CHAPTER NINE: CONCLUSIONS
9.1 This chapter considers the characteristics of abuse, summarises the support and protection available to vulnerable adults, and draws out the key findings of the review.
Characteristics of abuse
9.2 Over the past 25 years, a growing awareness has occurred with regard to the vulnerability associated with adults "at risk" of abuse and harm. Adults who are deemed vulnerable or "at risk" of abuse or harm include individuals who have:
- Mental health challenges
- Challenged communication
- Learning disabilities
- Developmental disabilities
- Complex disabilities
- Physical disabilities
Adults "at risk" of harm may also include individuals who are:
- Older or elder adults
- Refugees or asylum seekers
- Drug users
- Sex workers
9.3 An awareness of the characteristics of perpetrators of abuse has also increased over the past 25 years. The majority of potential perpetrators are individuals who have frequent contact with a vulnerable adult, and can include:
- Staff within professional organisations (for example, health and social care professionals)
- Staff within voluntary organisations
- Relatives or close family members of the vulnerable adult
- Other vulnerable adults
Support and protection for "at risk" adults
9.4 Advice, information, and support services can be a source of primary, secondary, and tertiary support and protection for vulnerable adults. Charitable support services such as Sense, Depression Alliance Scotland, Alzheimer Scotland, and Age Concern are just a few of the organisations that provide "at risk" individuals with advice, information, and accessible support; these services can be accessed at any point by a vulnerable adult or relevant party regardless of potential or actual abuse. In addition, some support services (for example, Sense) actively work towards increasing the awareness of protection policies for "at risk" adults. Alzheimer Scotland also implements an 'involvement policy' which enables individuals with dementia to provide their own perspectives on various issues; for example through the Scottish Dementia Working Group. Enabling individuals to provide an insight about their experiences and issues that they might face contributes to empowerment of the individual and subsequently their mental well-being. This insight also provides an effective source of information and an educational tool for professionals and other individuals who come into regular contact with vulnerable adults.
9.5 Advocacy rights are included in the Mental Health (Care and Treatment) (Scotland) Act 2003, and can be a source of primary, secondary, or tertiary support and protection. Advocates are required to provide advice and support to vulnerable adults when their needs are being discussed, or at times of transition. A list of advocacy agencies has been compiled by the City of Edinburgh Council to facilitate access to independent advocacy services 37; the list is also effective in identifying the scale of provision within the area for "at risk" adults. There are significant gaps in independent advocacy provision for children and young people, older people, people with dementia, physical disabilities, and ethnic minorities. However, several safeguarding agencies (see 9.12) exist to provide support and protection to these groups, and are complemented by the current legislation within Scotland. Perhaps the largest gap in independent advocacy concerns "hidden" groups that fall outside the better known groups of vulnerable adults, such as homeless people, people with a substance abuse problem, offenders leaving prison, refugees and asylum seekers, and other marginalised individuals. Care must be taken to provide these groups with effective communication and to not contribute further to the marginalisation that these groups experience.
9.6 Interpreters can be used as a source of primary, secondary, or tertiary support in regards to abuse, and can be used separately or in conjunction with advocacy services or advocates. Interpreters are important in facilitating access to services for "at risk" adults, and can assist with a range of duties; for example, gaining informed consent from vulnerable adults with regard to medication, educating vulnerable adults with regard to certain types of abuse, and explaining various procedures, whether legal or medical. Poor interpreting can lead to the disempowerment of an individual, as well as contributing to an adult's vulnerability to abuse. A toolkit for people requiring interpreters within mental health and learning disability settings has been developed by the Mental Welfare Commission for Scotland. However, toolkits need to be developed for all groups of "at risk" adults who may experience impaired communication; for example, individuals whose first language is not English or those with communication difficulties due to physical or neurological impairments.
9.7 Counselling is a therapeutic intervention aimed at supporting a vulnerable adult who may have been subject to abuse. Counselling is used primarily in cases of domestic violence; nonetheless, the potential transferability of counselling to victims of other types of abuse exists. For example, in cases of psychological or discriminatory abuse, counselling can be used to support a victim subjected to either a single occurrence of abuse, or short, or long term abuse. The counselling directory is a comprehensive (online) list of counsellors within the UK, and can be provided to victims of abuse by health or care professionals; see 4.25.
9.8 Education has been noted as a significant and effective factor in reducing the potential for abuse and neglect of vulnerable individuals. Increasing public awareness through improved education, and advertising support and advice services will assist in identifying vulnerable and "at risk" individuals and cases of suspected abuse or harm.
9.9 It should be mentioned that online sources of information (for example, lists of organisations or advocacy services) are only accessible to those individuals who are computer literate, and have access to the internet. Organisations that have an online presence need to consider this when advertising sources of information, to ensure that all groups of vulnerable adults and other individuals (who may not have access to the internet) have the same level of access to information and resources through alternative means.
9.10 'Assistance lines' or 'telephone help-lines' can provide support and protection with regard to potential or actual abuse. Telephone help-lines have been developed in a number of countries and have been indicated as effective tools in providing information and support to individuals suffering from various types of abuse (for example, financial abuse or domestic violence). Telephone help-lines are also provided by various charitable organisations that provide free advice and support to vulnerable adults or potential victims of abuse.
9.11 Legislation can be implemented as a source of support and protection for vulnerable adults. Civil Law can be used by a person who is being abused, or by a person who feels they are at risk of abuse or harm, against a potential or actual perpetrator of abuse. Criminal Law within Scotland sanctions the prosecution of an individual accused of a criminal offence, with the local police authority being involved in the investigation.
9.12 In cases of discriminatory and psychological abuse, the Human Rights Act (1998) provides as primary legislation and is used to clarify the rights and freedoms of individuals, with the Disability Discrimination Act (1995) enforcing the rights of individuals. This legislation is also applicable to the other types of abuse, as abuse can be generalised as infringing on the basic human rights of an individual. Therefore, the transferability of this primary legislation can be applied to the main categories of abuse identified within this report and utilised in the planning of policies, procedures, and provisions, as well as investigating and prosecuting civil and criminal law.
9.13 The Crime and Disorder Act (1998) acts as primary support and protection in relation to most forms of abuse, and can be used to prevent crime throughout the UK, with community safety partnerships being formed between the police and local authorities. This involves a multi-agency approach in the support and protection of vulnerable adults, to improve communication and collaboration between relevant parties involved, ultimately benefiting "at risk" adults in regards to empowerment, support, and protection.
9.14 The Adults with Incapacity (Scotland) Act (2000) provides assistance through a series of options to vulnerable adults who may lose or may have lost capacity in regards to their financial affairs, and can be enforced by the OPG.
9.15 The ASP Act 2007 can be used to inquire about an adult if they are thought to be "at risk" of abuse, as well as in instances that involve intervening to protect the vulnerable adult from serious risks of abuse.
9.16 'Safeguarding agencies' can be contacted as a source of support and protection for vulnerable adults in regards to any type of abuse, and have a role in complementing the available legislation within Scotland and the UK. These safeguarding agencies include the Mental Welfare Commission, OPG, the Care Commission, and the Disability Rights Commission. The Mental Welfare Commission has a duty of care in respect of "at risk" adults with mental incapacity. The OPG provides advice and support to vulnerable adults who lack capacity, with the overall aim of safeguarding the individual's financial interests, and is supported by the Adults with Incapacity (Scotland) Act (2000).
9.17 Stringent regulation and inspection of care facilities (such as respite care, in-patient care, and residential care) is enforced by the Care Commission; this is also supported by the Social Work (Scotland) Act 1968 which provides for a power of entry and inspection of accommodation provided by a local authority, voluntary organisation, or other party.
9.18 Effective mechanisms for criminal record checks and the recruitment of eligible staff to work with vulnerable adults are both important in facilitating the primary prevention of abuse or harm (Kingston et al., 2003). Although these processes are implemented regularly, they vary in effectiveness due to the rigour of checks. Therefore, more rigorous checks need to be implemented prior to the employment of individuals who will have regular contact with vulnerable adults.
9.19 In order to prevent ineligible individuals (such as people at high risk of being perpetrators of abuse or harm) making contact with "at risk" adults in either a formal or informal role, perpetrators can be placed on the prevention of abuse against vulnerable adults list, placed on databases stating that they are inappropriate to work with vulnerable adults, removed from their professional register, banned from owning or managing a residential home by the Care Commission, or prosecuted by the local authorities. Therefore, extensive checks need to be conducted in order to ensure proper and appropriate vetting of individuals wishing to work with vulnerable adults.
9.20 Supportive strategies for staff can be used to assist the recognition and report of abuse within facilities. For example, policies to inform and support staff can help to expose abuse and neglect, with the PCAW (Public Concern at Work) and Freedom to Care organisations providing advice and information for staff who decide to "whistle blow".
Effectiveness of interventions
9.21 This report has documented the use of various interventions in relation to different types of abuse, and has categorised those interventions as "primary, secondary, or tertiary" interventions. There are a number of common themes across the interventions which suggest transferability between types of abuse and stage of intervention; for example, advice and support services are used as interventions in relation to a number of types of abuse, and at different stages ( i.e. there is evidence that they are used as primary, secondary, and tertiary interventions).
9.22 The categorisation used in this report is not intended to suggest a rigid framework of interventions to be used at set stages or in regard to a particular type of abuse, but rather to identify what interventions are currently in place and how they are used.
9.23 Empirical research regarding the effectiveness of interventions remains limited, and we still await an appropriate evidence base for adult protection interventions. This will help determine the effectiveness of different interventions, the extent to which they are transferable, and the value in extending the use of particular interventions.