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CHAPTER THREE: AN INTRODUCTION TO ADULT PROTECTION
Introduction
3.1 This chapter outlines the emergence of a critical debate in the United Kingdom on the necessity to develop an effective social policy strategy to protect vulnerable adults.
3.2 The contemporary rediscovery 1 of the necessity for adult protection can be identified in the UK with the first reports by Baker (1975) and Burston (1977). These early papers outlined the phenomenon of elder abuse and neglect as an issue within the family setting.
3.3 Almost at the same time, the United Kingdom was involved in a series of scandals within the health and social care sector (Butler and Drakeford, 2003; Manthorpe, Penhale, and Stanley, 1999; Martin 1984). The scandals in the 1970's 2 were mainly found in long-stay institutions providing care for older people or people with learning disabilities; reports involved evidence of physical abuse, psychological abuse, neglect, and in particular systemic failures of management at all levels and amongst all professions within the institutional settings.
3.4 In the early 1980's a new literature started to emerge cataloguing various forms of abuse and neglect inflicted upon people with learning difficulties and mental health challenges 3.
3.5 From the 1980's onwards, numerous inquiries have taken place across the entire health and social care spectrum, including residential and nursing homes, statutory and voluntary sectors, NHS hospitals (including wards for older people, people with learning disabilities, and people with mental health challenges), and 'special hospitals'. Such inquiries continue unabated 4. In Scotland in particular, the Report of the Inspection of Scottish Borders Council Social Work Services for People Affected by Learning Disabilities outlines substantial failings in services designed to protect vulnerable adults (Social Work Inspectorate Services, 2004).
3.6 The early 1990's were noted for much activity, with conferences and discussions debating the way forward in adult protection. In 1993, the Department of Health (DoH) and the Social Services Inspectorate ( SSI) launched guidelines for the protection of vulnerable adults for England, Wales, and Northern Ireland with a clear expectation that such policies:
"should be developed and implemented by a multiagency group and, where ever possible, owned and operationalised by all members of that group." (Bennett, Kingston, and Penhale, 1997: 13).
3.7 The 1990's was a period of much legal debate surrounding the aspiration for a legislative framework for the protection of vulnerable adults (Brammer, 1996). The emergence of the Human Rights Act 1998 was influential in framing concern around the issue of adult protection.
3.8 In 2000, the DoH launched ' No Secrets: Guidance on developing and implementing multi-agency policies and procedures to protect vulnerable adults from abuse' (DoH, 2000a). To date, the Scottish Executive has not produced any guidance similar to the ' No Secrets' framework. However, complementary development of adult protection policies and guidance have taken place in Scottish health and welfare agencies, influenced by, and modelled on, the ' No Secrets' guidance.
Definitions: abuse, harm, and neglect
3.9 Definitions are the most contentious area within the literature on adult protection. Concerning elder abuse and neglect (although such a statement could be generalised to any victim), Phillipson and Biggs (1995:202) stated:
"Attempts to define and map the extent of elder abuse indicate that it should not be seen as a single monolithic phenomenon, but that it takes a variety of forms in different settings and in different kinds of relationships." (Phillipson and Biggs, 1995: 202).
3.10 One logical way forward would be to offer definitions within different professional spheres; for example, Bennett, Kingston, and Penhale (1997) suggest: legal definitions, care management definitions, and research definitions.
3.11 The first formal British definition ('formal' meaning a definition accepted within a policy framework document) appeared in 1993:
"Abuse may be described as physical, sexual, psychological, or financial. It may be intentional or the result of neglect. It causes harm to the older person, either temporarily or over a period of time." (DoH, 1993: 3).
3.12 The Scottish Executive's (2005a) Consultation on Protecting Vulnerable Adults - Securing their Safety used the definition from the 'Action on Elder Abuse' charity, albeit with minor modifications 5:
"a single or repeated act or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes the adult distress." (Action on Elder Abuse, 2000: available online).
3.13 The ASP Act uses the following definition:
"harm" includes all harmful conduct and, in particular, includes:
(a) conduct which causes physical harm
(b) conduct which causes psychological harm (for example: by causing fear,
alarm or distress)
(c) unlawful conduct which appropriates or adversely affects property, rights,
or interests (for example: theft, fraud, embezzlement or extortion)
(d) conduct which causes self-harm
Characteristics of abuse
3.14 The dynamics of abuse are complex (Brown, 2003). Factors to be considered include:
- The nature (and underlying intent) of the relationship between the potential abuser and the "at risk" adult; for example, the process of 'grooming' in respect to a vulnerable adult
- The process used to gain and maintain access to the vulnerable adult; for example, a perpetrator using the workplace to gain access to "at risk" adults
- The degree or severity of the harm to the vulnerable adult (including psychological elements)
- The degree of continuing risk to the vulnerable adult or other "at risk" adults in the setting; for example, when an accused member of staff continues to have access to the vulnerable adult
- Situations where there might be multiple components of vulnerability; for example, sexual abuse between service users
- The need to consider the situation where a conflict of interest might occur; for example, where an attorney may be connected to a family member and have their objectivity compromised
Interventions
3.15 Protection and support for "at risk" adults is available at three stages:
- ' Primary intervention' aims to prevent abuse occurring in the first instance
- ' Secondary intervention' aims to identify and respond directly to allegations of potential abuse
- ' Tertiary intervention' aims to remedy any negative and harmful consequences of the abuse, and put in place measures to prevent future occurrences
It is possible to identify a variety of interventions reported in the literature which fall roughly into two categories: legal interventions or therapeutic interventions
Transitions
3.16 It is essential that the transition from children's services to adult services is managed professionally, effectively, and safely. Scotland appears to be well served with the Scottish 'Throughcare and Aftercare Forum' (Scottish Executive, 2007) 6. Whilst the focus of this forum is on transitions in a general manner, it is essential to develop dedicated services for children and adolescents who are "at risk" of abuse (or indeed children and adolescents who are at risk of abusing) and are moving into adulthood. It is imperative that adults who may not require supportive adult services are not lost to the system; methods of support and monitoring are essential in the early years of adulthood. The Education (Additional Support for Learning) (Scotland) Act 2004 requires education authorities to plan well in advance when a child or young person with additional support needs is preparing to leave school. Education authorities should ensure that the arrangements required for transition to post-school services and care are clear so that the child or young person, and all relevant parties, know exactly what is happening, when it is happening, and who is responsible.
Research
3.17 The review found that the evidence base for therapeutic or legal interventions is sparse. The task for researchers in the coming years will be to analyse and evaluate interventions. This task is only just beginning in this rediscovered and emerging area, but organisations like the National Institute for Clinical Evidence and the Social Care Institute for Evidence are fully aware of the need for clinical evidence. As services develop, systematic reviews of evidence will need to be undertaken to offer 'evidence based practice'.
Beyond health and social care
3.18 It is apparent, particularly in Scotland and in the UK to a lesser extent, that several organisations, including those involved in education, sport, and faith communities, are aware of the vulnerability of certain adults to abuse. It is essential that any organisation that has contact with vulnerable adults has both a policy for staff and volunteers and an educational strategy. Good examples of policy and procedure include the Scottish Endurance Riding Club (Thomson, 2004) and Scottish Cycling (Scottish Cycling, 2006) 7; faith communities have also acknowledged the potential for adult abuse 8.
3.19 Three other groups of adults have been reported as potentially vulnerable: refugees and asylum seekers (Williams, 2004: see 4.6); prostitutes (Clark and Squires, 2005: see 4.6); and offenders (The Scottish Parliament, 1999: see 4.6 and 6.4).
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