Coming To Terms With Abuse Of Older & Disabled People

Society still needs to come to terms with abuse of older and disabled people. Do we need a shake-up of complaints and investigation? Chris Mahony reports

Child abuse was once Britain’s guilty secret. It may have taken 25 years of introspection, but we have broadly come to acknowledge its nasty reality. Now there is a growing sense that the abuse of vulnerable adults occupies a similar, half-concealed place in our national self-image.

The evidence is starting to mount. Research funded jointly by the Department of Health and the charity Comic Relief, and published in June, estimated that 342,000 people aged 66 or over were last year victims of abuse in their own homes, ranging from financial fraud to emotional abuse and even assault. The number of victims is more than the population of Leicester and equates to 4%, or one in 25, of all older people living in the community.

The research, carried out over two years by the National Centre for Social Research and King’s College, London, was based on interviews with 2,000 people. It excluded those with dementia and those living in care homes, lending credence to a report in the British Medical Journal as long ago as 1992 which estimated that 500,000 older people were suffering abuse at any one time. Yet in the intervening 15 years, notwithstanding the efforts of campaign groups such as Action on Elder Abuse, which made the case for the new research, the issue has remained relatively low-profile and low-priority.

One aspect of this has been the emphasis – or lack of emphasis – placed on complaints of abuse of older and disabled people. In this context, the health secretary, Alan Johnson, may have been interpreted as donning a hair shirt at last month’s Labour party conference when, speaking about yet another shake-up of regulation in health and social care, he reassured delegates: “The new regulator will have a much stronger focus on safety and quality across all health and adult social care services.”

Elaborating on the minister’s words, a Department of Health spokeswoman says: “There has been a lot of talk about this over the last 10 or 20 years and he was acknowledging that this [emphasis on safety] has not always been done. There has not always been the focus. Now we want some action, not just words.”

No doubt with an eye on this and on the regulatory shake-up that will form part of a health and social care bill, the Association of Directors of Adult Social Services (Adass) has issued its own, seven-point manifesto on the issue of abuse of vulnerable adults (see box, left). One of the points is a call for social workers to have a right of entry into people’s homes, in association with the police, to investigate suspected adult abuse. Another is a requirement on the new regulator to work with local authorities in “identifying and responding to instances of potential abuse and neglect”.

Existing protocols

The existing Commission for Social Care Inspection (CSCI) professes to be mystified by the need for such a requirement, pointing to existing protocols including the Protection of Vulnerable Adults (Pova) scheme. But the Healthcare Commission, with which the CSCI will merge, does acknowledge the need for some review of powers and duties. A spokesman says: “We are truly concerned with the scale of abuse we found in our investigations at NHS trusts in Cornwall and Sutton and Merton. In these cases the safeguarding systems were shown to be inadequate, and there was a poor awareness among NHS organisations as to what their responsibilities were.

“It may be that further examination of the safeguarding systems for adults needs to be undertaken to ensure that they are fit for their intended purpose.”

Adass is anxious to avoid the impression that it is seeking to question the inspectorate’s achievements. Anne Williams, the association’s president, says: “I think the regulatory regime has offered a lot in terms of driving up standards, but there really is still a problem. It is about the framework – whose responsibilities are what? We should apply a lot of the lessons we have learned about child protection and children’s services over the last 30 years. It is not about any one agency failing.”

Paul Snell, chief inspector at the CSCI, agrees that abuse of vulnerable adults is not yet viewed with “the same sense of outrage as the abuse of children”, but says this is starting to change. “Adult services can take powerful messages from the experience of agencies seeking to safeguard children, including the importance of multi-agency working, joint training, the raising of public awareness and the sharing of information.”

Snell argues that protocols developed among the CSCI, Adass and the Association of Chief Police Officers already clarify the role of the key agencies. Allegations of abuse or other service failings are routinely shared between councils and the inspectorate, he says. Councils have the lead role in completing such investigations, but sometimes the inspectorate may respond by bringing forward an inspection of a service.

David Congdon, head of campaigns and policy at learning disabilities charity Mencap, is more concerned that regulatory reform will mean that “good” homes will be checked only every two or three years. “It only takes a manager to change and a good home can change very quickly,” he warns.

Congdon thinks it unlikely, however, that any inspectorate will be able to make a massive difference in the risk of abuse going undetected in care home settings. “You can have inspections, visits in the middle of the night, but you need a relative or an advocate to know the person and spot changes,” he says. “We have heard about tightening regulation for 20 years. I wonder what substantial change there ever is, apart from changing the umbrella. There has always been this awful tension, especially when social services were inspecting homes: if we use draconian powers to shut it down, what happens then? The suspicion is they make checks to look for missing lightbulbs rather than abuse.”

On the argument for strengthened powers for social workers in cases of suspected abuse in domestic settings, Dwayne Johnson, Adass lead on adult protection, is clear. “There is a strong message emerging from directors of social services that we need some sort of legislation,” he says. “We want to unequivocally call for new legislation rather than for a review of No Secrets [the 2000 guidance on multi-agency working in this area]. Guidance always helps, but we want more powers coupled with that, partly because of the personalisation agenda.”

Cash budgets

It is this agenda, which will see many more clients given cash or paper budgets to purchase and arrange their own care and support services, which is the declared impetus for the Adass plan. And there is agreement that it does indeed pose a risk.

Congdon says: “I support things like individual budgets and personalised support, but there are questions that need to be answered. Do you have detecting abuse as part of the regulator’s duty or part of the social services director’s duty of care? You would have to try to assess the vulnerability of the individual and their isolation.

“When money is short, there will be a temptation to pare down the level of other support from the local authority for the individual. What checks will an employment agency do when it is providing people who will deliver care in someone’s own home behind closed doors?”

The General Social Care Council’s professional register will be open to domiciliary care staff from next year, but it is still discussing with the Department of Health if and when registration will be compulsory. Meanwhile a vigorous debate is raging over whether users of services, given freedom to arrange their own support, should in any case be required to use only registered and vetted care workers and personal assistants.

Nick Johnson, chief executive of the Social Care Association, believes there is no need for legislation along the lines proposed by Adass. But he agrees that the new regulator will be working in a very different world.

“I am a massive supporter of individual budgets etc, but people will be vulnerable to family, to carers, to people who might be their employees,” Johnson says. “It is predicted that half the social care budget might be spent in that way in a decade: how many people would we need to monitor that those payments, and the people receiving them, are not abused?”

ADASS manifesto

Powers sought by social care directors to investigate adult abuse:

1) Legal right for social workers to enter domestic properties where it is reasonably suspected a vulnerable adult is being abused

2) Duty to share information among the statutory agencies and regulators

3) Duty on all public authorities with responsibility for the wellbeing of vulnerable adults to cooperate with social care directors

4) Clarification of the duties and powers of other local authority departments and health agencies across geographical organisational boundaries

5) Duty to act or investigate complaints

6) Duty on regulatory bodies to work in partnership with local authorities in identifying and responding to instances of potential abuse and neglect

7) Clarity of terminology to remove “inconsistency” in language over what defines abuse.