There are around one million victims of elder abuse each year in the UK. How should healthcare physicians respond if they suspect elder abuse and what happens next?
Red flags for physicians
How should healthcare professionals respond to elder abuse and neglect?
The limitations of the Care Act in relation to adult safeguarding
The context of protection
Hate crime review
There are around one million victims of elder abuse each year in the UK, but this is likely to be an underestimation as only one in 24 cases are reported. This is mostly because older people are often afraid to report cases of abuse to family, friends, or to the authorities.
According to the World Health Organization (WHO), elder abuse is an important public health problem and it has recently called on the health sector, as part interdisciplinary collaboration with social care, to contribute to reducing the number of cases through the detection and treatment of victims.
Elder abuse, according to WHO, is a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person.1
The Care Act states that “abuse” includes:
- Having money or other property stolen
- Being defrauded
- Being put under pressure in relation to money or other property
- Having money or other property misused.2
A 2017 study based on the best available evidence from 52 studies in 28 countries from diverse regions, including 12 low- and middle-income countries, estimated that, over a year, 15.7% of people aged 60 years and older were subjected to some form of abuse.3
The Irvine's Centre of Excellence on Elder Abuse and Neglect lists amongst its red flags:
- Lack of basic hygiene, adequate food, medical aids (glasses, walker, teeth, hearing aid, medications) and clean appropriate clothing
- A person with dementia left unsupervised or bed bound person left without care
- Untreated pressure “bed” sores
- Financial abuse could be suspected if the caregiver has control of elder’s money but is failing to provide for elder’s needs or caretaker “living off” elder
- Elder has signed property transfers (Power of Attorney, a new will, etc.) when unable to comprehend the transaction
- Psychological abuse could be suspected when caregiver isolates elder (doesn’t let anyone into the home or speak to the elder) or caregiver is verbally aggressive or demeaning, controlling, overly concerned about spending money, or uncaring
- Physical abuse should be suspected if inadequately explained fractures, bruises, welts, cuts, sores or burns.
The appropriate response to elder abuse and neglect is to offer the most effective, but least restrictive and intrusive, support or assistance.4
Healthcare professionals will need to take note of the older patient’s circumstances and consider the following questions:
- Are there indicators of abuse, neglect or risk?
- Is someone responsible for the patient’s personal care?
- Is that person adequately informed, suitable for the task and able to provide care?
- Is there a need for additional support and assistance?
- What further patient support and assistance is required?
As safeguarding law and practice differs across the four countries of the UK, the General Medical Council's advice to doctors is to be familiar with the procedures where they work.5
All adult safeguarding processes and laws in the UK say that safeguarding procedures must be person-centred and must take account of the views and wishes of the adult concerned. Safeguarding is not something that is ‘done to’ a person and the steps you take will usually be agreed with your patient, in line with local safeguarding processes.
Challenging situations can, however, arise when confidentiality rights must be balanced against duties to protect and promote the health and welfare of patients who may be unable to protect themselves, and who refuse offers of help.
If faced with this situation, and there are no legal requirements to disclose information, it says to ask whether the adult has capacity to decide whether to accept help? Start from the presumption that the adult has capacity to make the decision, and maximise their ability to do so.
- Communicate with them in a way that best meets their needs. If necessary check with those close to the adult, or others in the healthcare team, about how to best to communicate with them
- Discuss their options at a time and place that helps them understand and remember what you say
- Ask whether having a friend or relative with them would help them to remember information or help them make the decision.
- Offer written or audio information if it will help.
If the adult doesn’t have capacity to decide, it will usually be appropriate to tell a responsible person or authority (such as a local safeguarding lead, or the local authority) if you believe that the person is experiencing, or at risk of, abuse or neglect. You should follow local safeguarding processes.
The GMC states that an important principle in its guidance is that doctors must respect patients’ rights to self-determination as long as they have capacity to make decisions for themselves, and their decisions do not expose others to a risk of death or serious harm. It, therefore, emphasises the importance of seeking consent to disclose confidential information and abiding by patients’ wishes.
But in very exceptional circumstances, a doctor may be able to justify disclosing information without consent, where:
- It is necessary to prevent a serious crime such as murder, manslaughter or serious assault
- There is clear evidence of an imminent risk of serious harm to the individual and no alternative (and less intrusive) methods of preventing that harm.
As this is an uncertain area of law, physicians should, if they can, seek independent legal advice before making such disclosure without consent.
Gary FitzGerald, CEO of Action on Elder Abuse, said that as a charity they have the following concerns about the Care Act in tackling the problem:
- The localised approach of the Care Act increases the potential for disparity between local authorities in terms of who might be eligible for adult protection
- The lack of powers to gain entry to private homes where a ‘third party’ is refusing access to a possibly vulnerable person
- A lack of any powers to practically intervene and protect.
He said that there is a statutory duty on Local Authorities to inquire (or cause an inquiry) into allegations of abuse, but as there are no regulations defining the nature or detail of such inquiries it is left to professional judgement.
There is a duty on councils to fund advocacy for assessment and safeguarding for people who do not have anyone else to speak up for them. But there is no duty to make safeguarding enquiries if the person is vulnerable but regarded as able to take steps to help themselves. So the duty is not all-inclusive or all-embracing.
FitzGerald added: “The Care Act 2014 was supposed to bring about a once-in-a-generation change in adult safeguarding that would see stronger protections put in place for vulnerable adults across England. Instead, the Safeguarding Adults Collection (SAC) statistics for 2016/17 released by NHS Digital in November last year paint a worrying picture of wildly divergent local practices in response to concerns about abuse. It has truly become a postcode lottery.”
FitzGerald said the reality of the current situation is that adult protection systems focus on stopping abuse, and preventing further instances, but they rarely focus on the prosecution of crimes.
Inspection and regulation systems focus on establishing and maintaining standards of care provision by regulated services but do not relate to the individual perpetrator. Therefore, most acts of cruelty, harm or neglect of older people are never perceived as actual or potential crimes and therefore never reach court.
Analysis by the charity shows that abuse of older people has a lower conviction rate of any hate crime or domestic abuse at 0.7%.
The Law Commission this year is to complete a wide-ranging review into hate crime to explore how to make current legislation more effective and consider if there should be additional protected characteristics such as misogyny and age.
The move was welcomed by FitzGerald who said it was time to give older victims of crime the same protections as other groups victimised for their personal characteristics.
He added: “Older people are being neglected and abused physically, financially, psychologically and sexually across the country every day, both in care settings and in their own homes. But the number of convictions for these crimes is tiny and, even when someone is found guilty; they often escape with flimsy sentences and paltry fines that do nothing to deter would-be abusers.
"We must make it clear that we as a society will not tolerate these cowardly acts against some of the most vulnerable people in our community.”
Alison Bloomer is Managing Editor of GM Journal
Based on a talk given by Gary FitzGerald, Former CEO of Elder Abuse, at the GM Conference - Meeting the Clinical Challenges of the Ageing Population - held at the Royal Society of Medicine in October 2018.