that really should have a short remedy.
Mr McClimont: I think I take the
point there but I would draw the parallel that has been drawn
with racism that you have both individual acts of intolerance
and there is clearly serious abuse and also you have institutional
issues. The response to it, what we do about it may be different.
The expression of blame that you might attach to it might be different
but you have to deal with both sets and whether you give it two
names, abuse or sub-abuse or whatever, it is intolerable and it
has to be dealt with.
Ms Fiennes: Certainly I would
go along with keeping abuse as a term which actually identifies
that all the activity and behaviour described. Practice—good,
bad or indifferent—is all encompassing . There must be a
zero tolerated position. I do think that it is very difficult,
as has been found in child protection, to assess neglect over
a period of time, however I would say that training of care staff
and the general public in terms of public awareness of these issues,
using the term abuse does bring it to the attention of everybody.
I was involved by example in an investigation into neglect and
other forms of abuse in a care home and that demonstrated to us
when we followed up and debriefed that the staff group concerned
were not aware, they were simply not aware, that some of the things
they did by routine and by rote, were (a) unacceptable, (b) poor
practice and (c) could be defined as abuse. Once they did realise
that, you had to do quite a lot of support to get them into a
position where they could go out and practice their care support
again. The indicator there was the fact that it was taken seriously
by the people concerned and the fact that they were confronted
with it.
Q50 Chairman: Can I pick up a point we
made in the first session where we were asking about how many
people we estimate are currently elderly people subject to abuse.
There was a clear consensus which you would have heard in the
first session that at least half a million elderly people are
subject to abuse. I think that is a staggering figure, a city
the size of Leeds roughly in terms of population is being abused.
Do you accept the accuracy of that assessment of the numbers or
dispute it? Tessa Harding made the suggestion that the figure
is probably significantly under-reported. Can I ask our colleagues
from the care home nursing sector, is that your view of the extent
of the problem or would you challenge that figure?
Mrs Ahmed: I think the only challenge
that I ever raised about this in public forums, with Gary as well,
is was it the number of alerts or was it the actual number which
were proven, that was the issue for me which I was not quite clear
about. I think I got a definitive response to that. Those proven
cases, then obviously the alerts have been raised, they have been
fully investigated. When I lived in the South East—and I
included in my own submission—the proven cases were much
less and the alerts raised were much greater because of the public
awareness.
Q51 Chairman: What you are saying is
you would want far more detail as to how the 500,000 figure has
been arrived at?
Mrs Ahmed: I would like to see
a bit more information about it. I am not disputing the figure
because if it is there in the public arena I presume somebody
has done the research and work on it. I just have not seen a definitive
statement.
Q52 Chairman: The second question I asked
was how do we do more firm, reliable research on the extent of
the abuse and I wonder what your thoughts would be, in view of
your answer, as to how we might ensure that we have reliable information
on the extent of the problem. What should we do about arriving
at an accurate figure?
Mrs Ahmed: The important thing
is that we have the No Secrets document and we have talked about
local authorities implementing in various ways. I have seen some
very good practice in local authority where I can and find statistics
out. I have graphs that show me where the alerts were. If that
was something that could be replicated throughout the country
as a central point, I think this has to have a national lead.
You need to have some kind of national panel which would then
look at the collated information and consider the issues that
are being outlined by it. Once that is done and the sector is
involved, the provider sector becomes part of that message and
we can move forward. All the time these kinds of statistics are
collated and the private sector perhaps does not have or the independent
sector does not have the information to hand, we are not able
to move with it to see how we can work together to resolve this.
Q53 Chairman: Mr Ursell, what are your
views on the figures given to the Committee?
Mr Ursell: It was my perception
from what Tessa Harding said in reply to your question that she
was talking about abuse generally, across the whole of the community.
Q54 Chairman: The evidence I quoted was
a study specifically related to elder abuse which dates from 1992,
stating that the probable figure is five to nine per cent of the
elderly population. Several of our witnesses have said that, even
at a conservative estimate, this works out at over half a million
people aged over 65 years being abused. Looking at the evidence
we have, a substantial proportion of the half million people who
have been abused would appear to be being abused within the care
and nursing home sector, within institutional forms of care. Do
you dispute this?
Mr Ursell: The problem always
is lack of figures. I was involved in some work with the BBC when
they did a series of vignettes a few years ago. They quoted that
about six per cent of all abuse occurred in the collective, residential
and nursing care sector. Gary Fitzgerald also said that two thirds
of all abuse occurs at home or in the home environment so it is
very difficult with the lack of evidence to deal with it. We are
not here to defend the fact that abuse happens. If it does happen,
we want to try and do something about it.
Q55 Chairman: What would your thoughts
be about establishing more accurate systems for information?
Mr Ursell: It is very difficult.
The NHS are now recording near misses in relation to some aspects
of their reporting and maybe that is the way forward. We have
a requirement within the National Care Standards Commission, regulation
37, that requires all care homes to report certain adverse incidents
to the National Care Standards Commission. It is a simple job.
Press the button and pull up these numbers, but I do not know
that they would include the near misses. The difficulty we all
face is trying to find a way of measuring those near misses and
determining what is a near miss. What is an abuse? What is an
unnecessarily loud voice once in a year? Until we can measure
these things, I do not think we can get a full feeling for the
breadth of the problem at all.
Q56 Chairman: Do any of the other witnesses
have any thoughts on the figures and how we might more reliable
figures?
Ms Fiennes: I think there is probably,
if not definitely, under-reporting.
Q57 Chairman: Do you accept the 500,000?
Ms Fiennes: Yes, easily.
Q58 Chairman: In your view, from the
ADSS, that is an under-reported figure?
Ms Fiennes: Yes. Mandatory reporting,
in whatever sector we are talking about, through the monitoring
of adult protection committees and the regulatory bodies and functions,
would give us a better picture. However, I would not want to get
into a position where research was stopped because we do not yet
know enough to make the case for it, because that just seems illogical
to me. I do wonder whether the Social Care Institute for Excellence
and the Health Institute for Excellence have a joint role here
in trying to establish what might be the underlying best practice
and the possibilities of research in this area alongside some
national leaders in terms of academic research in this area. There
is some potential there for doing more comprehensive research
in this area, without having to make the case that this is a big
problem and we know what it is.
Mr McClimont: I think it very
much is under-reporting. We should remember that in relation to
care something like five to six or maybe eight times as much care
is provided informally as is provided formally. The chances are,
even if you are talking only of care, it is an under-reporting
and at the moment we will have a disproportionate, apparent over-reporting
in those area where there is good reporting procedure—that
is to say, the regulated area. The introduction of regulation
is likely to increase the reporting and we are going to see a
higher number, I hope, in domiciliary care with the advent of
regulation. It is quite interesting to see that in child care
we are now recognising that this is a cross-disciplinary issue.
It is not just the care services and the health services; there
is also the need for the involvement of health and a wide range
of other people who come into touch with those who might be abused,
who are required to report and bring their actions to bear into
the one arena. As yet, I have heard no proposals that the same
kind of approach should be taken with elder abuse and with adult
abuse, and I think it should.
Q59 Chairman: One particular point that
was raised in the context of our previous session and accurate
figures related to the certification of death within care and
nursing homes. You heard the witnesses raise some concerns about
the current procedures. I have had evidence given to me that there
are certain worries about the way this process works in terms
of the accuracy of cause of death. Do you have any views on that
area, because obviously your members will be directly involved.
Mr Ursell: There are two points
I would like to make in relation to that. Firstly, over the last
two or three years, there has been quite a debate about the role
of GPs in certifying death to the extent that the BMA produced
quite a comprehensive set of notes to say that they had no responsibility
to certify death in care homes at all. I do not think that is
helpful because, if nothing else, the GP going along at whatever
time of the day or night to certify a death is in a position to
observe anything that might be untoward; whereas if it is left
until much later in a more clinical situation, perhaps in a funeral
director's premises, that evidence is lost. Secondly, the Registered
Nursing Home Association is often called upon by other organisations
for assistance. In the past, I have had calls from the local police
to say that the Coroner has identified two or three deaths in
a row in a particular home. We have also been involved in the
Shipman inquiry. As a consequence of the Shipman inquiry, ACPO,
the Association of Chief Police Officers, have a working group
looking at all the aspects of that. Again, we have been involved
in trying to assist in bringing that together. With my policeman
background again, it is the opportunity of immediacy which is
important and I believe that removing the role of the GP to certify
death is a retrograde step in this aspect.
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