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Elder Abuse

Volume 459: debated on Friday 20 April 2007

Motion made, and Question proposed, That this House do now adjourn.—[Mr. Cawsey.]

2.31 pm

Order. I have to say to the hon. Gentleman that he is extremely fortunate. Because of where he was sitting I might have thought that he was not in the Chamber.

I apologise for my laxness in not being in the right place at the right time. I am grateful to you, Mr. Deputy Speaker, for giving me the opportunity to speak on this subject.

I have come to the House in the past to express concerns about elder abuse, and I hope not to have to do so in future. I start by acknowledging that things are being done by the Government, the Commission for Social Care Inspection and other agencies that mark progress since I first raised these matters in the House in the early part of the century, in 2001-02. However, I want to deal with a number of issues that require more response, more action and more initiative from the Government. I look forward to hearing the Minister’s response.

I want to deal with two recurring examples of abuse of our elderly citizens. Indeed, they are recurring indictments of the failure fully to realise the nature and scale of the problem and what needs to be done to tackle it. The first is the appalling practice of elderly people in care homes being subject to chemical management by over-medication and inappropriate medication. The second is the continued failure of the “No Secrets” guidance to deliver the professional and compassionate protection that vulnerable and elderly people deserve.

Elder abuse is a widespread, growing and historically under-acknowledged problem. In many ways it is still a taboo subject. The most up-to-date research is from 1995, and I openly acknowledge that during the Health Committee’s inquiry the 1995 estimate of the number of older people being abused was not accepted by the Government as an indicator of the position today. The problem is that two or three years after the Health Committee published its report we do not have an up-to-date figure. The 1995 data given to the Committee during its inquiry indicate that at any one time 500,000 older people are being abused. That is without accounting for the abuse of people in care homes. In 2004, the Community District Nursing Association revealed that 88 per cent. of district nurses reported seeing cases of elder abuse. That cannot continue.

There is some evidence, from research by King’s College London, that public awareness of the problem is beginning to grow, thanks to campaigns such as those run by Help the Aged and Action on Elder Abuse. Some 55 per cent. of respondents interviewed felt that there was a great deal of neglect and mistreatment of older people in Britain, while 25 per cent. knew an older person whom they believed had been subject to neglect and mistreatment, with half saying that it had occurred either in care homes or hospitals. Lack of personal care was felt to be the greatest failing, and one in 10 respondents cited mismanagement of medicine as a core problem. Despite the growing public awareness, a lot still needs to be done to meet the challenge.

I come now to the question of over-medication and inappropriate medication. That is sometimes described as the “chemical cosh”, although that might or might not be appropriate. I have spoken on past occasions about the dangers of anti-psychotic drugs, their overuse in care homes, the tendency for care homes to use them to sedate patients to the extent that they lose mobility and mental capacity, the way in which the drugs strip patients of their dignity and autonomy, and the Government’s failure to address such abuse.

In 2001, I published a report entitled “Keep taking the medicine.” It detailed the worrying rise in the prescription of those drugs to people in care and highlighted the evidence that thousands of elderly people in nursing homes were being kept in a state of sedation for no medical reason. I updated the report in 2003, finding that little had changed and that action was still required. A third report in 2006 revealed that more than 25,000 people in care homes could be the victims of over-medication and inappropriate medication.

The evidence is clear: medicine is being given incorrectly; adverse reactions to the drugs are under-recorded; and better alternatives are available. The Minister may therefore understand the disappointment and concern that I felt last month when I read a report from the Alzheimer’s Research Trust confirming that anti-psychotic drugs are still being used to manage dementia patients, to the long-term detriment of their health, well-being and dignity.

Those drugs are not licensed for the treatment of dementia, yet they are prescribed to as many as 45 per cent. of sufferers in nursing homes, and are used in an attempt to deal with problems such as agitation, delusion, anxiety and aggressive behaviour. The trust’s findings show that far from enhancing the life of those patients, the drugs shorten life, they slow response, mobility and cognition, and they do nothing to treat the illness. That is to say nothing of the fact that the medicine safety experts state that patients suffering dementia are three times more likely to suffer a stroke if they are being given those drugs.

The issue of prescription is key. The Commission for Social Care Inspection published a report entitled “Handle with care.” The CSCI has stated that

“nearly half of all nursing and care homes fail to meet national minimum standards for how they manage residents’ medicines”.

It has also said:

“Over 200,000 people are living in homes that fail to meet the medication standard.”

In addition, it has said:

“The same problems persist, with homes keeping poor medication records, failing to train care workers adequately and to ensure good practice.”

Why is it that these drugs continue to be prescribed, over-prescribed and misused? I believe that there are three reasons for that: poor staff training, despite both guidance and support being given; under-resourced care homes that find it cheaper to sedate patients than to employ more qualified staff; and, underlying all of that, poor Government guidance and a failure rigorously to enforce the targets that are being set.

There are two easy steps to resolving the problem, and taking them is long overdue. I call on the Government to take action on both of them now. What specific action is the Department taking on the prescription of neuroleptic drugs—or anti-psychotics—covered in the Alzheimer’s Research Trust study? A combination of atypical and typical anti-psychotics are listed in the report. Will the Minister give urgent consideration to the report’s recommendation that their use be withdrawn when treating people with only mild cases of Alzheimer’s?

In my first report on the subject, I called on the Government to reassess the national minimum standards for training care staff, and to start to offer staff an alternative to the application of a chemical straightjacket. Research published last year by the British Medical Journal emphasised that where staff are offered training and support programmes that focused on alternatives to chemical management, the proportion of residents taking anti-psychotic drugs can fall by nearly a fifth; it can fall by 19 per cent. More importantly, that fall is marked by no increase in behavioural problems. So why has there been no progress in this area? What more progress can be achieved?

Secondly, and more broadly, if the Government feel that they can ignore the contributions of an individual Member of Parliament producing reports in this way, perhaps they need to take note of the CSCI report and to take it more seriously. I called for more frequent and more thorough reviews of prescription procedures for these drugs in 2001, but that is still not happening six years on. The national service framework, which sets standards for the care of older people, particularly in respect of medication, said that reviews should be delivered once a year for the over-75s who are on four or fewer medications and once every six months for the over-75s on more than four medications.

In 2005 the Department published “Room for Review”, which reported that only 8 per cent. of primary care trusts achieved the first target and only 5 per cent. the second. I take this opportunity to ask again what the Department has done to tackle the problem since “Room for Review”. This is a tragic case study of how best practice and target setting can prove useless without effective enforcement and determined leadership.

Lack of enforcement and guidance brings me to my second concern about the scandal of elder abuse—the continuing and well documented failure of the “No Secrets” guidance to provide thorough, professional and compassionate investigations into reports of abuse of those in care. “No Secrets”, which was widely welcomed, was published to establish local council social services as lead agencies in developing multi-agency codes of practice for the protection of vulnerable adults. Following from that were the equally welcome “Safeguarding Adults” protocols drawn up by the Commission for Social Care Inspection. The measures set out in “No Secrets” were supposed to be implemented and completed in full by October 2001—more than half a decade ago—and “Safeguarding Adults” has been in circulation for nearly two years. Although I commend the good intentions behind the guidance and the protocols, I believe that more still needs to be done. We should be showing zero tolerance for abuse of vulnerable adults. Having lists of those who have abused is not adequate prevention; it is merely catching people after the event.

In the past five years, I and other hon. Members have come to the House to raise case after case in which “No Secrets” has failed. Earlier this month, listening to Radio 4, I heard—sadly, but not to my surprise—of three more cases in which “No Secrets” failed the very people it had been put in place to protect. The report arose from research undertaken by the BBC showing that one sixth of the 150 local councils in this country that are responsible for the arrangements fail adequately to safeguard the adults in their care. I shall take two of the cases highlighted by the BBC to illustrate once again how essential it is to do more to protect vulnerable adults.

The first case is a story that I have heard far too often. An elderly lady fell and broke eight ribs after undertaking a simple task for which her home care worker should have been responsible—the simple matter of turning on a light switch. The incident went unreported and unassessed by that home care worker, and even though he had clearly seen what happened, he did nothing about it. It was not until her son found her three and a half hours later—she had not moved from her chair and was in a great deal of pain—that the hospital was contacted. The lady died from her injuries two weeks later.

It transpired that the son had made numerous complaints to social services both before and after his mother’s death, but they were ignored. He later discovered that they had been lost by the local authority in its internal e-mail system. Eventually, when he went to the local government ombudsman, the ombudsman upheld his view that the council had let his mother down. The question remains, however: why did the lady’s son have to push for an investigation when “No Secrets” should have put in place the very protocols and mechanisms necessary to trigger one?

During the radio interview, the Minister who has responsibility for this matter, the Under-Secretary of State for Health, the hon. Member for Bury, South (Mr. Lewis), who is not present—I can understand why—said that “this is not acceptable” and that

“they are learning from their mistakes”,

but how many more such cases must come to light before we truly have learned from the mistakes? A tragic, high-profile public case of the sort that convulsed the child protection in the 1990s, such as the Victoria Climbié case, should not be needed to trigger the changes that are necessary to put adult protection on the same statutory footing as child protection. “No Secrets” should have been implemented more than five years ago, but it seems that the most basic lessons have yet to be learned.

The second case I want to mention is that of an elderly lady who was attacked and killed in a care home by another, younger, resident. The younger resident had a history of mental ill health and physical violence, but the care home was not informed. The council still fails to admit its fundamental failings which allowed that to happen. “No Secrets” says it all, but the secrets are still being kept. Councils are clearly responsible for leading the sort of inter-agency work that is essential to uncovering the secrets and making a difference in people’s lives. I repeat: “No Secrets” should have been implemented by 2001. What is being done to establish the necessary performance indicators by which councils can be made accountable for delivering what is set out in “No Secrets”? I am not alone in stating that “No Secrets” is not working, and that it needs legislative backing. Until it has that backing, councils will not deliver. In Scotland, and overseas in America, Japan and even as far away as South Africa, legal protections for vulnerable adults are being put in place.

More than 10 years ago, the Law Commission produced a report on mental incapacity, which called for a reassessment of the legal protection offered to vulnerable people. It recommended

“that local social services departments should be under a duty to investigate where they have reason to believe that a vulnerable person is suffering or likely to suffer significant harm or…exploitation”,

and it recommended that courts be given powers to take necessary action in that regard. I congratulate the Government on introducing the Mental Capacity Act 2005; the differences that it will bring are to be applauded. However, they did not implement the proposals of the Law Commission when they had the opportunity, and that is a gap that still needs to be closed.

There are a number of initiatives that still need to be taken. First, the Government need to reassess the use of anti-psychotic drugs in care homes. The use of that chemical straitjacket really has to end. Secondly, the Government must follow through with the recommendations of the Commission for Social Care Inspection report and raise the abysmal standards of medicine management that are all too common in many of our care homes. Thirdly, the Government must do more to make sure that the procedures of “No Secrets” are in not only place, but are being adopted and enforced, are making a difference, and are grounded in law. Fourthly, we need the Law Commission protections in place. Finally and most importantly, as I have said, we need “No Secrets” to be put on a statutory footing, because that seems to be the way to get the necessary action. Every child matters, but at the moment every older person does not seem to matter. That is not the message that should be sent from this House. I hope that the Minister will respond positively to the concerns that I have raised, and that we can ensure that the next essential steps are taken to secure an end to the scandal of elder abuse in this country. Whether there are 500,000 cases of abuse or 1,000, there are too many, and it is time for them to end.

I begin by paying tribute to the hon. Member for Sutton and Cheam (Mr. Burstow) for securing the debate and, more broadly, for the personal effort that he has put into raising awareness of the crucial issue of elder abuse and the work that he has done on it. I bring apologies from the Under-Secretary of State for Health, my hon. Friend the Member for Bury, South (Mr. Lewis). The hon. Member for Sutton and Cheam will know that my hon. Friend takes a huge personal interest in the subject, and I have no doubt that he will read the proceedings in Hansard and will want to make his own response to the hon. Gentleman.

The Government endorse much of what the hon. Gentleman said and they are, of course, determined to root out abuse in all its forms. There is no room whatever in social care for those who would harm people or place them at risk and we have already done much to help to support that important idea, and I am pleased that he acknowledged that in his remarks. Everyone should feel safe, secure and well looked after, wherever they live, so that they are able to maintain their dignity at all times. We want vulnerable and older people to be treated with respect by everyone who works in social care. They must receive the dignity that they deserve.

The Government are appalled to learn of terrible instances of abuse in institutional settings and in the community in the recent past. We acknowledge that in a small number of settings, things have been far from ideal. Obviously, abuse takes in a whole spectrum of behaviours—at a basic level, it includes ignoring someone or speaking to them in an unfriendly way, and it goes right the way through to more extreme forms of abuse. Speaking from family experience, it is not uncommon—let us put it that way—for families to have some form of unhappy experience when a loved one is in a residential or nursing home. It has to be said that on the whole, the dedication of the individuals who work in care homes is outstanding and they give a great deal of attention and support to the people under their care. Sadly, however, there are too many instances of care that is not of the standard that we expect, which leads to some deeply distressing and upsetting incidents for the families concerned. This is therefore a rare occasion on which there is a cross-party commitment to work together to improve our systems further so that we make those incidents even fewer and further between, and remove them from our social care and nursing care system.

The hon. Gentleman began by referring to the scale of the problem. When people begin to engage with the issue, they will discover that it is appallingly widespread and that there are far too many incidents a year for anyone to be comfortable with. He is right, however, that we do not have the robust level of information that Members of Parliament, councils and other authorities need to give due prominence to the situation. We are therefore extremely pleased to partner Comic Relief in a research project that looks at the abuse of older people who live in their own homes. We expect the results of that research to be published shortly. We are looking, too, at introducing a national collection of reports of abuse to local authorities. At the moment, information about reports of abuse varies across the country, so a single data collection would tell us how many investigations are carried out by each council. There are signs, as I hope the hon. Gentleman accepts, of improvement, but he is absolutely right to point out the issue as it underpins all the policy initiatives to which he has drawn attention. If we have that sound evidence base it will make much of what he has called for more likely and more effective.

The Government are giving every consideration to measures that will effectively tackle the growing concern in our society about this matter. Older people and adults with disabilities have the right to expect that everything is done to minimise the risk of abuse. I trust that the hon. Gentleman will permit me to mention some of the things that the Government have done to help to deal with the problem. On 14 November last year, the Department of Health launched the first ever national dignity in care campaign. Our intention is to create a care system in which there is zero tolerance of abuse of, and disrespect for, older people, as well as a situation in which people are as outraged by the abuse of parents and grandparents as they are by the abuse of children.

The Department launched the protection of vulnerable adults scheme in July 2004. In short, the POVA scheme is a work force ban, and is one means of ensuring that known abusers who have abused or mistreated vulnerable adults in their care do not remain in the work force or find their way back into such positions again. POVA has significantly increased the level of protection for vulnerable adults. As at the end of March, 6,352 people had been referred to the scheme. I can update the hon. Gentleman: more than 1,009 individuals have been prevented from working in social care, with a further 1,300 provisionally listed, awaiting confirmation. The POVA scheme was set up under the Care Standards Act 2000. In some instances, standards of care are unacceptable and staff need to be disciplined or, in the case of managers, have their registration removed. Care workers in regulated settings prescribed by the Act—adult placement schemes, care homes and domiciliary services—must be referred to the POVA list when misconduct has caused harm or put people at risk of harm. As the hon. Gentleman will know, it is illegal not to do so. I acknowledge, however, that our analysis shows a significant proportion of POVA referrals do not result in people being placed on the list.

To assist providers’ understanding of their responsibilities, the Department commissioned the Social Care Institute for Excellence to develop practice guidance to encourage referrers better to understand both the referral process and the information required to aid the POVA team to process referrals effectively. We believe that that will lead to better referrals. The guidance was published on the Department of Health and SCIE websites on 17 May 2006. If the hon. Gentleman is not aware of it, may I recommend that he look at it?

I come to some of the specific issues that the hon. Gentleman raised. He rightly referred to the importance of people receiving the right medication in care homes. Indeed, he has produced his own report on the issue—“Keep Taking the Medicine”. In February last year, the Commission for Social Care Inspection reported that about 88 per cent. of homes meet, or almost meet, the national minimum standards on medication management. However, we fully accept that work still needs to be done to improve on that. The Department acknowledges the findings in CSCI’s follow-up study and is disappointed that care homes have made little progress towards meeting the national minimum standards on medicines management since the last report in 2004.

Through the National Prescribing Centre and Medicines Partnership, we have worked with several primary care trusts to identify what works best and to share that learning with others through the national Medicines Management Services Collaborative. Nearly half of all PCTs have participated in that programme to implement local medicines management schemes so that people get more help from their GPs, pharmacists and others in using their medicines.

I am grateful for the Minister’s response. Will he write to me giving some indication of the likely time scales for 100 per cent. of PCTs to be implementing those changes to medicine management?

I certainly will. If the hon. Gentleman will permit me, I will also write to him with a fuller answer on the issue of anti-psychotic drugs, on which I do not have any specific briefing to give him.

The hon. Gentleman asked about “Room for Review”, a guide to medication that was published by medicines partnership in conjunction with the Medicines Management Services Collaborative. That was followed up by the publication of the medication review for patients, which better prepares patients and enables them to ask the appropriate questions. Although the focus has been on older people, the principles apply to other patients, including those with learning disabilities. He asked what the follow-up has been since the publication of “Room for Review”. The national prescribing centre is currently working on an updated version to be published later this year. That will help to deal with some of the issues that he has brought to the House.

Let me turn to “No Secrets”, which formed a large part of the hon. Gentleman’s remarks. He will know that CSCI, in assessing the performance of local authority social services, takes into account how “No Secrets” is being implemented. I appreciate that that is different from his call for it to be placed on a statutory footing, which he has made on other occasions. This is the system that we have at present, and there is no reason why it cannot and should not be effective, given that it is reflected in the star ratings that councils receive. I am told that CSCI will also consider how local authorities are ensuring that directors of adult social services have the resources that they need to meet their adult protection responsibilities. Again, that will be reflected in their overall rating.

I understand the hon. Gentleman’s concerns, and those raised through the Association of Directors of Social Services and others, about financing the implementation of “No Secrets” guidance. That issue is on the Department’s agenda, and I am sure that my hon. Friend the Under-Secretary will want to update the hon. Gentleman in due course as we further consider it.

Usually, I would want to refer to further measures to reassure the hon. Gentleman that we are taking action on a range of fronts. However, given the time that remains, I shall just give a brief indication. Of course, the Safeguarding Vulnerable Groups Bill has become the Safeguarding Vulnerable Groups Act 2006, which will bring into place the new vetting and barring scheme. As a former Home Office Minister, I think that it will have a huge beneficial impact right across our health, education and social care system in ensuring that timely and relevant information is put before employers so that they can make good decisions. I hope that the hon. Gentleman agrees that that will be a considerable step forward. Encouraging progress on the issue is being made and it will build on the principles of the protection of vulnerable adults scheme.

I thank the hon. Gentleman for introducing this debate. He said that the message sent out should not be that old people do not matter. I agree entirely, of course, and we need to work together to make sure that the opposite message is heard loud and clear.

Question put and agreed to.

Adjourned accordingly at Three o’clock.