Intended for healthcare professionals

Editorials

Elder abuse in the UK: out of the shadows and on to the agenda

BMJ 2021; 375 doi: https://doi.org/10.1136/bmj.n2828 (Published 25 November 2021) Cite this as: BMJ 2021;375:n2828

Linked Opinion

Healthcare professionals have a vital role to play in safeguarding older people from abuse

Linked Opinion

Predatory marriage: Doctors can help to spot and prevent this exploitation

  1. Carolyn Stephens, honorary professor of global health1,
  2. Nicolas Mays, professor of health policy2,
  3. Rita Issa, clinical research fellow3,
  4. Lesley Perkins, general practitioner4,
  5. Rebecca Scott, general practitioner4
  1. 1UCL Bartlett Development Planning Unit, London School of Hygiene and Tropical Medicine, London, UK
  2. 2Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
  3. 3Institute of Global Health, UCL, London, UK
  4. 4Bromley-by-Bow Health Centre, London, UK
  1. Correspondence to: C Stephens Carolyn.Stephens{at}lshtm.ac.uk

Primary care has a key role

Elder abuse is a major public health problem, facing one in six older people globally (defined as aged 60 and older).12 Older people with dementia are at much higher risk,3 and the disease is predicted to affect over a million people in the UK by 2025.4

In 2021, a report by the House of Lords described abuse of older people, particularly those with dementia, as complex, poorly measured, and hidden.5 Physical abuse includes violence, but psychological and financial abuse is recorded as the most common form of harm, including manipulation of older people to obtain assets through marriage, wills, and abuse of lasting powers of attorney.6 Controlling and coercive behaviour by perpetrators and social isolation of victims make elder abuse difficult to detect or tackle.7 The UK General Medical Council recommends that health professionals should be familiar with different types of abuse in order to identify patients at risk, noting that many abuses are now criminal offences.8

UK policy changes—and challenges

Since the previous editorial on this subject in The BMJ in 2011,9 UK legislation has substantially changed. New domestic abuse crimes have been introduced, including forced marriage (2014)10 and coercive and controlling behaviour (2015).11 The Domestic Abuse Act 2021 introduced a statutory definition of domestic abuse in UK law for the first time.12 The Forced Marriage Unit was established in 2005 to protect victims coerced into marriage, and the Office of the Public Guardian was established in 2007 to protect people from abuse of powers of attorney. In health and social care, adult safeguarding guidance and multiagency safeguarding teams now exist.8 Together, these have great potential to prevent abuse or intervene when it occurs.

We do not yet know whether these changes have led to more action against abuse. This is because basic data on the scale of elder abuse in the UK are lacking, creating “systematic invisibility.”13 For example, the Crime Survey for England and Wales excluded respondents older than 59 until 2017 (it still excludes people older than 74) and does not survey group residences, thereby excluding elderly people in care homes.14

Little evidence also exists to quantify action taken by responsible authorities. In the year to March 2020 alone, the police recorded 758 941 domestic abuse related crimes in England and Wales, including 24 856 offences of coercive control. The proportion of domestic abuse cases declined by age for women and increased for men, but the data are not disaggregated further.15 Most domestic abuse cases are closed by police with no further action.16

The Forced Marriage Unit recorded 11 519 reports of forced marriages between 2012 and 2020. We calculate that 9% (1048 cases) involved people with learning difficulties or mental incapacity, and 20% of victims were male.17 Reports of forced marriages of older people have increased over the past five years.17 To date, only four prosecutions have been brought for forced marriage, none involving older people or those with limited mental capacity.18

Between 2015 and 2021 the Office of the Public Guardian investigated around 12 000 cases of potential abuse of power of attorney.19 Again, the majority ended in no action. In 2017 Denzil Lush, a now retired senior judge at the Court of Protection, wrote that he would never sign a lasting power of attorney because “I have seen so much of the pathology associated with powers of attorney and the causes and effects when things go pear-shaped, that I find it difficult to recall cases where powers have operated smoothly.”20 His coauthor, Caroline Bielanska, commented on the increased digitalisation of the Office of the Public Guardian’s processes and increased risks of manipulation of older people.20

Two more proposed changes to UK law risk substantially increasing financial abuse of older people: the Law Commission proposes to “modernise” marriage law21; and the Ministry of Justice proposes “modernising” lasting powers of attorney.22 Both proposals aim to make procedures simpler and easier. Although both include limited safeguards, lawyers and experts argue that these are unlikely to prevent vulnerable individuals, particularly older people with failing capacity, being coerced into either marriage or powers of attorney.2324

Role of health professionals

Health professionals have a vital role in protecting vulnerable older people from abuse. General practitioners and practice teams are often the professionals in closest contact with older patients, and may be the only contact for those who are socially isolated. Primary care is therefore an important space for identifying and recording elder abuse.25 Health professionals can also support marriage registrars who become concerned about possible coercion in a marriage process and support solicitors concerned about coercion in the context of powers of attorney or wills.26 They can also back MPs lobbying for change. Together, these actions support Age UK’s call to increase the visibility of elder abuse.13

When protecting vulnerable older adults, health professionals must weigh up the ethical imperative to maintain patient-doctor confidentiality against a duty to escalate concerns to third parties—in patients’ best interests—if abuse is witnessed or suspected.2728 Furthermore, guidance needs to be developed urgently on the new duties for health professionals to cooperate, enshrined in the 2021 Domestic Abuse Act.29 Given the increasing risks of elder abuse in the UK and the rapidly changing legislative environment, health professionals, especially in primary care, would welcome more training—and support—on how to detect, record, and report suspected abuse, so the appropriate action can be taken.

Acknowledgments

We thank the Office for National Statistics Centre for Crime and Justice for statistical support.

Footnotes

  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following: CS has personal experience of some of the issues raised in the editorial. RS is employed by St Helen’s Church Bishopgate as safeguarding officer for one day a week.

  • Provenance and peer review: Commissioned; externally peer reviewed.

References

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