Is an escalation in regulatory activity the only answer to tackling the abuse of vulnerable people? Possibly not, says Billy Boland

At the National Children and Adults Services conference last month, Jeremy Hunt drew attention to the 112,000 cases of suspected adult abuse in 2012-13 in England, saying that something was “badly wrong”.

‘The real driving forces in uncovering abuse are those that deliver care: nurses, doctors and social workers’

Concerned about harm to vulnerable people including the elderly, he has argued that regulation of care is improving. In demonstrating his commitment to this, senior leadership in the Care Quality Commission has been revamped with the creation of new roles, including the post of chief inspector of social care, who Hunt has referred to as the “whistleblower in chief”.

Identifying poor care

He is looking to Andrea Sutcliffe, the post’s new incumbent and former chief executive of the Social Care Institute for Excellence, to lead the response in identifying poor care and enforcing improvements in practice. Less than two weeks into the job, she announced her intention to launch a consultation on the potential use of “mystery shoppers” and hidden cameras as new regulatory solutions to uncovering abuse, aiming to bring whistleblowing into the 21st century.

Sutcliffe is also intending to increase the use of people who have received of care, or “experts by experience” to carry out inspections and other regulatory activity, as a way of enhancing the service user voice regarding quality. People who have received care can bring a unique perspective in reviewing the way it is delivered, and can help to complete a more holistic assessment of a service.

It seems the intention is to employ these people alongside personnel Hunt has requested be more “specialist” than those the CQC has typically used. He has already made it clear that he wants to employ Ofsted-style inspections using professionals that have a more in-depth understanding of the services they are inspecting.

But is an escalation in regulatory activity the only answer to tackling abuse of vulnerable people? A more detailed look at the 112,000 cases suggests otherwise.

Hunt’s data is drawn from the Abuse of Vulnerable Adults in England provisional report 2012-2013, recently published by the Health and Social Care Information Centre. It provides information on adult safeguarding referrals for alleged abuse of vulnerable people from across the health and social care sector.

Of the 112,000 cases, information on the source of referral was known for 108,490. Of these, 47,030 were referred by social care staff and 23,620 by staff in health. Families raised 8,230 concerns and 2,335 people referred themselves. In contrast, only 1,810 (or 1.7 per cent) cases of alleged abuse were identified by the CQC, the body Hunt is charging with solving the problem. A mere drop in the ocean, these figures demonstrate the real driving forces in uncovering abuse are those that deliver care: nurses, doctors and social workers.

So what does this tell us? If Hunt’s desire to improve adult protection is authentic, then his faith in regulation as the solution is misplaced. Even if the number of concerns identified by the CQC doubles, this will remain only a tiny proportion of all referred cases.

Need for cultural change

Instead, resources might be better invested where the lion’s share of activity currently sits. In his report into Mid Staffordshire Foundation Trust, Robert Francis QC identified the need for cultural change in healthcare systems in order for concerns about poor practice, including abuse, to be more readily shared.

‘If we are to get to the root of the problem of abuse, then it makes sense to empower all staff, not just the regulator, to stop it before it happens’

Professionals in the health and social care sectors identify the majority of safeguarding concerns, so changing organisations to make it easier to speak out may be most likely to yield the greatest results. Enhancing leadership and investing in education on abuse will empower people to identify concerns sooner and act more swiftly.

And what of prevention? If we are to get to the root of the problem of abuse, then it makes sense to empower all staff, not just the regulator, to stop it before it happens. Helping vulnerable people better protect themselves, mobilising families, supporting colleagues while holding each other to account are all within our gift, but retain untapped potential.

Of course, regulation has its place and introducing new regulatory techniques such as those the CQC is proposing could do much good. However, this needs to be balanced against development of staff and services, so that the eradication of abuse climbs higher up their agenda.

For those most in need, people who use health and social care services rely on the staff delivering them taking action when things go wrong. Promoting regulation without investing in services risks creating a Big Brother mentality where staff are more afraid to speak out and concerns of abuse go ignored. For some of the most vulnerable people, this could make their vision of an end to abuse even more remote.

Billy Boland is a consultant psychiatrist and lead doctor in safeguarding adults at Hertfordshire Partnership University Foundation Trust

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