Contexts to safeguarding older people from abuse
Contexts to safeguarding older people from abuse
Abstract and Keywords
This chapter sets out the book’s themes and origins. The book originated in the author’s work on a number of independent case reviews where an older person had suffered abuse. These, variously, indicated the influence wider social and political contexts had on the actions and decisions professionals made when safeguarding an older person from abuse. The chapter outlines the book’s call for ‘right action’ – theory-informed, critically aware, ethically-driven policy and practice – in the care, support and safeguarding of older people from abuse. In considering ‘failures’, where older people have suffered serious abuse, the chapter trails the book’s case for a rigorous, lucid and critical use of theoretical concepts, theory-informed research and learning in adult safeguarding policy and practice.
Mrs R’s family were concerned that she would not receive food and drink while in Southampton University Hospitals NHS Trust unless they helped her to eat and drink.
When Mrs H was transferred from Heart of England NHS Foundation Trust to a care home, she arrived bruised, soaked in urine, dishevelled and wearing someone else’s clothes.
The care and treatment that Surrey and Borders Partnership NHS Foundation Trust gave Mr L contributed to a loss of his dignity and compromised his ability to survive pneumonia.
These are three of the ten cases reported by the Parliamentary and Health Service Ombudsman for England on 14 February 2011. Nine of the ten people discussed in the Ombudsman’s report – titled Care and Compassion? – died during, or shortly after, the events considered occurred. The Ombudsman observed that ‘the circumstances of their deaths have added to the distress of their families and friends, many of whom continue to live with anger and regret’ (Parliamentary and Health Service Ombudsman, 2011, p 8).
This book is about safeguarding older people from abuse. Notwithstanding reference to the Parliamentary and Health Service Ombudsman cases referred to above, it is not intended as a hand-wringing, head-shaking ‘where did we go wrong’ account of care and support to older people, nor as a hatchet job on social care or publicly funded, free-at-the-point-of-delivery, healthcare or on those who deliver it to citizens irrespective of their means. Older people may be abused and mistreated in community-based, domestic settings by people they know and would otherwise trust, for example, paid carers, family members, friends and neighbours.
A core intention of the book is to identify and critically appraise the influence of contextual factors on decision-making by those involved in adult safeguarding, including social workers, and their NHS (National Health Service) and police partners. The book’s purpose is (p.2) three-fold. First, it sets out to understand, at a deeper, theoretical level than the transient reporting of scandals of mistreatment, with their attendant action plans and the familiar ‘learning of lessons’ suggests, why otherwise decent, initially well-motivated, highly trained professionals, such as nurses, social workers and doctors, and other practitioners or paid carers, can appear blind to poor and abusive care of older people or, worse, why they may apparently perpetrate egregiously bad ‘care’.
Second, the book aims to examine contexts of care and support to older people who are abused. That abuse and mistreatment happens in families and domestic dwellings, as well as in private, public or not-for-profit institutional care. If there is one message this book wants to convey, it is that we ignore the nature and the impact of those contexts of care at our peril. Except that ‘peril’ will not generally be visited on the ‘aging enterprise’ (Estes, 1979) that constitutes adult safeguarding systems and processes particularly, or the care and support to older people more generally. Rather it is the older people at risk of abuse who suffer the threat, danger and risk that this ‘blindness to context’ poses. If action plans and ‘lesson-learning’ were enough to stem the abuse and poor care of older people, they might have prevented systemic failures (with devastating outcomes for younger as well as older patients) such as those reported in Mid Staffordshire NHS Foundation Trust, England (Francis Report, 2013a), or they might have better succeeded in raising public awareness about elder abuse.
Third, this book is a call for ‘right action’ in safeguarding older people from mistreatment. ‘Right action’ is used here to mean the construction and maintenance of theory-hungry, ethically, compassionately and competently delivered care and support to older people who have been, or are at risk of being, abused. It is a call for a clear-headed, compassionate and dispassionate politics, policy and practice in safeguarding older people from abuse. It is an appeal, not for vacuous policy sloganising about ‘putting people first’ or ‘caring for our future’, the customary chanting of which can become an end in itself, but for committed professional and political intention, with systems to support it that can critically interrogate contexts of health and care, generally, and safeguard older people from abuse, in particular. That call is not for more standards, targets, or witch-hunts of often hapless front-line health and social care staff, accompanied by their ritual sheep-dipping through hastily constructed re-training programmes if things have gone wrong, but for a policy, practice and political awakening to the sound-surround system, as it were, of elder abuse. That surround includes ageism, a socially and culturally created and sustained fear and loathing of dependency, frailty and ‘oldness’, a public, political policy (p.3) obsession with targets, service-system fragmentation and profit in the UK generally, and in England particularly. A key message of the book is that more numerical targets in health and social care will result in more box-ticking bureaucracy that may or may not hit the hallowed targets, but may well miss the point. The point is the older citizen at risk of abuse. The point is the priority their health and well-being is afforded.
Although this is not primarily a theoretical book, nor one directed at one particular profession or discipline, it makes the case for a rigorous, lucid and critical use of theoretical concepts, theory-informed research and learning in adult safeguarding policy and practice development. Social work and social policy, for example, have not shared the closest of relationships at the ground level of social services agencies. Still less, understanding the realities, the constraints and dilemmas of policy implementation by human services workers has too often been carried out in the breach – think of 8-year-old Victoria Climbié (who died in London in 2000 at the hands of her great aunt and her boyfriend, and who was known to two police child-protection teams, two housing authorities, the NHS, four social services departments and a leading child protection charity) – not in the routine, the mundane, the everyday stuff of front-line healthcare, social care, social work, or safeguarding practice more widely.
This book argues that any professional or practitioner distaste for ‘theory’ as an ivory-tower activity endured for the sake of meeting qualification and subsequent continuing professional development (CPD) requirements, would be as ill-considered as any academic view of ‘practice’ solely as a source of data, ‘partnerships’ or ‘networks’ necessary for research grant capture. Both are instrumental views of the ‘other’. Both are means to an end but that end may not be the abused older person. The case for bringing findings of research into practice and policy-making, and for driving research endeavour, policy development and health and social care practice by the reality of elder abuse, and the centrality of the experience of the older person, is argued here to be an end in itself. Here, the process is the goal. In Buddhist practice, for example, ‘right action’ forms part of a practical guideline for ethical behaviour and development of compassion and kindness. In this frame, ‘right action’ involves honesty, kind and compassionate behaviour, and an abstinence from causing harm to sentient beings. Used thus, ‘right action’ – ethically driven policy and practice – is a goal this book seeks to present, for policy-makers, academics and practitioners.
(p.4) Origins of the book
This book derived directly from research, policy and practice in safeguarding older people from abuse, and particularly from case reviews this author had undertaken over a number of years, commissioned by various UK statutory bodies, where adults at risk, including many older people, came to harm. As is usual, the findings and recommendations of these reviews remain confidential to the agencies and organisations that commissioned them. Nonetheless, these cases and the circumstances they uniquely and collectively presented, raised three particularly recurrent themes (Ash, 2011a).
First, in cases where the adult at risk (who may have been a person with learning disabilities or mental ill-health problems, or an older person) had come to harm, the potential for harm, or ‘risk factors’ to use the ubiquitous professional vernacular, were known about before the events under investigation occurred. In other words, these cases had a hinterland which, with increasing predictability, the retrospective reviews of what went wrong cast light on. The professionals and paid workers involved in health and care delivery of one type or another usually had available to them information that could have alerted them to harm, had they followed the ‘trail’, for example, joining up their information with others’ information and raising a safeguarding alert. But this did not always happen. Professionals were reluctant to raise concerns about the quality and the care offered by other paid professionals to the adult at risk. They would tick their own box, for example, make a phone call (and record it – they understood the professional risk if the next recording audit found they had not) to pass on information, but either did not follow it up, or showed a reluctance to put the information in words that conveyed concern or challenge of other professionals. The anodyne passing of information was stripped of its core purpose, and devoid of any challenge to poor or failing support to the adult at risk. But that box ticked, the paid worker or professional had to turn to deal with the myriad other demands they faced that day.
Second, in some of these cases that had gone wrong, there had been a professional reluctance to use adult safeguarding policy. If used, adult protection (or safeguarding) procedures provide a multi-agency framework to bring together social services, the police, NHS and other partners. But in some cases under review, often those where mental health and NHS staff were the key professionals involved, this had not always happened.
A third theme from these reviews was a professional reluctance explicitly to draw on, or else an ignorance of, well-established findings (p.5) of research on, say, family violence or elder abuse, or any critical interrogation of the validity of common-sense understandings of those risk factors. Professional understandings of the stresses of care-giving and care-receiving, of the nature, exercise and abuse of paternal, parental or filial power in conflicted family relationships, are part of the bread-and-butter basics of professional health, medical and social care practice. They are omnipresent, empirically supported social phenomena. Nonetheless, in some cases these understandings were sidelined to adult protection exigencies of holding meetings within a set number of hours or days. Professional skills of intervention in the conflicted, abusive dynamics of some family situations seemed not to be drawn upon, if indeed any longer practised, in the multi-agency world of adult safeguarding.
Further, the outcomes of inquiries, case reviews, routine or exceptional inspection reports on health and social care services would, inevitably, generate one or more action plans, allowing items to be ticked off, training days to be delivered, reports made back to a regulator and elected local politicians, and for the box-ticking show to go on. It is, obviously, entirely proper that those charged with statutory responsibilities have sound data that tell them, for example, how many social services or NHS staff have completed awareness training of the signs of elder abuse. But these cases that were reviewed often highlighted behaviours, practices and ways of thinking, from senior managers down to front-line staff that, for instance, viewed delivery of thousands of hours of awareness training as an end in itself. There was less critical questioning about ‘so what?’ Were older people or other adults at risk safer? What research-informed content was delivered to these people? What happens to paid staff when they go back to work? How do the systems, structures and processes of their work, their day-to-day practice, drive their understanding and recognition of elder abuse, and what should they do if they are concerned? Does that context itself support right action and sound practice in the messy, predictably unpredictable worlds of human beings using human services?
These three themes were the impetus behind research that set out to examine that context of care, and the influences on professional decision-making in safeguarding older people from abuse. That research is reported in Chapters Six and Seven; aspects of it have been reported in Ash (2010) and Ash (2013). Its findings, if nothing else, highlighted some outcomes of a policy and practice blindness to the influences on professional decision-making that lie at the heart of adult safeguarding decisions. This book attempts to set out elements of that context. This context includes ageism, and a social and cultural aversion to getting (p.6) and being old; fragmented, under-resourced health and care services and systems that some older people have to rely on; a policy-making, public and political overestimation of what regulation and compliance-driven activity can achieve in adult safeguarding, and an ignorance of what it cannot; an uncritical policy obsession, particularly in England, with chasing of numerical targets and cost-shunting between health and social care; and a naïve worship of the gods of ‘choice’, ‘control’ and ‘independence’, devoid of any deeper interrogation as to their meaning and implication in the care and safeguarding of older people. The findings of the research reported in Chapters Six and Seven highlight some of the unintended consequences of ‘doing things right’ – for example, uncritically embracing an older person’s ‘right to make bad choices’ as upholding their self-determination – rather than ‘doing the right thing’, for example, working with the older person to understand options, risk and protection, and providing support and protection while they are doing this. Abused, battered, denigrated beings may be in need of a bit of help and support to remember what choice and control are. They may need a while, safe and free from harm, and in loving and compassionate circumstances, to get to grips with empowerment.
Structure of the book
The book as a whole is a challenge to policy-makers, academics, teachers, managers, professionals and practitioners to engage in critical, theory-informed work in safeguarding older people from mistreatment. Chapter Two makes the case for this in policy and practice to safeguard older people from abuse. Chapter Three considers the process and outcomes of ‘naming of elder abuse’ in the UK and internationally. Research on the prevalence and nature of elder abuse is discussed and, in particular, the incidence and response to domestic violence in older age. That discussion is set within a context of ageism and reference to the fundamental and irreducible human rights of older people.
Chapter Four discusses the development of policy and practice in adult protection and the safeguarding of older people from abuse against the backdrop of personalisation and individualisation of care. This chapter considers legal and policy development in adult safeguarding across the UK, and the differential foci of the development of personalisation across the UK’s four nations. It discusses potential impacts of this policy trajectory on safeguarding older people, and other adults at risk, from abuse.
Chapter Five situates discussion about action to protect an older person from abuse within a theoretical frame. In particular, this chapter (p.7) considers Michael Lipsky’s (1980) work on street-level bureaucracy, and discusses the nature and extent of the exercise of discretion by public servants using policy to safeguard older people from abuse. Chapter Five considers the significance of context in understanding both the action adult safeguarding professionals may take when dealing with potential abuse of an older person, and the constraints and realities they grapple with when weighing up what to do. In essence, the chapter sets out the conceptual scaffolding for the research reported in the following two chapters.
Chapters Six and Seven describe the findings of research carried out in a social services department in Wales that aimed to identify the constraints and dilemmas social workers and their managers faced when using adult safeguarding policy to protect an older person from abuse. Among the findings of this research was the reticence of social workers and other professionals to challenge known poor care to older people. This leads, in Chapter Eight, to a wider discussion about cultures and contexts of complicity, and the features and factors implicated in this apparent silence and tacit tolerance. Chapter Nine returns to the theme running throughout the book, that of the significance of contexts, whether social, political or cultural, on the quality of care and support older people might receive and on safeguarding elders from abuse particularly. A case is made for the development of ethically driven systems, structures and contexts that support work to safeguard older people from abuse. Without ethically driven public policy and a supportive state that embraces, rather than commodifies or out-sources ethical action, system failures in adult safeguarding will continue to be met with increased regulation, standards and restructuring that may hit targets but, again, are likely to miss the point – the older person at risk of abuse.
A note on the terms used in this book
The book mostly, but not exclusively, considers safeguarding older people from abuse in the UK. Health and social care have been devolved areas of government and administration in the UK since 1999, so legislation, policy and terminology have increasingly diverged in the four nations.
‘Social services’: Adult and children’s services are not separate entities in Wales or Scotland as they are in England. ‘Social services’ is a term used in Wales and Scotland. ‘Social care’ has come to replace it in England to describe provision to adults rather than children, and ‘adult services’ arrange delivery of this. In Scotland, ‘social service (p.8) workers’ includes people working in social work and social care, such as care homes, community-based services to adults and children and nurseries or after-school clubs.
This book uses the term ‘social services’ in the context of safeguarding older people from abuse. ‘Social services’ is also used to denote local authority (local council) engagement in safeguarding older people from abuse; social services have a lead role in co-ordinating adult protection intervention under the law in Scotland, and national policy in England, Northern Ireland and Wales.
‘Adult protection’ and ‘adult safeguarding’: the book uses both terms, noting the differentiation made by the Law Commission (2011), which is discussed in Chapter Four. Both terms are used to describe action by statutory, not-for-profit and private agencies to intervene to prevent or stop abuse of an older person. From the point of view of the abused older person, or their family, friends or loved ones concerned to stop abusive actions or behaviour, professional semantics as to whether this activity requires ‘protection’ or ‘safeguarding’ are unlikely to be their primary concern.
‘Elders’ and ‘older people’ are used synonymously, to reflect the language adopted in international campaigning against elder abuse, and that used by international scholars whose work is discussed. (There, ‘elder’ is used as a courtesy to those writers). While ‘elder’ may not be a term most older people I have talked and worked with use, the book has tried to avoid unnecessary distractions: the issue is understanding and preventing the abuse and mistreatment of older people, and it is to that end the book is directed.