Elder Abuse

– in Westminster Hall at 12:00 am on 1st July 2004.

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[Relevant documents: Second Report from the Health Committee, Session 2003–04, HC111, and the Government's response thereto, Cm 6270.]

Motion made, and Question proposed, That the sitting be now adjourned.—[Dr. Ladyman.]

Photo of John Austin John Austin Labour, Erith and Thamesmead 2:30 pm, 1st July 2004

I apologise at the outset for the absence of my hon. Friend Mr. Hinchliffe, the Chair of the Health Committee. All those who serve on the Committee and hon. Members generally will recognise that my hon. Friend is passionate in his concern for vulnerable people and has demonstrated that in both his political and professional career. He is very sorry not to be here, but he has an important speaking engagement with the Health Development Agency in Leeds and is unable to be with us.

This has been a short inquiry. The Health Committee has now decided that, as a matter of policy and in addition to its major inquiries such as that on obesity and the one on which it is about to embark on pharmaceutical services, it will conduct a series of short inquiries on important topics of the day. That puts an additional burden on members and also the staff of the Select Committee. On behalf of the Committee, I extend our thanks to the staff for the additional work that we have put their way and for the excellent quality of service that has resulted in an excellent report. It is also important to thank our advisers, Melanie Kenwood and Chris Vellenoweth, who have served the inquiry well.

In our introduction to the report, we refer to the death of Margaret Panting, a 78-year-old woman who died after suffering unbelievable cruelty while living with relatives, but that event cannot be dismissed as an isolated incident. During our inquiry, we heard horrific stories of various forms of abuse by positive and deliberate acts and by neglect.

In my local newspaper this week I read about the coroner's verdict on the case of 78-year-old Jean Bore who died in a private care home in a constituency neighbouring mine. Mrs. Bore had been admitted to hospital following a stroke in May last year, and in September was transferred to the care home. The following month, her condition had deteriorated and she was re-admitted to Queen Mary's hospital, Sidcup where staff were surprised at the extent and size of her bedsores and the consultant was shocked by her condition. During her five-month stay in hospital, staff had been able to prevent any bedsores developing, but during a short period in a care home she developed bedsores that were so horrendous that the coroner said that they had contributed to her death. He said in his verdict:

"The development of and delay in diagnosis and treatment of sacral pressure sore contributed to Jean Bore's death."

No wonder her son is calling for better monitoring of private care homes and regular checks on their residents. BUPA, which runs the home, said that the care fell short of the standards that it expects. Mr Bore was right when he said that

"if this could happen to my mother, there's every chance others have been treated in the same way".

All of us know of incidents of elder abuse in our constituencies. I know that my right hon. Friend Mr. Bradley will want to comment on the Rowan ward in the Manchester mental health care trust.

That is why we must raise awareness of elder abuse and why we need effective systems in place to prevent abuse from occurring. The Committee has received evidence of various forms of abuse: physical abuse, such as slapping, hitting, burning, scalding, pushing, inappropriate restraint, inappropriate use of medicine, withholding medicine as punishment, lack of consideration, roughness when handling or treating people or helping them to the toilet, changing dressings and so on; psychological abuse, such as shouting, swearing, frightening, threatening, withholding or damaging something with emotional importance, and failing to deal with elderly people with the respect and dignity that they deserve; financial abuse, including stealing and fraud; sexual abuse; neglect, including failure to provide food, heating, adequate care or bathing; and neglecting care, such as the example that I gave of Mrs Bore.

In some extreme cases there should have been criminal prosecutions, but that is rare and some witnesses referred in evidence to the lack of effort on the part of the Crown Prosecution Service. I hope that hon. Members will raise some of those issues during their routine meetings with their local police and criminal justice boards, and their regional CPS offices. I hope that the Minister will raise those concerns with my right hon. and learned Friend the Solicitor-General.

Our evidence showed that most abuse—67 per cent. was the figure quoted to us—occurs within the home. That is not such a surprising figure given that the majority of older people live at home. Other research suggested that almost half the abuse within the home is by relatives or friends and about one third by paid workers. Abuse in the home is difficult to tackle, and more often than not it goes unreported. In some cases the abuser, possibly a partner or sibling, may themselves be elderly. Research by Help the Aged showed that three quarters of older people who live with the person for whom they care receive no regular visits from health or social services and only one in 10 older carers receives regular home care.

Action on Elder Abuse told us that figures from its helpline suggest that 13 per cent. of abuse is carried out by care staff, domiciliary carers and home helps. Over the past 10 to 15 years, the nature of domiciliary care has changed considerably as local authorities have been required to stimulate the private market and encourage the growth of private sector provision. It has resulted in an explosion of small, often locally based agencies with little by way of regulations or statutory standards.

It is easy to see how abuse can take place within the home and not be seen. Part of the evidence from Action on Elder Abuse puts it better than I can:

"Domiciliary care by its nature is based upon one-to-one relationships between (often) single workers and isolated, dependent individuals. Many of these workers provide excellent services and are valued and respected by the older people in receipt of their support and it would be wrong not to acknowledge this reality.

However, it is intrinsic to this service that such relationships are difficult to manage within professional parameters, and are certainly difficult to monitor and inspect. Home care staff who subscribe to good practices, whether as a consequence of training or supervision or personal values, are statistically in the majority. However, the very nature of the home care service lends itself to the potential for abuse because of the relationships that are established, the opportunities that present, and the isolated one-to-one relationships that are inevitably created."

That is why we need adequate training, support and supervision of the domiciliary care market.

The vast majority of workers and voluntary care providers provide a good service that is valued by those who receive it. However, we must recognise the personal toll and stress that it puts on informal carers, who often neglect their own health and suffer financial loss. We must not lose sight of the need for care and support for the carers, too.

What we have seen with domiciliary care is what we saw with residential care in the 1980s—an explosion of small private homes, some excellent but some providing poor quality of care with untrained staff and little stimulating activity. The hon. Member for Wakefield described it at one conference as "wall-to-wall geriatrica". That sector has changed over the years with increased regulation and inspection, and I hope that the new Commission for Social Care and Inspection will build on the work of the National Care Standards Commission and lead to more improvements that are long overdue.

Despite these regulatory controls, the Select Committee was shocked to hear evidence of serious abuse in many homes. It included the inappropriate use of medication, often used not for the benefit of the elderly but to provide a quiet life for the staff. We should not ignore the dedication, commitment and concern of many professional care staff providing high-quality care services, but the new regulatory agencies, local government, the Government and local authorities' health trusts must do much more to raise awareness of the problem of elder abuse.

We have been in denial for too long. It is only in the past 20 years that we have spoken openly and acknowledged the existence and extent of domestic violence and child abuse. There is a growing awareness that such things take place, and often in the least suspected places. Teachers, nurses, general practitioners and staff in accident and emergency departments, as well as those working in voluntary organisations, neighbours and friends, are getting better at recognising the tell-tale signs of abuse in children and—mostly female—younger adults. We need to create the same awareness about elder abuse, and I believe that our report will assist in that process.

We need the Government to act, and many of our recommendations are aimed at them. However, we need action at a local level, too, and in this case Members of Parliament have a role to play. Our report can be used locally to raise awareness. My constituency is served by two local authorities and two primary care trusts. One is a first-wave care trust, and I discussed the report with it, as I know other Committee members will have done in their areas. In both boroughs in my constituency there is a well-established multi-agency adult protection working group, which was set up following the publication of "No Secrets" in 1999, and after the Government's White Paper, "Modernising Social Services", which highlighted the issue of protection.

The role of the working groups is to ensure that all agencies work together to establish a robust system for monitoring and for investigating complaints, and to provide training in adult protection awareness and multi-agency training in investigating abuse. I examined the last report of the Bexley adult protection monitoring group. In the past year, it investigated 38 instances of alleged abuse—a considerable increase on the 29 instances of the previous year. The allegations related to several different conditions involving vulnerable adults. Of the cases of abuse investigated, 24 were of physical abuse, two were of physical neglect, five were of psychological abuse, three were of financial abuse and four were of sexual abuse. Eighteen of those cases occurred in the individual's home, four occurred in someone else's home and 13 occurred in a residential or nursing care situation.

The potential vulnerability of people in their own homes confirms the importance of the training offered to domiciliary agencies. The fact that 13 of the instances were alleged to have taken place in residential or day-care settings suggests that the strategy of providing awareness training to staff in such settings is also of great importance. I hope that the Department will encourage all MPs to engage with their local agencies in promoting the recommendations in our report. The report is timely because it comes on the eve of the introduction of the new protection of vulnerable adults guidelines and changes in the legal regulations.

I come to the recommendations of our report and the Government's response, which, in the main, has been positive. I hope that the Minister will understand if I concentrate on the parts of the response that I regard as negative. I am sure that my colleagues on the Committee will want to expand on my points. I am sorry that the Minister felt unable to accept our suggestion that the no secrets definition of elder abuse should be extended to include those who do not require community care services. Such persons can still be isolated and vulnerable to abuse.

The Government's response to recommendation 3 about the need for multi-disciplinary research is welcome but I am concerned that the Minister has reservations about the figure of 500,000 elderly people experiencing abuse at any point in time. Despite the measures that the Government have taken since the 1992 study, my guess is that this is an underestimate and not an overestimate. I believe that the figure will rise, and continue to do so. That is not necessarily due to higher incidences but heightened awareness, systems for reporting and monitoring and more reporting in general, as we have seen in cases of child abuse, domestic violence and hate crimes.

Regarding recommendation 6, I welcome the continued funding for the Action on Elder Abuse helpline, and the recent TV and press coverage of the problem. On recommendation 7, we look forward to the outcome of the Commission for Social Care Inspection's consultation.

I welcome the acceptance of the need to train care staff as set out in our recommendation 8, but I feel that the response to recommendation 21 is rather too neutral. I appreciate that the Minister is not responsible for the content of nursing training, but I would have hoped that the Department would be in discussion with the Nursing and Midwifery Council on that issue.

Photo of Stephen Ladyman Stephen Ladyman Parliamentary Under-Secretary, Department of Health

It may help my hon. Friend to know that we have an appointment with the Nursing and Midwifery Council in two weeks to discuss that very issue.

Photo of John Austin John Austin Labour, Erith and Thamesmead

I am grateful for that comment. If care assistants need training in identifying abuse and how to deal with it, so do other carers such as nurses.

On recommendation 11, I regret that the Government are not able to accept our suggestion for more frequent reviews of medication. On recommendation 22, I am sorry that the Minister does not share our view that the formal complaints procedures may be inadequate to support older people and enable them to complain. Personally, I regret the Government's rejection of our suggestion that the proposed equality and human rights commission should be given enforcement powers as well as powers to assist, and act on behalf of, abused individuals.

On recommendation 26, I regret that the Minister does not seem willing at this stage to consider amending the national service framework for older people in line with our thinking. I hope he gives that further consideration. I had also hoped for a more positive response to recommendation 30 and the urgent need for registration of domiciliary and other care workers, which is one of the key ways of improving the quality of care.

On the whole, I hope that the Minister sees the report as positive; in the main, the Government's response has been positive, which I welcome. I have raised the issues of concern to me and my fellow members of the Committee, and those concerns are shared by a number of organisations. I understand that he had a meeting earlier this week with Age Concern, Help the Aged, Action on Elder Abuse, the Prevention of Professional Abuse Network and the Community and District Nursing Association. Certainly, the latter has echoed to me the concerns about the more negative responses that I have highlighted. I hope he will share with us the discussions that he has had with those bodies and the outcome of that meeting.

Photo of Sir David Amess Sir David Amess Conservative, Southend West 2:48 pm, 1st July 2004

This is a very difficult and sensitive area, but as ever the Health Committee has done a magnificent job in producing a report in such a short time. I hope that no one thinks that the Committee is any sense suggesting that it is the norm for elderly people to be abused. Such abuse is the exception. I will come back to that later.

Before coming here, I checked whether my office thinks that its own Member of Parliament is guilty of abusing elderly people. I say that because the chap running my office is aged 81. I looked him straight in the eyes and asked how I am treating him. He said that he willingly comes to work and enjoys it, and that, as far as he is concerned, I have a good record on the matter. The constituency that I represent is No. 1 out of the 659 in terms of people aged between 100 and 112, so, on a personal level, I have a great deal to do with elderly people.

I hope that no one will seize on the idea that the majority of care homes abuse the elderly people they look after. Years ago, elderly people were not looked after in care homes, but that has all changed. The modern way of living means that there are many people in care homes, perhaps because there is one family member who makes a decision or there are no family members at all. I have visited all the care homes in my constituency and, by and large, they all do a splendid job, but then you would expect me to say that, Mr. Deputy Speaker.

Care homes figure heavily in the report, and to me it is unfortunate that the National Care Standards Commission has laid many duties on them, because the love and support that the proprietors and their staff give to elderly people is necessarily infinitely more important than whether the room is 2 in too small. The training of staff is also absolutely fundamental. I would be interested to hear from the Minister something further about whether the Government might look carefully at the training of people who work in care homes.

The overwhelming majority of people who work in care homes are not terribly well paid, but special skills are needed to look after elderly people. One must have bags of patience—what I am about to say will result in many letters being written—as they are a little like babies or the very young. Several bodily functions have to be attended to, and I have heard relatives complain about the care given to elderly people. Given the pressures and stresses, it is a challenge to meet all the demands of elderly people. That is why our report tries to define elder abuse. Perhaps we will hear later whether we have come up with the real definition and one with which the Government are comfortable.

We hear of children being abused, but we do not hear quite so much about elderly people being abused. Elder abuse is not a new phenomenon, as we have already heard. It has always existed, but there is more publicity about it now. Gary Fitzgerald of the charity Action on Elder Abuse gave evidence to the Select Committee inquiry, and made a sound point. He said that much is reported in the media about young children who have been abused—quite rightly so—but little is mentioned about elderly people who are abused even though such incidents are just as important and take place in private homes, care homes and hospitals each and every day.

Perhaps in one sense that is an exaggeration and a little tough, but the letters I get that are critical of hospital care tend to be about wards in which people are charged with looking after elderly people. Nine times out of 10, the complaint is that someone's mother wanted a commode but no one was available to produce one, or their dad had a cup of tea or a bit of food plonked in front of him and then half an hour or an hour later it was taken away and there was no one to coax him. Such services are not easy to deliver. Perhaps the Minister will touch on that point.

Mr. Fitzgerald stated that

"we know about Victoria Climbie, we know what happened to her, we know of the abuses, but many, many of us do not know about Margaret Panting and the difference between them is 70 years."

She suffered the same number of injuries and the same sorts of abuse, but her case was not publicised in the same way as the one involving a child.

The summary of the report states:

"Abuse of older people is a hidden, and often ignored, problem in society."

That was reiterated in the introduction to the report. Gary Fitzgerald stated:

"The voice of older people is rarely heard by those who have a responsibility for commissioning, regulating and inspecting services."

Towards the end of my speech, I shall tell the Minister about an excellent advocacy service in Southend, West.

Like other colleagues on the Committee, I was shocked to hear about Margaret Panting. The local community apparently knew about what was going on, but Mr. Fitzgerald raised a poignant issue in saying

"as a nation we do not" know about elder abuse

"and that does pose the question: why is it that we do not know about these things with elderly people?"

We cannot ignore the issue, which is why I was delighted that the Committee decided to hold the inquiry. It was not my idea, but I think we produced a valuable document.

Our report says

"it is misleading to talk of elder abuse as a single phenomenon."

The Committee came to the conclusion that abuse takes place in all manner of environments and ways—in nursing homes, hospitals and the person's home. In 35 per cent. of cases, the form of abuse is physiological, in 20 per cent. financial and material, in another 20 per cent. physical, in 10 per cent. neglect and acts of omission, in another 10 per cent. discriminatory, and I am glad to say that it is sexual in just 2 per cent. of cases.

It is disturbing that 67 per cent. of all cases of elder abuse take place in the person's home. Quite how any Government can monitor that, I am not sure. The abuse happens behind closed doors, with a care worker or a district nurse providing one-to-one care—domiciliary care. That is the most common form of abuse, yet it is difficult to detect and to combat. All political parties now think that if an older person wants to stay at home for as long as possible, they should do so, yet here we are with those frightening statistics.

Another worry is that there must be far more cases of abuse than are reported to the authorities. The Committee recommended that awareness of elder abuse should be increased. Highlighting a problem is a way of combating it, as people would be more inclined to report abuse. Yes, all that is true.

I am delighted that the Government are taking abuse in domiciliary care seriously. The helpline run by Action on Elder Abuse, which the Government fund, is providing a central point for vulnerable adults to talk through and report their concerns. The draft Mental Incapacity Bill will make a new arrestable criminal offence of ill treatment or neglect of a person without capacity.

Elder abuse is being put in the public domain for the first time and I welcome that. Local and national newspapers and television also highlight such matters. On 27 April, The Times ran the headline, "The seasoned campaigner Erin Pizzey aims to stop the abuse of old people by their children or carers". The Daily Record came out with a similar report on 29 April in a letter from Mr. O'Hare. That is all in our report.

The BBC "Panorama" programme broadcast in November 2003 used an undercover reporter. Some of us may have doubts about that method of investigation, but there we are. "Panorama" showed how vulnerable elderly people who use care homes are. I saw the programme myself and it did not show matters in a good light. Newspapers and the television are certainly great avenues for highlighting the abuse, but as parliamentarians we have a serious duty to ensure that elderly people, who have done so much for us all, are properly protected.

The Minister gave evidence to the inquiry, saying:

"I do not dispute that it is a very significant problem and there is a very significant number of elderly people who are now abused."

He mentioned a figure of 500,000. During his evidence session with the Committee, he said that Ogg and Bennett used a very wide definition of abuse and that that is not helpful. He insisted that, because the figure of 500,000 is an extrapolation from the 1992 figures, it assumes that nothing has been done to improve the situation since 1992.

The Minister then suggested that the figure is probably lower than 500,000, but he did not dispute the fact that there is a significant problem. I must say that the Department of Health might have made more recent figures available if something has been done. No doubt there is an answer to that.

Given that 500,000 elderly people in England suffer abuse at any one time, and even if the figure is lower, as the Minister suggests, the Committee is right to be perplexed about why the Department of Health has not commissioned research to establish exactly how many elderly people suffer abuse. Recommendation 29 says that the Government should commission research to ascertain the extent to which elder abuse is a problem in our society.

We know that 500,000 elderly people are being abused, but those are only the cases that are reported to the authorities. I am therefore very pleased that the Government's response to the Committee's inquiry was recently to begin to fund Action on Elder Abuse and to explore the possibility of having a national recording system for the incidence of adult abuse. Before we can tackle the problem, we need to be clearer about its scale. Recording data would be a useful first step on the road to dealing with the problem, and I welcome the commissioning of that research.

The Committee strongly endorsed the suggestion that advocacy services for older people be made available to tackle elder abuse. The availability of such services throughout the country is hit and miss. The number of people with Alzheimer's disease, senile dementia, or whatever else one wants to call it, and the number of people suffering from strokes is increasing, as is the number of elderly people in my area who have no relatives. Those people need advocates, and advocacy services should be made more available to them.

Southend, West is very lucky to have a wonderful service called the South East Essex Advocacy Service for Older People, which is funded partly by staff and partly by volunteers. The Health Committee recommended that the Government take steps to facilitate the network of existing voluntary and non-voluntary organisations. Those organisations do a marvellous job, but they constantly struggle to secure funding. So often, the local authorities make a grant, but say that they do not receive enough money to fund all the duties that are placed on them.

This is not stated explicitly in the report, but I hope that the Government will do all they can to ensure that such organisations are given at least the hope of proper and adequate funding so that they can carry out their essential work instead of using their time to fight to secure funding so that they can stay afloat.

Elder abuse is a real problem. It should not be exaggerated, but we need to act now before it gets out of hand. The report is an excellent start, and we are all delighted with the Government's response. The problem of elder abuse is now in the public domain, and it is up to us, as parliamentarians, to keep challenging the Government to see how we can best tackle it before it becomes too serious.

Photo of Mr Keith Bradley Mr Keith Bradley Labour, Manchester, Withington 3:04 pm, 1st July 2004

My contribution to the debate will be brief, because my hon. Friend John Austin has already laid out the Select Committee's recommendations brilliantly and has made the point that I specifically wanted to make about the appalling situation that arose at Rowan ward at Withington hospital in my constituency.

My hon. Friend spoke about carers. It is relevant that carers week was only a few weeks ago, when many hon. Members attended meetings, had visits and recognised, through a variety of activities, the incredible amount of informal caring that goes on. Informal caring is estimated to save the taxpayer about £60 billion a year—if that saving can be calculated. Therefore, in our discussions about care in the community, care in the family home and care generally, we parliamentarians have to recognise the huge amount of activity that goes on on our behalf. We must also do more to support carers, particularly by providing respite care, because they cannot keep caring for others at the level and quality that they do if they are not properly cared for themselves. I wanted to reiterate that point, because I do not think that we should ever forget the amount of caring that goes on.

What happened at Rowan ward was particularly appalling elder abuse—it was appalling for the patients and for their relatives. We must learn lessons from that where abuse is taking place in national health service establishments. Regardless of the arguments about numbers, I hope that the problem is not prevalent in the NHS, but we must look carefully at what happened at Rowan ward to ensure that it cannot happen in other NHS establishments.

Our report referred to Rowan ward. Recommendation 10 states:

"We recommend that the Department reviews the frequency and effectiveness of the inspection of NHS establishments providing care for older people. We also recognize the importance of lay personnel having an input into the inspection process and urge that further measures are taken to increase user engagement. We believe that lay visitors, by talking to residents informally and alone, are more likely to obtain information about abuse from embarrassed or frightened victims. Further measures may need to be introduced to make staff aware of their responsibility to report abuse and to allow them to do this in a confidential manner."

I believe that the Government are sympathetic to that recommendation, but we must turn that sympathy into real action, because if the essence of that recommendation had been implemented at Rowan ward, there would have been a far better reporting system there, which would have allowed the problems to be identified earlier.

Our recommendations should be considered in relation to the recommendations of the Commission for Health Improvement inquiry into Rowan ward and those of the internal inquiry into the standards of care at Rowan ward. The CHI report states that

"There is an urgent need to strengthen management capacity and leadership at every level in the trust" and that there must be

"executive capacity and vision in clinical matters", which clearly need to be strengthened. It goes on to say:

"In any further major capital projects or reprovision development, the trust and health community partners must ensure that vulnerable services are not left isolated during the process."

Given the danger that there might be many such cases around the country and that, as the nature of hospitals changes, we are to reprovide secondary and community services, we must not forget the situation that arose in Withington—the final element of in-patient care was one isolated ward of vulnerable elderly people, left in the middle of a building site. We must be much more sensitive and caring about how we ensure that reprovision is in place and that it can be smoothly managed, so that we do not get into further situations that leave vulnerable people such as those in Withington at risk.

The other recommendation in the report was that

"The Department of Health should evaluate the process for consideration of applications for care trust status."

An underlying problem, which was highlighted in all the reports, was the robustness of the trust when it was first established, and its capacity in a relatively short time to manage mental health services and social care services for the mentally ill in a city such as Manchester. There is a duty on the Department of Health—and on all of us—to ensure that new trusts have the capacity to undertake the job with which we charge them, so that they can make new services available to their communities.

I fully endorse the view of my hon. Friend the Member for Erith and Thamesmead that we must ensure that the way in which services develop is recognised in the community. I am pleased to say that there is now a new leadership team at the mental health trust in Manchester, including a new acting chief executive, Laura Roberts, who will, I hope, become the chief executive in the near future. The new management team—a chair is going to be appointed—has introduced a robust action plan to try to tackle the issues that have been identified as a result of all the inquiries into Rowan ward.

As my hon. Friend said, it is incumbent on parliamentarians to involve themselves in the process. We must be aware of problems that arise in trusts, so that we can bring them to the attention of the Department. We cannot just stand back and assume that all is well in our communities. If we have learned those lessons, we have paved the way towards ensuring that, at least in Manchester, the mental health partnership can provide high-quality care. We need to discuss matters with it, as I have done as a result of what happened at Rowan ward, and address the points that it believes need to be highlighted, as we have done in our abuse report. Situations are not static and we must keep reminding ourselves of the key issues.

There have been no prosecutions as a result of the problems that arose in Rowan ward and the subsequent investigation. The management have changed and key staff members have left the trust. However, relatives concerned about future care still query why nobody was prosecuted. The trust is clear that it must work closely with the police at the earliest opportunity, consult on concerns or suspicions and agree an investigation process wherever possible. Health services need to build a relationship with the police in respect of vulnerable adults, so that, rather than merely reacting to situations, they have a protocol and procedure that involve consulting the police at the earliest opportunity. Manchester would welcome such a development.

We mentioned in our report the delays in the protection of vulnerable adults register, a fact that the Minister recognised when he gave evidence to the Select Committee. The earliest possible registration of health staff is still a live issue. We have been given assurances, but I want to re-emphasise that aspect of the report. We have already heard about the need for health and social care staff to receive professional training in abuse matters. Unless there is mandatory training, so that staff recognise abuse as a key issue, they will not feel the confidence or have the ability to engage in the reporting and investigative process. I welcome the Minister's intervention, where he said that discussions will be taking place on the matter. However, I urge speed and effective action to ensure that we introduce such training at the earliest opportunity.

Specific legislation regarding vulnerable older people is also an issue. The Minister recognises that. It is similar to the protection of vulnerable children issue. We need to look at the way in which child protection issues are handled to see how that can be effectively replicated for adults. We need to look at the range of possible legislation, to consider what is in place now, to see where the gaps are and to ensure that there is a continuum of legislative framework with which we can ensure that vulnerable people can be properly protected. I am sure that the Minister will give some more thoughts on that matter.

Rowan ward was an appalling example and, as I said, I hope that it was not typical of care in national health service establishments and certainly not typical of the care that people receive from the health services in Manchester. However, on behalf of those vulnerable people and their relatives and friends, we must not forget what those investigations found—the weakness of the management, of the protocols and of the interrelationship with other agencies—to ensure that Rowan ward does not happen again. We should ensure that we learn the lessons and that the practice and procedures brought in as a result of our wide-ranging report into elder abuse are effectively implemented by the Government.

Photo of Paul Burstow Paul Burstow Shadow Secretary of State for Health 3:17 pm, 1st July 2004

I rise to speak in this very important debate on a subject about which a number of hon. Members have already spoken eloquently. They have expressed particular areas of concern from their own experience of the inquiry.

I start by echoing something from the evidence that we received during the inquiry; it was a telling point about our attitude as a society towards the abuse of adults and particularly the abuse of elders, compared with our attitude towards the abuse of children. Mr. Amess referred to the matter, which is also referred to in the evidence.

The sole difference between the cases of Margaret Panting and of Victoria Climbié is the 70 years that separates them and not the abuse they both suffered. One case produced a major national inquiry, convulsed the whole system and led to substantial change as a consequence; the Laming inquiry report and the Children Bill, which is currently going through the House of Lords. However, Margaret Panting's epitaph seems to be less. The case is now perhaps recognised in part through the Committee's report, but we require a substantial shift; not only in terms of the Government's approach to and thinking on the issue, but towards its being a more widespread issue of concern in society.

During the inquiry we were told that, as a society, we are still probably 10 or 20 years behind in our attitude towards, alertness to and awareness of elder abuse. I feel strongly that that is true. I understand the point that has been made by those who are anxious not to tar good practitioners of care—whether they are care home providers or domiciliary providers—with the brush of the abuser. However, it is also incumbent on us not to downplay the issue to the extent that we do not manage to provoke the necessary action to ensure that we have a clear picture of how widespread the problem is.

Although we have the benefit of the work done by Action on Elder Abuse and of the survey research done in the early 1990s, which led to the figure that 500,000 were being abused, and although the Government response has suggested that work will be done on national data collection on reporting of incidents, none of that deals with the fundamental concern of giving us a fix on the true prevalence of elder abuse.

Until we have established the necessary sound research methodology to do that, we cannot be certain that the reporting mechanisms are a reliable way of identifying and protecting victims of abuse. The systems may not be as robust as we should like them to be. I shall shortly discuss aspects of the matter to which "No Secrets" is relevant, and some of the systems that have developed from that, which are particularly important.

The debate about the abuse of older people and other adults is still in the realm of the taboo. We do not have reliable statistics and there is still much denial in the care sector, and more widely. Often abusers do not recognise their actions as abuse. Will the Minister say more today about this to give us some confidence and hope?

Work is to be done in connection with the data collection system being discussed with Action on Elder Abuse; but what will the Government do to set up the research to give us confidence in the Minister's contention, made in evidence to the Committee, that the figure, suggested by research, of 500,000 people being abused at any one time is not reliable? Before that figure ceases to be used, we need to know that research is being set up. A sense of the time scale for that would be useful. The data collection that is proposed will give a much better fix on the tip of the iceberg but will not reveal its entirety.

The "No Secrets" definition has been referred to, and it is important to draw out the concerns about it. The fact that that definition does not apply beyond formal care must be a matter of concern, not least because of the remarks that have been made about the valuable contribution made by informal carers, and the fact that a large amount of care—probably the bulk of it—is provided outside the formal care sector. In addition to the 6 million carers there are many others who probably never even label themselves as carers even when asked about it in the census.

The Committee made recommendations about the fact that the regulations on domiciliary care do not require instant reporting, which is required for residential and nursing homes. The Government response argued that that is more difficult in a domiciliary setting, because incidents may occur when there is no responsibility for domiciliary care, raising the question as to whether there is a burden on a particular agency to report them when another agency may already have done so.

Part of my response to that response would be that that is surely something to be dealt with by the multi-agency co-ordination to be established by "No Secrets". At least if the safety net has a few additional cords to it, resulting in multiple reporting of the same incident, we will obtain the information. However, if everyone thinks that someone else might be reporting it, we will not. Will the Government think further about regulations to impose on domiciliary care agencies a duty to report incidents?

I want to underscore what other hon. Members have said about training and the importance that the Committee placed on the absolute value of more and better training for staff, and refresher training. I welcome the Minister's news, in an intervention, that he will meet representatives of the Nursing and Midwifery Council in a couple of weeks. Perhaps, rather cheekily, I want to ask the Minister to explain not so much what the details of the discussion will be but by what mechanism its outcomes will be reported, so that the Committee can find out whether our recommendations and this debate have had any purchase in moving matters on.

Not surprisingly, perhaps, I want to say a bit about the inappropriate use of medication. I have been concerned about the issue for some years, and particularly since 1997, when I read a report by the Royal College of Physicians about the medication of older people. The inappropriate use of medication can reduce a person's quality of life, shorten their life or, in some cases, take their life. Over the past few years, I have asked parliamentary questions about the issue, introduced Adjournment debates in Westminster Hall about it and published a couple of reports on how far the Government have got in dealing with it.

Studies in Manchester, Glasgow, south London and Bristol published in peer-reviewed journals have also contributed to my anxiety about the issue. What emerges from them is that, on average, a quarter of nursing home residents are prescribed anti-psychotic drugs, and eight out of 10 of those who receive such drugs are the victims of inappropriate prescribing. What do those who undertook the research mean by that? They mean that the prescribing bears no relation to the condition that the person has; in other words, they gain no benefit from using anti-psychotics.

The studies also consider the issue of poor record keeping, which makes it hard to see whether there was a real purpose to prescribing the drugs in the first place. Beyond that, the studies examine whether adequate attempts were made to reduce the dosage of the drugs that were prescribed and whether there had been a medicine review.

Medicine review is one of the keys to unlocking the problem of the inappropriate use of medication, and the Committee explored the issue with the Minister, officials and others. It is worth bearing in mind that the national service framework says that older people who are on less than three medications should have a medicine review every 12 months; if they are on more than three medications, they should have a review every six months. One piece of research that I looked at, which was drawn to the Committee's attention, showed that about two thirds of GPs did not have adequate systems in place to deliver those NSF goals. There are some interesting comments about that on page 8 of the response

"The National Service Framework for Older People required that, by April 2002, everyone aged 75 or over should have their medicines reviewed once a year—every six months for those taking four or more medicines"—

I apologise for saying that it was three medicines. The response continues:

"The Medicines Partnership Taskforce has undertaken a review of Primary Care Trusts to determine the extent of medication reviews carried out as per the National Service Framework requirement. Results will be available shortly."

I hope that the Minister can tell us whether those results have come through or, if not, when they might be made available so that we can get our hands on them. It would be useful to see them.

The concern about reporting comes through particularly in the evidence that the Committee received from the then National Care Standards Commission, after its first look at medication reporting. In its first full year, the commission found that 1 per cent. of care home providers exceeded the medicine standards, 45 per cent. met them and 42 per cent. almost met them. We had an interesting exchange with the commission about precisely what that meant, and we deduced that about half of the care homes in the 42 per cent. that had almost met the standard could not be dealt with easily or quickly and that a programme of work would have to be put in train. Some 12 per cent. of care homes—about 1,600—completely failed to meet the medication standard.

The Government's response suggests that the evidence this year shows an improvement, which is good. Again, it would be useful if the Minister could share a little more of that information on that. However, the commission told us that the majority of prescribed medicines used in care homes are provided by a GP because care staff, not users, ask for a repeat prescription. That is an interesting and significant fact. As the Government move down the road of pharmacy repeat prescribing, we need to be absolutely certain that the new pharmacy contract is aligned properly with the GP contract, to ensure that it, too, incentivises medicine review and that critical thought is applied to those repeat prescriptions.

Photo of Sandra Gidley Sandra Gidley Women and Older People, Non-Departmental & Cross-Departmental Responsibilities

Recommendation 12 says that

"a review of the medication of care home residents should be conducted by their GP every three months".

Given what my hon. Friend said about the changing role of pharmacists, does he agree that they would be in an excellent position to conduct a review if the problem is one of resources?

Photo of Paul Burstow Paul Burstow Shadow Secretary of State for Health

Resources must one of the constraints on a GP's ability to take on the increased work load that would flow from the NSF. The new pharmacy contract should be fully aligned with the GP contract in that respect, so that pharmacists who deal with repeat prescribing are mindful of the need to review the prescriptions as well. The issue is not only about the volumes, but about whether the individual benefits. Pharmacists could play a useful role in that.

My concern about aligning the GP contract with the pharmacy contract relates also to recommendation 11 and the Government's response. Among the indicators in the contract, there are

"two that specifically incentivise regular review of medication."

They are:

"A medication review is recorded in the notes in the preceding 15 months for all patients being prescribed four or more repeat medicines (worth seven points)"; and

"A medication review is recorded in the notes in the preceding 15 months for all patients being prescribed repeat medicines (worth eight points)."

The Government's response says 15 months, yet the NSF talks about 12 months for people on fewer than four medications and six months for people on more than four medications. How do the terms of the GP contract fit with the NSF? How can we be confident that we are sufficiently incentivising the delivery of the NSF on the basis of the Government's response? It would be useful if the Minister said more about that.

Protection of vulnerable adults has been mentioned. I look forward to hearing the Minister talk about the NHS, which will be brought into POVA in due course. We had an exchange about that in the Committee, so will the Minister say where the Government are on rolling that out? Can the Minister say a bit more about the timetable for the General Social Care Council? The Government say in the response that they will hold a discussion with the council. When will that take place? As the Minister knows, the council is due to register about 60,000 people a year. However, there are about 1.2 million people in the work force, which would mean we would have to wait until about 2023 before everyone was registered. Having a clear sense of what the next priorities will be—the Committee thinks that they should include domiciliary care—would be useful.

One of the most interesting and illuminating things about "No Secrets" was the memorandum of evidence that the Department submitted as part of our inquiry. The Department referred to work that it had commissioned from the Centre for Policy on Ageing. On page 45 the report quotes the memorandum, which said:

"The analysis indicates that by and large local councils have met the requirements required by No Secrets and that considerable progress has been made towards improving co-ordination between agencies when dealing with adult abuse cases."

I have had a chance to look at the survey to which the memorandum referred; it contains a useful table at the back, detailing whether or not local authorities are compliant with various aspects of "No Secrets". Those details add to my concern about whether "No Secrets" really is getting sufficient traction on the ground in making the difference that we all want it to have.

For example, the designated lead officer across the organisations is someone at whom the buck stops for delivering "No Secrets". However, when the survey was published—in June 2002, I think—61 per cent. of respondents did not have a lead officer. That is a worrying statistic. The situation may have significantly improved in two years, but we are as yet none the wiser.

We have talked about training, which is a serious concern. When asked about

"Reference to existence of adult protection training plan",

79 per cent. of respondents answered in the negative, and when asked about

"Reference to production of available public information" about plans to protect vulnerable adults, 86 per cent. had nothing to say. Mr. Amess rightly talked about how we make people more aware of the problem so that we, as a community, can safeguard people. "No Secrets" does not appear to have the strategies in place to ensure that everyone knows what they should do if they suspect abuse so that they can report it to the appropriate authorities, who can then take action. At least, such strategies were certainly not in place in 2002.

I am sure that we would all agree that we want to prevent abuse in the first place. "No Secrets" states that 79 per cent. of correspondents said that they did not have a dissemination plan for a preventive agenda. More disturbing is the evidence of service development priorities identified around the preventive agenda; some 91 per cent. said that they did not have any. I entirely understand that the Department wants to reassure us and to give us the impression that it has a direction of travel and is committed to dealing with the problem. I do not underestimate the Government's commitment or their desire to deal with the problems of elder abuse, but the memorandum of evidence gave too glowing a picture.

The "No Secrets" table, and plenty of other statistics that I could have given, show that we cannot be confident that we are making the progress on the ground that we want to make. That is why I am worried by the Government's response to the suggestion of a joint inspection of adult protection along the lines of "No Secrets", which was, "Well, we might do that in the future, but there is a whole host of other pieces of work that we will do first." Again, will the Minister say what sense of urgency the Government have, and what the time scales might be?

The hon. Member for Southend, West was absolutely right about the need for advocacy. That point arose in the context of the draft Mental Incapacity Bill, which will provide an opportunity to explore the matter further as it passes through this House. The evolution of advocacy services in this country seems to have been piecemeal. We should examine more closely what is being done in Scotland, which has developed an advocacy strategy at national level and is working closely with local organisations to develop grass-roots advocacy services. At the moment, living in an area that has advocacy services of a quality that meets one's needs is happenstance and a matter of good fortune. Not every area has them. They need to be provided universally to meet the needs of vulnerable people.

As I said at the beginning, the wider debate is about the attitude that we, as a society, have to older people and the language that we use. Our language colours our acceptance and our willingness to be as concerned about the abuse of older people as we might be about the abuse of children. I think of the words that are bandied about in television programmes, such as "grumpy old", "boring old", "silly old" and "dirty old". In this place, we use language such as "demographic time bombs". We do not use the phrase "bed blocking" quite so often these days, but it has been used. All that serves to turn older people into a problem rather than what they really are, which is members of society; citizens who have made a contribution and continue to do so. The best way of safeguarding older people is to change and to challenge how we, as a society, think about them.

The inquiry and the report have cast a spotlight on abuse. I hope that, after today's debate and the Government's response, the spotlight does not move on to something else. Too much about elder abuse is still hidden. The spotlight needs to stay on elder abuse until it is all exposed.

Photo of Richard Taylor Richard Taylor Independent, Wyre Forest 3:38 pm, 1st July 2004

I, too, express my regret that Mr. Hinchliffe cannot be here today, but I thank John Austin for introducing the debate so well. That does not leave someone who gets left until rather late in the debate with very much to add, but I do want to make several points.

We discussed the definition of abuse, but we did not describe the definition of "elder". In an idle moment, I looked for the definition of the word in a dictionary or two, and picked out my favourite—the 1907 edition of "Webster's" dictionary, which defines it as "advanced beyond middle age." I then looked up "middle age". In 1907, middle age was 30 to 50. A slightly more modern edition of "Webster's" was not quite so definite. It defined middle age as being

"between youth and old age."

It went on to quote somebody called Harrison Smith, who referred to

"that increasingly elastic expanse called middle-age".

I was relieved last week to see that middle age now extends to 69. So, there are only 16 members of the House who qualify at the moment.

I shall pick out only a few points. Abuse at home has already been mentioned by several hon. Members. Like Mr. Amess, I was staggered to find that 67 per cent. of the cases of abuse that are recorded occur in people's homes. It is worth reminding the House that the report picked out the risk factors that help people to spot that abuse might be occurring in a patient's own home. The first factor is isolation. Elderly people who do not get out and do not see other people are particularly vulnerable. There is also often a poor quality long-term relationship in the house, a pattern of family violence, and dependence of the abuser on the abused. The abuser may have a mental illness or a personality disorder, or there may be an issue with drugs or alcohol. So, there are certain pointers that mean that, with more training, people who come across such cases can pick up on abuse.

Inspection has been mentioned by several hon. Members. It came to my notice when several of my constituents who are on the list of recognised lay inspectors came to a surgery. They were very concerned that, with the change from the National Care Standards Commission to the Commission for Social Care Inspection, they were being neglected and forgotten. I asked a parliamentary question on the subject in 2003. Apparently, there was a pool of 84 trained lay assessors in 2002. In 2003, the number had declined to 77. My constituents were worried that their expertise was going to be lost.

In the inquiry, I was pleased when one witness—Tessa Harding, senior policy adviser for Help the Aged—said:

"I would say that I think lay involvement is absolutely essential. What we should be aiming to do is encourage open cultures. It is the closed culture, the closed institution that breeds the potential for abuse, not always abuse but at least the potential for abuse."

I was pleased to note that the answer to recommendation 10, which Mr. Bradley drew attention to, states:

"The Government values lay inspectors as do residents of care homes."

Lay inspectors are very important and I ask the Minister to push the new organisation, CSCI, to say how it will involve lay assessors and use the pool of trained lay assessors who are not necessarily being used at the moment.

Physical abuse by over-medication has also been mentioned by several people. General practitioners can gain points under the new contract for reviewing drugs, but I think that it says that the review has to be entered in the notes. How is it planned to check on that? Will there be a random or a systematic review of notes?

In recommendation 13, we raised the possibility of making more use of local consultant psychiatrists and local consultant physicians with an interest in the elderly. They should perhaps have had a more regular input into what is happening in residential and nursing homes.

We mentioned the possibility of GP specialists. I am worried about that, however, because whenever we have an inquiry we recommend that GP specialists should take on more of the load.

I was pleased about the mention of pharmacists, because they visit hospital wards more and more and check on medication. A visit from a pharmacist to a nursing home to go through the drug charts and pick up incompatibilities would be very useful.

Recommendation 40, while I am discussing the professional side, refers to GP retainer fees. I was rather puzzled by the Government's response, the final sentence of which states:

"However, where the management of a care home that provides nursing care requires the professional services of a doctor or other health care professional to assist in the management of their business, the Government believes that it is reasonable for the business to bear that cost."

My understanding is that GPs are not retained to assist in the management of the business.

On the complaints process, I support what has been said that it is quite unrealistic to think that an elderly person who is alone has a chance of talking to the patient advice liaison service or the independent complaints and advocacy service. In my area, ICAS representatives will go around and talk to people, but elderly people must know how and have the ability to get in touch with ICAS. That brings me back to the importance of lay visitors who go in during an inspection and see some of the residents on their own without anyone else being present.

Training was mentioned by almost every witness as being by far the most important single factor to come out of the inquiry. There should be better training in the recognition of elder abuse.

My final point concerns what happens in ordinary NHS hospitals. The hon. Member for Southend, West alluded to abuse by omission when food is just put in front of a patient who cannot eat it. I have had distressing examples drawn to my attention. One was of an elderly gentleman who sat sideways on a trolley, trapped in position by the cot side of the trolley. The only reason for that was that the overworked staff on the ward could not control that poor old chap in any other way. Elderly people are shut in side wards where they cannot get out.

I remember from my own experience real difficulties in controlling elderly, confused people who were wrongly placed on an acute ward. For the good of the other patients, who had recently had heart attacks and desperately needed a quiet night, the only way of controlling elderly, confused patients for the duration of the night was sedation, which, in the circumstances, was probably given not for the good of the patient concerned, but for the good of the other patients on the ward. There certainly needs to be more training in how to cope with such problems. A physician or psychiatrist who is interested in the elderly could be called in the next day to provide expert help.

The report has raised many important issues and has provided some good answers and some inadequate answers. I remind the Committee of the book by Paul Flynn entitled "Commons Knowledge" in which he sets out 10 commandments for Back-Bench MPs. The best is:

"Neglect the rich, the obsessed, the tabloids and seek the silent voices."

These really are the silent voices—the elderly and abused who live on their own in their own homes. If we can draw attention to these silent voices, we shall have achieved something.

Photo of Sandra Gidley Sandra Gidley Women and Older People, Non-Departmental & Cross-Departmental Responsibilities 3:50 pm, 1st July 2004

It is nice to be back with Health Committee members. I have missed you lot—life is not quite the same without our weekly get-togethers.

I recall a letter I wrote in my dying moments on the Committee. Someone wrote to me about a subject and asked me to put it forward as a suggestion. I wrote to him to say, "I'm sorry. I'm off the Select Committee now, but I will pass the suggestion on." I told that person to be of good cheer, because my successor is my hon. Friend Mr. Burstow,who is passionate about the subject. Without doubt, he will make a strong case. I do not know whose decision it was—

Photo of Sandra Gidley Sandra Gidley Women and Older People, Non-Departmental & Cross-Departmental Responsibilities

I thank the hon. Gentleman. I am sure it was the Committee's decision, but the inquiry is nevertheless welcome.

Hon. Members have drawn comparisons between the Margaret Panting and Victoria Climbié cases. It struck me that cases of elder abuse may make the local paper—it is not seen as much of a story—but child abuse is headline news. Social workers are hung out to dry, people ask how such a thing could happen and so on. Sadly, society treats the two cases very differently. That is something we must address.

I am very impressed by the Health Committee's report, which contains some thoughtful and strongly worded recommendations. I would not have expected anything else. Am I being a little churlish in thinking that the Government response is just a little complacent and wishy-washy?

Photo of Sandra Gidley Sandra Gidley Women and Older People, Non-Departmental & Cross-Departmental Responsibilities

The hon. Gentleman says from a sedentary position that I am being very churlish. Well, I am not alone.

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health)

As a member of the Health Committee, I said that because I do not think that by any stretch of the imagination one could describe the issue as party political—except, perhaps, in respect of the Liberal Democrat party. There are times in politics when, if only for one's self-respect, one should give some due credit if the Government issue a response that is meant to be helpful and is constructive in advancing the situation.

Photo of Sandra Gidley Sandra Gidley Women and Older People, Non-Departmental & Cross-Departmental Responsibilities

I was intending to give some due credit to the Government, but I think that their response is not good enough. It may have its heart in the right place, but I do not think it is committed to enough action. I shall go through some recommendations and responses, and perhaps the hon. Gentleman will agree with me. In case he thinks that I am alone, I refer him to this week's Community Care magazine. The opening paragraph of one article says:

"The government is being urged to tear up its response to the health select committee inquiry into elder abuse and start again."

I am being quite mild compared to that. Action on Elder Abuse said

"the lacklustre reaction indicated a failure to 'hear or fully understand the difficulties and shortfalls within the current system'."

Photo of Stephen Ladyman Stephen Ladyman Parliamentary Under-Secretary, Department of Health

Like Mr. Burns, I do not want to make the matter party political, because I think it is one where we share a lot of common ground, but the article the hon. Lady is referring to was no doubt prompted by the press release from Action on Elder Abuse of 23 June. Perhaps if she had done a little more research she would have seen its press release of 29 June, which is headed:

"Organisations Welcome DH Response at Meeting on Elder Abuse."

It pointed out that, having discussed the report, the organisation has revised its view and now realises that we are making major progress. It also said:

"We have all commended Stephen Ladyman's commitment to the protection of vulnerable adults and support him in the work he has undertaken so far."

Photo of Sandra Gidley Sandra Gidley Women and Older People, Non-Departmental & Cross-Departmental Responsibilities

I wait with bated breath to see what next week's press release says. If that organisation is not enough, Gordon Lishman said that the response was "a bitter disappointment" and that

"the Government had taken the view that the existence of advice and helplines was an adequate response to the select committee's call for advocacy."

I do not wish to be churlish and I do not seek to make party political points, but we must examine the Government's response. There are cases where we all agree that the problem must be dealt with and we can legitimately question whether enough is being done. By asking those questions I got a positive response, such as the one a few moments ago. There is no problem with raising some of those issues.

I will canter—unless I get held up by interventions—through some recommendations that received an inadequate response. John Austin agreed that extending the definition of elder abuse is a good idea. The Government's refusal to widen it means that they fail to understand the wider problem. As Mr. Amess pointed out, the Minister is unwilling to accept the figure of 500,000. The Government's response states that

"the Department of Health will continue to express reservations about the figure" because of the wide definition.

I accept that some work has been done since the definition was produced, but we are into a circular argument because if one widens the definition, one increases the number of people who are suffering abuse according to the official description. The problem is that there are categories of abuse that the Government are unwilling to consider. The categories are, nevertheless, abuse at some level. It may be a low level, but if we do not intervene at that level how do we know that a higher level of abuse later on would not be prevented?

Recommendation 6 acknowledges that a great deal of abuse takes place in domiciliary care. The hon. Member for Southend, West legitimately highlighted the fact that the Government are rightly trying to encourage more people to receive care at home, if they wish. By the same token, those people are put in a vulnerable position. It becomes even more important that people in their own homes have almost greater protection than those in a care home, because in a care home—unless there is institutionalised abuse, which, I hope, is being eliminated—there are usually other people around to see what is going on, which adds checks and balances to the system. The same may not be true of a vulnerable older person away from their family who sees only the domiciliary care worker. Indeed, they may not have any close family.

I am not saying that all care workers are a problem. We must acknowledge that a small number pose a problem, however, and they should not be given any opportunities to abuse. I welcome the introduction of the protection of vulnerable adults scheme, but the work force lack knowledge of it. That was highlighted by a constituency case where something inappropriate happened not to an older person, but to a younger person. Nevertheless, none of the workers seemed to be aware that such a programme exists, so I would be interested to hear from the Minister what measures are being introduced to ensure that staff dealing with people are aware of it.

The Select Committee rightly acknowledged some inadequacies in regulation. It said that

"the failure of the National Minimum Standards for domiciliary care to require reporting of adverse incidents is an anomaly that should be removed."

That is one of the responses that I am very disappointed with. The attitude seems to be, "Well, hmm, let's not do this." For example, there could be an adverse incident that has nothing to do with the domiciliary care agency that is providing support. It could be inappropriate and burdensome for that agency to have to report the incident, particularly when family members or other agencies, including health professionals or the police, might have taken the necessary action. However, they might not.

Would we take the same attitude towards children? I return to the opening gambit of many of today's speeches, because that attitude seems to be at odds with the response to recommendation 10, which talks about producing

"a policy pack to provide support to organisations in developing and/or reviewing whistle-blowing policies and procedures."

I think we live in a culture where we sometimes look the other way and think, "Oh, somebody else will pick up on this problem." I want the onus to be on people to report a problem if they believe that there is one. As has been mentioned, we are talking about vulnerable people. We should provide every protection rather than providing get-outs.

I will briefly touch on training, which is often cited as a cure for the problem. The attitude is, "It's okay, because everybody will be trained." Of course training is good and I am delighted that the Government want staff, particularly in care settings, to be trained to NVQ level 2. In care, that level includes a compulsory unit covering elder abuse. That is good, but in relation to a parliamentary question I asked on 4 May the Government have no idea how many home-care workers have achieved that level and how many have yet to achieve it.

Work in various publications has highlighted the gap, and it could be some years before all staff have managed to access that training. We must bear it in mind that the care home sector is in a state of churn because of the low wages that have been alluded to. There is high staff turnover and an ongoing need for training. If the Government have any up-to-date figures on the percentage of workers in the field who have been trained, it would be useful to know what they are.

My hon. Friend the Member for Sutton and Cheam spoke at length about medication and covered some points that I was going to mention. There are two aspects to medication abuse. When I worked as a pharmacist years ago, the problem was intentional abuse—the administering to older people of medication to keep them quiet. We have come a long way since then. If people think that things are still bad, they should know that, in the early 1980s, nursing homes were able to order packets of 500 sedatives and dish them out willy-nilly, supposedly under the care of a GP. The previous Government rightly changed that. All prescriptions now have to be on a named patient basis.

Working with one particular home was illuminating for me. It had a high rate of dispensing—that was great as it provided lots of income for a pharmacist—of those medications. The home was taken over by new owners, who decided to review the medication. Practically overnight, they took most of the elderly patients off the sedatives. There were no adverse effects; the older people did not need them. Those medications were just being used as a chemical cosh. Clearly, that is a separate issue from the standard medication reviews of older people.

My hon. Friend the Member for Sutton and Cheam rightly highlighted the fact that, last year, only 45 per cent. of care homes met the standard. He also rightly emphasised that the incentives for doctors do not match the criteria for older people in the NSF. We did some research to find out whether the situation has changed and sent out a survey to all the primary care trusts. We received a good response, but found out that 48 per cent. of the PCTs that responded were unable to provide information on the frequency of the review. Of the 50-odd per cent. that did, 65 per cent. said that they gave annual reviews to over-75s, and 72 per cent.—slightly better—said that reviews took place every six months if the person over 75 was taking four or more medicines.

I understand that the Government are to produce some new findings on that, but it is disappointing that this issue simply is not being addressed at the primary care trust level. I do not know whether that is because the target is not linked to money, but it is clear that the NSF is not having an effect in delivering care and the right services, which we all genuinely want people to receive.

Recommendation 16 deals with physical restraint. Again, I find no fault with it, but I was a little disappointed by the Government's response, which seems half-hearted. They say that it is up to the Commission for Social Care Inspection to publish findings and that further clarification would be helpful. Forgive me if I am wrong, but I do not believe that that is a very strong response. Perhaps the Government are active behind the scenes or perhaps it is the wording, but something inappropriate is being touched on and I would like a strong commitment from the Minister that efforts will be made to discover the extent of the problem, if it exists, and to address it.

I have already discussed mandatory training, but I want to mention nurses. Recommendation 21 says that all nurses and care workers should receive mandatory training of some sort. Again, I feel that the Government's response could have been better:

"Qualified nurses progress into specialist areas such as elder abuse services by undertaking post-registration specialist training."

All well and good, but that completely ignores the fact that someone who goes into medicine today and works in the acute sector will treat a much larger proportion of elderly people. The Government should make a strong recommendation to the Nursing and Midwifery Council that relevant training be a core part of the curriculum. In many ways, as with child abuse, people do not always know what to look for. Training on how to identify problems would be helpful in ensuring that adequate safeguards are put in place when people who may have been subject to abuse of some sort in a home setting return to that home.

I quote at my peril a comment from a discussion that I had with Dame Deirdre Hine, who is passionate about these issues. She said that anyone going into medicine these days needs to accept that geriatric medicine, as we used to call it, will be a core part of their business, because, on the whole, that is what they will deal with as people become healthier.

We may not have liked the patient advocacy changes, but some, although they are in a bit of a muddle, work well at a local level. However, I return to a figure that has been quoted a number of times: 67 per cent. of abuse takes place in victims' homes. I am not sure who is the advocate for those receiving domiciliary care services. I am particularly concerned because of the increased move towards direct payments, and the fact that those do not seem to be adequately covered. It has been recommended that people providing services via direct payments be registered, but there is no compulsion.

People who access services by direct payment receive back-up of variable quality from county and city councils, depending on the individual dealing with them. Some are proactive and keep closely in touch, but—as I know from case studies that I have received—others leave people feeling slightly abandoned. They have been persuaded to go on to direct payments, but have found those difficult. They have coped initially, but when the person being cared for has deteriorated, the practicalities have made the situation more difficult. It is hard to know who the advocate is in such cases.

While I am on the subject of domiciliary care services, I have concerns about the consultation on relaxation of checks through the Criminal Records Bureau. In a care home, where people are appointed to oversee what is happening, there are checks and balances; other staff will spot a rotten apple. To allow a worker to go into a domiciliary care setting after minimum supervision, and then only ad hoc, is a matter for concern. It may be that the consultation has picked that up and it will not happen, but I would be grateful if the Minister clarified the situation regarding CRB checks in relation to domiciliary care. We need to provide more such checks and balances, not fewer.

May I talk briefly about the single assessment process? It is a good thing but, in the recent survey of PCTs, many reported problems in completing it. A couple of years ago, only one in five were completed within two days, about half in two weeks and just over 70 per cent. within six weeks. Only 44 per cent. of care packages were received within two weeks. If the Minister has figures to show that the situation has improved, they will be very welcome, because I believe that joining the services in the way that is planned can only be to the good. However, there are clearly concerns that delays in the system might tempt people to take short cuts.

Finally, I am delighted to learn that the POVA initiative will be implemented on 26 July. However, as the deadline has slipped a number of times, can the Minister confirm once and for all that that will be the date?

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health) 4:14 pm, 1st July 2004

Like my hon. Friends and colleagues on the Select Committee, I welcome the report. The Committee was unanimous in its decision to embark upon it, following private discussions to which Sandra Gidley was not privy. However, Liberals never fail to try to jump on a bandwagon and gain credit if they think that they can get away with it.

This is an important debate because, as many have said, at all levels—Government, police, newspapers and possibly here, too—the difference in the response to cases of child abuse and to cases of elder abuse is staggering. I suspect that that is partly due to naivety on all our parts. We simply do not, or did not, believe that elder abuse could be going on—certainly not on the scale that it seems to have been happening. That is why it is important that the report, debates such as this, Government responses and interested parties outside this building have focused attention on the matter. Together, we can seek to come up with ideas, and means and mechanisms by which to try to minimise or even to eradicate—if that is humanly possible, though that may be a little idealistic—the problem, which is a stain on any civilised society.

I shall concentrate on three main areas: definition, prevalence and the role of CSCI in moving forward and seeking to minimise the problem in society, as it has an important part to play in that. Much has been said about the "No Secrets" report and its six definitions of elder abuse. I have noted the Government's response. I wish that they would be a little more adventurous with such definitions. The obvious ones—physical, sexual and psychological abuse, financial or material abuse, neglect, acts of omission, and discriminatory abuse—will come to everyone's mind but, as has been pointed out, the majority of care of the elderly is domiciliary and carried out in the home, and that is potentially far more dangerous in terms of opportunities for abuse.

At least in a care home there are lots of people working together and lots of residents, so people are more aware of others' actions. It is much easier, for various reasons, for abuse to be carried out or perpetuated in a one-to-one situation in someone's home without anyone discovering the nature of that abuse. It may not be discovered because of victims' feelings of fear, low self-esteem or shame, even though the abuse is no fault of their own, and because they would rather keep quiet and have the matter swept under the carpet than face the difficulties that would come with exposing the perpetrator of the abuse.

Another form of abuse is the rapid change of people providing domiciliary care. That is a form of abuse because there is no continuity or security of service by one individual, who can build a relationship of trust and understanding with the client.

The Government are right not to expand the definition, so that it becomes almost meaningless because it has been diluted so much, but I ask them to remain open to the possibility of expanding, or fine tuning the definition if and when it is thought to be relevant and useful to do so. I agree with the report's recommendation that the definition should be expanded to include individuals who do not require community care services but may have some assistance, particularly if they live alone in their homes. Abuse is not contained by any Government definition. That would be helpful.

The extent and prevalence of abuse is another problem. That is partly because people will not speak out for various reasons, and partly because of the nature and setting of abuse—with domiciliary care, in an individual's own home, for example. It can be difficult to detect, expose and stop abuse in such situations. That does not mean that we should not seek to do so, and to put in place mechanisms and procedures to expose such abuse, but it makes it much more difficult.

While we were taking evidence and during this debate, a lot has been said about the figure that has been bandied around of half a million cases of abuse. I have considerable sympathy with the Minister and the evidence that he gave to the Select Committee. It is intellectually ludicrous to use the figure of half a million as a fact when that figure was discovered, for want of a better word, in 1992 as part of a survey and was then extrapolated. That is no sound or scientific basis on which to try to quantify a problem.

The important thing is to move on from the figure and the way in which it was concocted and to ensure that there is proper research to reach a meaningful and realistic identification of the scale of the problem. If we do that on scientific and factual evidence rather than extrapolations that are 12 years out of date and were highly suspect from the beginning, that will help to guide us on the ways in which we can move forward to the far more important issue. Rather than bandying around statistics, it is far more important to come up with procedures, policies and mechanisms to minimise the problem.

That is why I have more sympathy with the Minister than the recommendation in our report did—although I did sign up to the report. I welcome the Department's response to the matter, the money that it has given to Action on Elder Abuse, and the other measures that it has taken to try to expand our knowledge on a more factual basis. Anyone with any common sense would agree that that is the right way forward.

It is not simply a question of numbers and arguing about that. We must spend more time gleaning information on the ground to establish across the board the depth, extent and scale of the problem. In one of those areas, a great deal can be done. That is spelt out in paragraph 160 of the report, which states:

"We recommend that the shadow Commission for Social Care Inspection, the successor body to the National Care Standards Commission, should review its care home inspection methodology and ensure that where possible more conversation takes place with service users to validate their findings."

That is crucial. Often, as I go around the country visiting care homes, their owners, those who work in them and the residents, I hear their complaints. One of the complaints that comes up time and again, particularly from care home owners—it is a valid complaint—is that, under the National Care Standards Commission, when the inspectors went to inspect the homes, they spent far too little time speaking to the clients in the home, who of course have the greatest experience of the way in which they are being looked after.

It is interesting that paragraph 159 of the report states that Action on Elder Abuse

"recognised the contribution the Commission made to improving practice but considered there were inherent limitations on what could be validated through an inspection process. In their view, much of the inspection work of the NCSC focused on processes rather than outcomes."

That is a crucial observation. The report continues:

"They illustrated this by citing the NCSC survey of 100 inspection reports, randomly selected, which showed that in only 7 per cent. of cases had the inspector sought to validate what was being said by homes staff through conversations with service users. A similar view was put to us by Frank Ursell of the Registered Nursing Homes Association, who argued that the NCSC has been driven by reporting on policies, not by seeing if policies work."

That is a perspicacious comment, and there is a great deal of truth to it.

There is a danger that those involved in regulation and inspection go native and become more concerned with filling in forms and reporting on policies than with the more important issue of whether those policies are being carried out in the way that Parliament, the Department and its Ministers intended and are having the greatest impact on raising standards of care.

I have had discussions with the Commission for Social Care Inspection. I found it refreshing to come across an organisation—it is a new organisation, although a great number of its staff have many years' experience in the sector—with such a sense of openness. It is quite open about the fact that it is interested in raising the standard of care, so that individuals benefit, rather than in ticking off this and that on a checklist and stamping X hundred pieces of paper when they have been dealt with in the right way. Ultimately, the quality of the care given to residents is the most important thing.

It is important that we have a regulatory body that is responsible for inspection and that has an open mind. It is good that we seem to have a body that recognises, as it told me long before this debate, that speaking far more to residents in care homes and recipients of domiciliary care is critical to fulfilling its functions and achieving its aim of raising standards. In that way, it can find out about their experiences—what they get from the service, what they are happy or not so happy with, and how the service can be improved. It is good that CSCI, rather than just talking about such things, is actually prepared to go out and do something about them. Given its determined rhetoric, I have no reason to doubt that it will be successful. It is refreshing that, for the first time in a very long time, we have a body that has refocused itself on what I think we all agree should be its crucial role.

Photo of Sandra Gidley Sandra Gidley Women and Older People, Non-Departmental & Cross-Departmental Responsibilities

I am grateful to the hon. Gentleman for giving way. He may be surprised to know that I agree. I have had similar conversations with CSCI, and I was similarly impressed. However, it is early days, and I have not yet managed to pick up a sense of whether the rhetoric and the ambition at the top are being translated into action at the grassroots level. Has he managed to reach any preliminary conclusions about that?

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health)

I am grateful to myself for giving the hon. Lady the opportunity to put her comments on record, because they show that she is following where I lead. I have spoken to CSCI's senior management, who deeply impressed me with their views about its direction, but I do not confine myself to talking only to the generals—I like to talk to the troops on the ground, too.

It is only early days and we should not forget that CSCI is a new body. However, it was taking on the role of an existing body, as well as some additional responsibilities, so its staff were not brand new when it started up and many of them have many years' experience in the care sector. Although it is early days, the message is going out loud and clear to the whole organisation that it is not the National Care Standards Commission but a new body, with some new responsibilities and a new head. The news is filtering down that it means business and means to work differently from the normal, stereotyped regulatory inspection body. It means to try to make a difference by putting the interests of the clients first without compromising quality or standards. It will be concerned with ensuring that minimum standards are achieved, and with what is over and above that. That is heartening.

I do not want to prolong the debate unduly by rehashing what many others have said, but I have one more point to make. It is a plea about the protection of vulnerable adults. I assume that the Minister will confirm the commencement date of 26 July, given that it has slipped a month—what is a month between friends? However, I urge Ministers, as I have in the past, to be very careful. I think that they have learned from the experience of the Criminal Records Bureau.

No one doubts that safety is of paramount importance, along with the checking and vetting of people, so that unsuitable people do not work with a frail and vulnerable group. We are all united on that aim, but we may differ on how to achieve it. In the case of the Criminal Records Bureau, the Government were warned that they were biting off too much too quickly and that there was not the manpower to carry out checks in the times that Ministers in Committee optimistically told us were enough.

Problems arose immediately and the CRB could not meet deadlines and targets and provide the necessary service. If checks that people need take ages and it is possible to earn more money per hour at Tesco, with less responsibility and fewer unsocial hours, most people will do that. To be fair, there have been improvements in recent months, after a rocky start, and more has been done to ensure that time scales are reduced for unproblematic checks.

To sound a cautionary note, I hope that, having learned from the problems with the Criminal Records Bureau, we do not encounter similar problems with POVA after 26 July. I hope that it will be a seamless service that will run efficiently and smoothly, to the standards and at the levels that are anticipated.

We are all interested in what the Minister has to say in response to the issues, which, as we shall see if we read Hansard tomorrow, boil down to broadly similar ones for most hon. Members. We must never forget that we are concerned with a frail, vulnerable and elderly group in society, which deserves the respect, care and protection that the state can offer. We must ensure that, when the debate ends, the report, the Government's response, the high hopes and the calls for action do not gather dust on a shelf in the House of Commons Library and in the bowels of the Department of Health. We must carry on and ensure that the problems that have been highlighted are tackled, so that we can remove this stain on our society.

Photo of Stephen Ladyman Stephen Ladyman Parliamentary Under-Secretary, Department of Health 4:34 pm, 1st July 2004

Seldom have I agreed with so much that Mr. Burns has said; it is a pleasure to follow his speech. I shall make a few comments on it in a moment, but I particularly wanted to refer to what he said about CSCI, which was also mentioned by Sandra Gidley. Both hon. Members are right; CSCI is going to be a little more flexible and open, and focused on outcomes, in addition to fulfilling its regulatory responsibility. It has wider responsibilities than its predecessor. It inspects not only the providers of care, but the commissioners of care, which is a completely new arrangement. That gives CSCI considerably more power and an extra opportunity that was not available to its predecessors.

CSCI's predecessor, the National Care Standards Commission, has often been unfairly criticised. We sometimes forget that it took over the inspection regime that local councils ran previously. Each local council had its own set of regulations and inspectors, and took its own decisions about how rigorously it would enforce those regulations. The commission's job was to pull all that together and try to create one organisation, yet it had only two years for that; indeed, it was two weeks after the commission was established before an announcement was made. In the period in which the commission operated, it did a remarkable of job of pulling those operations together.

The structures that the commission created might have seemed rather rigid. Also, there may have been problems with people's attitudes to regulation, especially where people had not been exposed to regulation before and had never had to work with any minimum standards, let alone the new minimum standards. However, the National Care Standards Commission did a remarkable job. The commission was concerned with inspecting, writing reports and dealing with them.

CSCI takes over that and inherits a situation that is far better than the one that the National Care Standards Commission faced. CSCI has the opportunity to grow up a bit and take the evolution to the next stage. That was what the hon. Member for West Chelmsford detected when he spoke to the senior management. The chair and chief executive of the commission are both focused on exactly what the hon. Gentleman described; a new openness, a willingness to talk, to be flexible—but still to demand that the national minimum standards are met—to inspect rigorously, and to try to drive forward the standard of care.

The chair and chief executive will, without question, have an impact on the subject that we are discussing, just as their predecessors did. One or two hon. Members who have commented have perhaps forgotten that the domiciliary care sector has been inspected only since 2003. The process is new to the sector. Whatever abuse or bad practice might have gone on prior to 2003, one would hope that people are now starting to address it.

There is no one in the Chamber who does not think that the problem is a scar on our society. Elder abuse is an awful thing. Hon. Members are right that we have closed our eyes to the problem in the past, that we have tried to think that it does not happen and that we have not given it enough attention. However, that is not to say that nothing has been done. In that lies my objection to the figure of 500,000 and the prevalence statistics on which it is based. As the hon. Member for West Chelmsford said, that figure was based on a survey that was conducted in 1992. The survey covered only 2,000 people, of whom only 600 were old, and used a very broad definition of abuse, which included raising one's voice to an older person. The attitudes of those 2,000 people were extrapolated to the entire population and were extrapolated from the older population in 1992 to the older population today. The survey assumed that nothing had changed since 1992.

The issue is not party political, so I am happy to say that things were happening even back in 1992, under the previous Government. In the middle of the 1990s, the National Health Service and Community Care Act 1990 started to kick in and major improvements were made. The hon. Member for West Chelmsford had my ministerial portfolio for a period. I am sure that he would be horrified to hear it suggested that nothing was done and that the matter was not taken seriously. I have no doubt that major improvements were made, even between 1992 and 1997.

Since 1997, there have been many improvements, with the National Care Standards Commission and the work that the Care Standards Act 2000 has brought about. The Criminal Records Bureau checks have created opportunities, the national minimum standards have been introduced and significant new investment has taken place. The "No Secrets" guidance has been issued. We can discuss whether its definition is right or wrong or whether we can make improvements, but all that has been done since 1992 and it is nonsense to suggest that it cannot have had some impact.

If the figure was 500,000, we must assume that it is less than that now. It may have been much higher than 500,000 in 1992 for all I know. We do not have good figures, which is one reason why I welcomed the Committee's report. The figure was perhaps helpful to the Committee and those of us interested in raising the profile of elder abuse, because it at least captured the headlines and got the country talking about elder abuse.

The Government's problem with the figure is that we have to make plans, and a 500,000-person problem requires one set of plans and a 1,000-person problem requires another and a different way of thinking. We do not yet know where we need to be, which is why I agree with the Committee that we must do the research and obtain some decent figures. We have asked Action on Elder Abuse to review the "No Secrets" guidance and the information that is held throughout the country under the "No Secrets" rules to see where its figures lead in relation to 500,000.

When I receive those results I will reflect on them and no doubt we shall debate them. We shall then decide where we go with the next piece of research. Without knowing the results of the review by Action on Elder Abuse, it would be foolish of me to commission further research, because I would lose the opportunity to guide it in the right direction. It is more sensible to obtain the first research, with a new figure and new guidance and then, if need be, commission further work to ensure more certainty about those results. We can base on our planning on that.

Photo of Sandra Gidley Sandra Gidley Women and Older People, Non-Departmental & Cross-Departmental Responsibilities

That is very good news, and I am glad that the Government have commissioned the review, but will the Minister tell us when the results will be available? What time scale are we looking at?

Photo of Stephen Ladyman Stephen Ladyman Parliamentary Under-Secretary, Department of Health

Offhand, I think that the results will be available in the next few months, but I am happy to write to the hon. Lady with the exact time scale.

I will try not to be overly party political, because we had a little hiccup in cordial relations in the Chamber earlier. However, I must point out the conflicts in the hon. Lady's comments. In one part of her speech, she talked about the need for more regulation, more data collection and more inspection of the domiciliary care industry; in another, she talked about the fragility of the industry and the staff churn.

When I make decisions about matters such as the relaxation of CRB checks, I have to resolve such conflicts. I would dearly like to say that nobody could start work in the care industry without a thorough and enhanced CRB check. However, when the National Care Standards Commission decided that as checks were taking only four weeks, it could adopt that position, we discovered that it became impossible for the social care industry to recruit staff, who are by and large lowly paid. If they cannot start work the following Monday, they go and work for somebody else. They are not prepared to sit around for a month waiting for work.

I would dearly love to address the training, skills, qualifications and pay structure of that work force. I am working on those areas; I have made speeches and organised conferences about them and tried to make employers realise that they must drive up standards to create a skilled work force. I have talked to commissioners and organised national conferences to explain to them that they must be prepared to pay extra for the use of services provided by employers who take those attitudes. It will, however, take a long time. If we introduce these things too rigorously, we will not be able to recruit staff until we have done all that work.

We must also consider the balance of risks. I have to balance the risk of older people not receiving the care that they need tomorrow morning because there are no care workers to provide it against the possibility that a few people might carry out acts of abuse under the radar. Balancing those risks is not an easy job. The hon. Lady might not have realised that the Commission for Social Care Inspection and its predecessor, the National Care Standards Commission, returned to the interim guidance that allowed people to start work without CRB checks so long as their pre-employment checks had been done and the CRB check had been applied for. CRB checks are done only where necessary. At the moment, however, that means that people could be working in domiciliary care for four weeks before their CRB check comes through.

It is still my intention to begin POVA on 26 July, although legally it is quite complex; there are one or two legal problems still to resolve. I hope to lay the regulations before the House next week, which will allow it to begin on 26 July so that Parliament will get an opportunity to discuss it if it so wishes. POVA proscribes anyone from working in this industry without a satisfactory POVA check. In other words, people will have to have a completed POVA check before they can start working. If they have to wait four weeks for that, we will be in exactly the same position that we were in with the CRB checks.

We are trying to put in place something called POVA First, which means that we will try to secure an immediate response to a POVA application so that an employer can find out within two or three days whether the person whom they want to employ is on the POVA list. That is followed by a period of induction training, after which the person can start work. That is an improvement on the current interim guidance because, for the first time, a check will be in place before the person starts work. However, there will not be a full CRB check in some cases, because that will not be available until a week or two later. I put my hand up and admit that that is a compromise. The situation is not as I want it to be, but the alternative is that no one starts work until the CRB check is in place, the industry grinds to a halt and older people do not receive the care that they need tomorrow. That would also be abusive, because they need that care to survive and to operate, so we need to make compromises.

One or two hon. Members talked about the "No Secrets" definition of abuse. I have a feeling that there is confusion about "No Secrets" and to whom it applies. "No Secrets" applies to people who are eligible for social care. It does not matter whether the council provides them with social care; they may be self-funders, but they are still eligible for social care, so "No Secrets" applies to them.

The hon. Member for West Chelmsford touched on a possible problem when he talked about the definition of elder abuse. I am happy to say that I will keep an open mind on that definition. I have no reason to be restrictive about it but, from a planning point of view, it may be about where the responsibility for it lies. It is clearly abuse when an older person is mugged while walking down their street, but one would not expect social care to be responsible for that form of abuse. A form of abuse for which social care is responsible is abuse in a care setting, by an informal carer, a relative or a person providing professional care.

"No Secrets" is concerned with abuse in a care setting, rather than the wider forms of abuse that might be suffered by people who do not otherwise have a care need, or who are not in a care setting. We can debate that. Maybe we have it wrong; I am prepared to listen to arguments. If we think that it would be helpful to widen the scope, then we can do so.

A spectrum of abuse has to be eliminated. At one end is criminal activity; horrendous forms of abuse in response to which none of us would have any doubt about what to do. We should catch the person who did it and put him or her in jail. That is one end of the spectrum. At the other end is a form of abuse that is, effectively, neglect; bad or incompetent caring. That is unacceptable as well. However, we may need different tools to detect the abuse at each point of the spectrum. The tools needed at the end of the spectrum that involves neglect and incompetent caring are training—to qualify the staff to look after people—regular inspection, management and leadership. My right hon. Friend Mr. Bradley spoke of management and leadership.

We often overlook in parliamentary debates the importance of management and leadership to any organisation. In an organisation concerned with care and the quality of care, management and leadership are vital. Some people think that abuse started when we brought the private sector into caring. That is nonsense. Why should people be more abusive because they work for one organisation or another? Others imply that the commercialisation of care is part of the problem and that if the state were providing all the care, abuse would not occur.

However, where was the worst example of abuse of which I have heard in recent years? It was in the constituency of my right hon. Friend the Member for Manchester, Withington, in a national health service ward; the Rowan ward. That was the worst place. It was an atrocious example of abuse. I do not know whether hon. Members read the report into that case. I read it over a weekend, and I am a pretty hard-boiled son of a bitch, yet I had tears in my eyes to think that that went on in this country in a care setting within the national health service.

We have to ask ourselves what went wrong. I have had meetings this week with the Community and District Nursing Association. One of the questions that I have put to it and to other organisations representing nurses is, "Why did no nurse report that?" They have a code of conduct that says that they are supposed to report such things. They have a professional and ethical duty to report them, but not one of them reported anything, so far as I am aware; not one of them did anything about it. Nor did any doctor. It was not low-paid staff who ignored the abuse, highly paid, highly skilled, highly qualified people working in a national health service ward ignored that form of abuse, and we have to ask ourselves why.

The reason is a lack of management and a lack of leadership. The culture of the ward was not one in which people felt confident to go and report that sort of abuse. That is a difficult situation to be in. If one sees bad treatment or abuse going on at the hands of one's colleague, one has to find somebody to tell. I do not believe the excuse, "We did not know who to tell." Everybody apart from the Prime Minister has a supervisor, and even the Prime Minister answers to the public and to Her Majesty. Everybody has a line manager to whom they can turn, or a policeman they can go to, or a matron or a chief executive. Everybody can find on the internet the Action on Elder Abuse helpline. Anybody could have written an anonymous letter and nobody did. We have to ask ourselves why nobody did so and why, whenever we hear of abuse in a care home, it becomes clear that, very often, it is not one person doing it—if it is one person doing it, other people know about it—and nobody does anything.

The problem is about management and leadership. It is about getting an ethos into places that allows people to report things and to say, "I won't take second best. I won't accept this and I'm going to do something about it." We are a long way from achieving that.

One of the things that I have been doing, and one of the reasons I am delighted that we are having the debate, is making a series of speeches about the new vision for adult social care that I announced that we would write in April. In those speeches, which have got widespread support on all sides of the House and in all sectors of the social care community, I have been saying that we have a model of social care that was essentially designed in the 1980s and 1990s and was appropriate for those decades. We are not in those decades anymore. We need a model of social care for our decade and the next one.

That model of social care must be about empowerment and about generating independence rather than creating dependence. It must be about putting structures in place that will not accept abuse and—more than that—will empower the people who receive care not to accept abuse.

That model must be so different from the way in which we deliver care at the moment. At the moment we say, "Somebody decides what care you need, puts a plan in place and does it to you". We need to get to a situation where we say, "You decide what care you need, with assistance and advocacy if necessary. You access the care, you are in control of it and when that care is not working for you, you can say, 'Stop, I want something else'."

That is why the hon. Member for Romsey mentioned direct payments. I think that direct payments are fundamental to the new vision of social care because they empower people to plan and deliver their own care and to say when that care is not working. Direct payment will allow us to put in place structures that empower older people to say when things are not working for them. With the regulatory regimes that we put in place—such as CSCI, the CRB checks and POVA—perhaps we can start making an impact on the problem.

I have also said that, in the new model of social care, we need to go beyond that. On Monday, I told the Local Government Chronicle that if we want to deal with these things fundamentally, we must start designing communities for ageing. Why are town planners and urban designers not involved with social services when we decide where to put accommodation for older people? Why, when people want to build sheltered housing, is the response not, "No, we don't want sheltered housing, we want extra care housing and we want you to put it in a certain place and design it in such a way that older people can remain part of their communities"?

If that happened, we could rebuild those informal networks of care that my hon. Friend John Austin, who introduced our discussions, mentioned, did as the hon. Members for Southend, West (Mr. Amess) and for Sutton and Cheam (Mr. Burstow).

Today I made a speech to the Salvation Army, in which I pointed out that those traditional forms of care—those informal care networks—are increasingly disappearing, because we are handing responsibility to the state to do our caring for us. We expect the state or commercial care to step in where previously family, neighbourhood and community were responsible for care.

The state cannot afford to do it all, simply because it would cost about £70 billion to replace all those informal care networks. So, in the new vision of social care, we must find ways to support carers and those informal care networks—neighbours and communities—that want to provide care. We must recreate some of that old-fashioned tradition.

I am not one of those people who think that everything was wonderful back in Victorian days. I was wandering around Broadstairs parish church a few months ago, reading the book of the parish guardians, which told of some chap who came in and asked for a shilling to support his destitute family for the next month. The parish guardians said, "We won't give you a shilling, we'll give you two shillings, so long as you get out of the parish and never come back." Those were Victorian values.

I do not hanker for such values, but I do hanker for some of the traditional, informal caring networks that allowed neighbourhoods and communities to say that abuse of older people was not acceptable and said that such things were horrifying. In such networks, leaving people on their own was not acceptable and not doing shopping for them was inappropriate. As children, we realised that we had duties to mum and dad, just as they had duties to us. It is only when we have done those things and realised that new vision for social care—one where we are genuinely trying to generate independence, put people in charge of their own care and create communities that care about older people—that we shall start making inroads into the levels of abuse of elder people.

In the mean time, we have to rely on many of the techniques and tools we have already put in place. We have to refine and review them in order to make them work better. We have to make CSCI and POVA work better and ensure that the national minimum standards are right. We have to ensure that commissioners are commissioning for quality when they buy services, that care providers are aware of their responsibilities and that training levels, qualifications and management and leadership are right. That is how we shall start making inroads in the short term.

I welcome the debate, the ideas in the report and the opportunity to continue working with the voluntary sector and others necessary to ensure the agenda comes together. The Government are not complacent; we know we have only scratched the surface of the problem. Whether the figure is 500,000, or 100,000, or one, it is too high. I know that, the Government know that and all of us here know that, but let us not kid ourselves that we can wipe it away through a few recommendations in the report. It will take long, hard work and a lot of money.

Question put and agreed to.

Adjourned accordingly at two minutes past Five o'clock.