Abuse by health and social care workers

Introduction

Health and social care professionals have a duty of care to ensure the wellbeing of service users. Most professions have set out good practice guidelines. Contravention of these guidelines may constitute abuse or neglect.

This is for people with mental health problems who use or have used health and social care services. It may also be of interest to friends and carers of people with mental health problems, people who work in health and social care services and other members of the public.

What are health and social care professions?

The health professions focus on a person's medical or clinical condition. Health professionals who are likely to be involved in mental health care and treatment are: general practitioners (GPs), psychiatrists (medical doctors who have specialised in mental health), nurses (in hospital or community settings) and health care assistants.

Allied health professions may also be involved in mental health care and treatment. These include psychologists, counsellors, psychotherapists and occupational therapists. Allied health professionals usually focus on social, emotional or practical issues that can impact on health and wellbeing.

The social care professions focus on social, emotional and practical issues. Social care professionals who may be involved with mental health care and support include social workers, support workers, care assistants, day centre staff and housing support workers.

More information on all of these professions can be found in Mind's factsheet, Who's who in mental health: a brief guide.

Standards and regulation

What standards can I expect?

All health and social care professions have identified certain principles and ways of working as 'good practice'. Being aware of what 'good practice' means can help you to identify abuse or neglect.

Some aspects of good practice have been made law through government legislation; others are standards set by professional associations. More detailed information on the legal issues surrounding professionals standards can be obtained from Mind's Legal advice service (see 'Useful contacts').

Profession-based standards

Health and social care professionals cover a wide range of roles that focus on many different aspects of their service users' welfare. Each profession has its own rules and guidelines, covering both competence (the skills and knowledge required do their job to agreed standards) and ethics (the legal and moral issues relevant to their job).

To find out the details of any profession's rules and guidelines, contact the relevant professional regulator (see 'Who regulates health and social care professions?' (below) and 'Useful contacts').

Duty of care

Health and social care professions have in common the concept of a 'duty of care' toward their users. This means that the wellbeing of the service user should be central to their work. All treatment given must have a therapeutic benefit to the user or must be essential for saving life.

Information about treatment

Service users should be given sufficient information about any treatment they are offered so that they can make an informed decision about whether or not to take it. ^[1] Information should include the benefits and possible risks of the treatment, the likely duration of treatment and any financial costs. The service user should also be given information on alternatives to the treatment being offered.

Mental Health Act 1983

Generally, service users detained under the Mental Health Act 1983 must be told what the Act has to say about treatment for mental disorder. This includes the circumstances, if any, under which they can be treated without consent, the circumstances in which they have the right to refuse treatment, the role of second opinion appointed doctors, and, where relevant, the rules on electroconvulsive therapy. Where a particular treatment is proposed during detention, the service user has a right to be given sufficient information to ensure that he or she understands the treatment in broad terms, including its nature, likely effects and significant possible adverse outcomes, the likelihood of its success and any alternatives to it. However, the Act allows service users to be given certain treatments in an emergency, for example in response to an immediate crisis; in this situation the health professionals are not legally obliged to ascertain whether a patient is capable of consenting to the treatment, or to discuss the treatment in full. As a matter of good practice, however, notes relating to an individual's mental capacity and attitude to receiving the treatment should be recorded on his or her medical file. Mind has produced an outline guide to the Mental Health Act 1983.

Where health and social care professionals have reason to believe that the service user does not have the capacity to understand the information or make an informed decision, they must act in accordance with the Mental Capacity Act 2005. Mind has produced a series of briefing documents relating to the Mental Capacity Act.

Choice

Over the past two decades the concept of choice has become important to the health and social care professions, and to the government departments that make policies affecting these sectors. It is now widely accepted that service users should be able to make informed choices about the most suitable treatments for themselves. However, a patient does not have a legal right to demand a particular treatment and complete choice does not always happen in practice (e.g. the preferred treatment may not be available within a service user's local area).

Service users have the right to refuse treatment (unless they are sectioned under the Mental Health Act or have capacity issues covered under the Mental Capacity Act 2005). ^[2] Health and social care professionals should treat service users in ways that enhance their capacity to choose, and should not undermine their capacity (e.g. by withholding necessary information or presenting alternative options in a negatively biased manner).

Dignity

Health and social care professionals must treat service users with dignity. The concept of 'dignity' can be subjective, and each person has his or her own idea of what this means. But issues such as gender, culture, religion and previous life experience will impact on an individual's idea of dignified treatment and finding out about these issues is a crucial part of treating a person with dignity.

The Department of Health and the Social Care Institute for Excellence use the following definition of 'dignity' in health and social care: "Dignity in care ... means the kind of care, in any setting, which supports and promotes, and does not undermine, a person's self-respect regardless of any difference." ^[3] Professional associations often have their own definitions of what it means to treat service users with dignity; in many cases, this is linked to the profession's 'duty of care' (see 'Duty of care', above).

People sectioned under the Mental Health Act and people with capacity issues must also be treated with dignity: a 2007 amendment to the Mental Health Act has increased the penalty for professionals guilty of 'ill treatment or neglect' of people under section. ^[4] Service users covered by the Mental Capacity Act 2005 must always be treated 'in their best interests', including attention to the beliefs, values and wishes of the individual. ^[5]

Who regulates the health and social care professions?

Health and social services

Health authorities (including primary care trusts and mental health trusts) and local authority social services are legally responsible for all the staff they employ. This includes ensuring that appointed staff have the necessary qualifications and competence to perform their roles and that there is no reason to believe that staff could pose a risk to service users (e.g. following up references and checking with the Criminal Records Bureau that prospective staff have no criminal conviction that could affect their work). Health authorities and social services departments should ensure that staff receive the ongoing supervision, training and support needed to carry out their work. A health authority or local authority is liable if a member of their staff is found guilty of professional misconduct. [6]

Statutory regulatory agencies

Health and social care services as a whole are regulated by  the Care Quality Commission  (CQC, see 'Useful organisations'). The CQC inspects health and social care services to check that standards are being met. The CQC also performs this regulatory function for services used by people sectioned under the Mental Health Act.

Children's services are regulated by Ofsted.

Professional regulatory agencies

Most health and social care professions are also regulated by independent agencies relevant only to their own profession. Examples of this include the General Medical Council for doctors, and the Nursing and Midwifery Council for nurses. In order to be allowed to do their jobs, workers in these professions have to be registered with their regulatory agency. An individual who is found guilty of professional misconduct (whether through abuse or neglect) will be disciplined by their professional agency.

A number of professions, including clinical psychologists and (from 1 August 2012) social workers, are regulated by the Health and Care Professions Council.

Professional associations

Psychotherapists and counsellors are not at present covered by a regulatory body that has legal powers. What this means in practice is that anyone can call themselves a 'counsellor', even if they have not had the necessary training or gained a recognised qualification. It also means that members of professional associations cannot be prevented from practising, even if they have been removed from the register.

To protect clients from therapists who may be unqualified or in any way unfit to practice, the two main associations that represent therapists also have a regulatory function. These are the British Association for Counselling and Psychotherapy (BACP) and the United Kingdom Council for Psychotherapy (UKCP) (see 'Useful contacts'). Membership of these associations is voluntary, but in other ways they operate in a similar way to legally binding professional regulatory bodies in developing and enforcing professional standards for their members.

For more information on finding talking therapists, see 'Useful contacts'.

Criminal law

Criminal law covers actions such as physical and sexual assault, theft and other financial crimes. Any crime committed by a health or social care worker against a service user is a matter of professional abuse. Regulation of the health and social care professions is in addition to the protection of service users conferred by criminal law.

References

[1] Mind 2008, Mind rights guide 3: Consent to treatment, Mind.
[2] Mind 2008, Mind rights guide 3: Consent to treatment , Mind.
[3] SCIE 2008, Practice guide 09: Dignity in care, Social Care Institute for Excellence.
[4] Mind 2008, Legal briefing 1: Amendments made to the Mental Health Act 1983 by the Mental Health Act 2007, Mind.
[5] Mind 2008, Legal briefing 4: Healthcare and Welfare/Personal Care Decisions under the Mental Capacity Act 2005, Mind.

Types of abuse

Professional abuse

Professional abuse occurs when a health or care worker acts in a way that goes against their own professional standards and, in some cases, criminal law. Professional abuse undermines, and in many cases destroys, the therapeutic value of a health or social care service and is rooted in a violation of the service user's trust. WITNESS, the main organisation working to combat professional abuse and boundary violation (see 'Useful contacts'), has written:

... trust is vital because of our vulnerability when we seek help, the degree of intimacy involved in such relationships and the inherent power difference between a professional and the person seeking help. As a result these relationships are open to exploitation and abuse, sometimes unintentionally, with often devastating effects for the patient or client.^[7]

In many cases, abuse can be the result of a gradual erosion of boundaries between the client or service user and the professional involved. For example, the professional may disclose personal information, initiate contact outside agreed sessions or try to get involved in areas of the service user's life that are outside their professional remit. If boundaries are eroded in this way and the relationship is changed over time, it can be more difficult for the service user to identify unprofessional or abusive behaviour.

Abuse can take many forms but can usually be defined as physical, sexual, financial or psychological/emotional.

Physical abuse

Physical abuse is non-accidental pain or injury inflicted on a service user by a health or care worker. This can include hitting, shaking, rough treatment or inappropriate use of restraint.

The health and social care professions do not permit any physical contact that is not necessary for administering a treatment, or for which the service user has not given their consent.

Sexual abuse

Sexual abuse usually refers to any sexual activity that is unwanted and is inflicted by physical force or other methods of coercion such as threats or intimidation. Sexual contact between workers and service users is forbidden in the health and social care environment ^[8] because it could be harmful to the therapeutic value of the treatment being given and is likely to be based on the exploitation of a service user's vulnerability and the power imbalance inherent in the relationship.

Financial abuse

Financial abuse covers any way that a health or social care worker unlawfully uses his or her relationship with the service user for financial gain. This includes, but is not limited to:

• charging a fee for services that should be free of charge
• charging for services that are not in the service user's best interest
• unnecessarily prolonging treatment for financial gain
• increasing agreed fees after a treatment has begun
• receiving financial inducements for recommending other products or services to the service user
• theft from the service user (including items being 'borrowed' and not returned).

Psychological/emotional abuse

This refers to the psychological or emotional exploitation of the relationship between a health or social care worker and a service user. It is the most difficult form of abuse to define because it relies heavily on individuals' feelings and perceptions rather than on physical or tangible evidence. The following principles can be useful in identifying psychological or emotional abuse.

• Is the health or social care worker disclosing sensitive, personal information to the service user?
• Is the worker making psychological or emotional demands on the service user that do not appear to contribute to a therapeutic process?
• Is the worker trying to make contact with the service user outside the agreed working environment?
• Does the worker appear to be trying to humiliate or belittle the service user?

If the answer to any of these questions is 'yes', the worker may be guilty of psychological or emotional abuse.

Neglect

Neglect cuts across all the areas described in this section. Abuse is usually defined as harmful action; neglect can be understood as a form of abuse by failing to act. If a health or social care worker has failed to do something within their professional remit that is in the service user's best interest, this is neglect. Examples of neglect include, but are not limited to:

• failing to act on a service user's concerns about their physical or mental health
• failing to act on a service user's complaints about the care or treatment they are receiving from others, or on the signs of ill-treatment or neglect
• failing to act on indications that a service user's health, or ability to care for him or herself, is deteriorating
• failing to act on a service user's expressions of extreme mental distress, such as suicidal feelings.

References

[7] Home Office 2003, Working within the Sexual Offences Act 2003, TSO.

Taking action

How can I take action if I believe abuse has occurred?

All health and social care providers (e.g. health authorities and social services departments) and all associations that regulate health and social care professions should have a complaints procedure. It is good practice to provide service users with information on how to complain; this information should be readily accessible on health and social care premises.

All service users have the right to complain if they feel that their care has been substandard or that they have experienced abuse. People who are sectioned under the Mental Health Act should have access to an advocate who can communicate the service user's complaints, and to the relevant authority. Those who have capacity issues covered by the Mental Capacity Act 2005 may have complaints made on their behalf by third parties operating in their best interests. More information on advocacy can be found in the Mind guide to advocacy or by contacting the Mind Legal Line or the Advocacy Research Exchange (see 'Useful contacts').

Complaints about NHS and social services

If you have experienced abuse or neglect while using NHS or social services, the usual way to make a complaint is through their complaints procedures. All NHS and social services are legally obliged to have a complaints procedure in place and to inform service users of how to use it (which includes providing any support needed to enable the service user to make a complaint).

If you receive no response to your complaint within the timescale specified in the complaints procedure, or if the reply you receive is not helpful, you can complain through other channels. If your complaint is with an NHS service, it is usual to begin with the health authority's Patient Advice and Liaison Service (PALS); any member of staff will be able to provide you with details of your local PALS. If you would prefer an independent advocacy service, you can contact the Independent Complaints and Advocacy Service (ICAS), which was set up to support patients and carers in their complaints against NHS services. You can find contact details of your region's ICAS from a member of staff or via the Department of Health.

The Parliamentary and Health Service Ombudsman and the Local Government Ombudsman (see 'Useful contacts') investigate individual complaints about health and social services that have not been resolved by local complaints procedures. These services were set up to ensure that standards are met in NHS and social services.

You can also complain to the Care Quality Commission.

You may wish to take legal advice or contact a local advocacy service (such as services provided by many local Mind associations). If you are in any doubt about the best course of action, contact Mind's Legal advice service or WITNESS's helpline (see 'Useful organisations') to discuss your situation.

Complaints through professional regulators

Professional associations have rules on what constitutes 'good practice' by their members. If a health or social care professional breaks any of these rules, their professional association is obliged to investigate the situation and take any action needed. In extreme cases the health or social care professional may be expelled from the association and forbidden to practise their profession ('struck off').

If you are using private or voluntary sector services outside the NHS (e.g. a private counsellor), you would usually make your complaint through the complaints procedure of the relevant professional association (e.g. the British Association of Counsellors and Psychotherapists). You would need to check which professional association (if any) the practitioner belongs to, and then check with that professional association. All professional associations must have a complaints procedure.

Police

If you have experienced abuse of a physical or sexual nature, or financial misconduct such as theft, the health or social care worker has committed a criminal offence. This means that you have the right to report such an offence to the police and have the abuser tried through the criminal justice system.

People sometimes choose not to report crimes to the police for a variety of reasons, such as not wanting to relive a traumatic event by telling it to someone else, fears of not being believed or previous negative experiences of the police.

However, in recent years many police forces have made big improvements in the way they treat victims of physical and sexual violence. Some have also implemented new processes for reporting these crimes. One of these is the introduction of 'third party reporting' in which an organisation can report a crime on behalf of a victim who wishes to remain anonymous. You can find out if third party reporting operates in your area by contacting your local police force.

If you feel that an advocate would be helpful to ensure that you are treated fairly and can communicate your experience clearly to the police, you can make contact with a local advocacy service. To find out what is available in your area, use your local directory or contact Mindinfoline (see 'Useful contacts'). Mind has produced a Guide to advocacy in mental health.

You can also find support to help you through the process of reporting a crime through local organisations, such as some local Mind associations and Victim Support (see 'Useful contacts').

What if I don't want to report my experience?

You always have the choice of whether or not to make a formal complaint about an experience of abuse or neglect. All the organisations that offer support to survivors of abuse by health and social care workers (such as WITNESS) or of crime (such as Victim Support) will offer you their services whether or not you choose to make a formal complaint. A range of local support services is available for the victims of abuse; you can find out about these by contacting Mind's infoline.

Useful contacts

Useful organisations

Advocacy Resource Exchange (ARX)
Portman House
53 Millbrook Road
East Southampton SO15 1HN
tel: 0151 734 3047
advocacy finder helpline: 08451 22 86 33 (Mon-Fri 11am - 2pm)
email: enquiries@advocacyresource.org.uk
website: www.advocacyresource.org.uk
An organisation that provides information and advice about advocacy, including how to find an advocate.

British Association for Counselling and Psychotherapy (BACP)
BACP House
15 St John's Business Park
Lutterworth LE17 4BH
tel: 01455 883 330 (general enquiries)
client information helpdesk: 01455 883 316
email: bacp@bacp.co.uk 
web: www.bacp.co.uk 
The biggest UK membership organisation for counsellors and psychotherapists. The website also includes a 'find a therapist' section.

Care Quality Commission
7th Floor, New Kings Beam House
22 Upper Ground
London SE1 9BW
tel: 03000 61 61 61
web: www.cqc.org.uk 
Regulates the quality of health and social care and look after the interests of people detained under the Mental Health Act.

General Medical Council (GMC)
London office
Regent's Place
350 Euston Road
London NW1 3JN
tel: 0845 357 8001 (London); 029 2050 4060 (Cardiff)
email: gmc@gmc-uk.org 
web: www.gmc-uk.org 
The GMC is a statutory agency that registers and regulates doctors practising in the UK.

Health and Care Professions Council (HCPC)
Park House
184 Kennington Park Road
London SE11 4BU
tel: 020 7582 0866
web: www.hcpc-uk.org
Statutory agency that regulates social workers in England. The website provides a register of health professionals who meet the HPC's standards and also gives advice on how to make a complaint and about 'fitness to practice'.

Independent Safeguarding Authority (ISA)
information line: 0300 123 1111
email: scheme.info@homeoffice.gsi.gov.uk
web: www.isa-gov.org.uk 
The ISA was created to help prevent unsuitable people from working with children and vulnerable adults. The CSI works with the Criminal Records Bureau to gather relevant information on every person who wants to work or volunteer with vulnerable people.

Local Government Ombudsman
PO Box 4771
Coventry CV4 0EH
tel: 0300 061 0614
web: www.lgo.org.uk 
Carries out independent investigations of complaints about local authorities/councils that cannot be resolved at local level, including social services.

Mind infoline
PO Box 277
Manchester M60 3XN
tel: 0300 123 3393
email: info@mind.org.uk 
For information on mental health and related issues.

Mind legal advice service
PO Box 277
Manchester M60 3XN
tel: 0300 466 6463
email: legal@mind.org.uk
For information and advice on mental health law and other legal issues relating to mental health.

Mind's Policy and Campaigns Unit
15-19 Broadway
London E15 4BQ
tel: 020 8215 2282
email: puadministrator@mind.org.uk 
For information on Mind's policy work and other policy and campaigns relating to mental health issues.

Nursing and Midwifery Council
23 Portland Place
London W1B 1PZ
tel: 020 7637 7181
web: www.nmc-uk.org 
Statutory agency that registers and regulates nurses and midwives practising in the UK. The Council sets standards for education, training, conduct and performance and ensures that the standards are met, in order to safeguard the health and wellbeing of the public.

Ofsted
Ofsted National Business Unit
Royal Exchange Buildings
St Ann's Square
Manchester M2 7LA
tel: 08456 014 772 (for complaints about a service)
email: enquiries@ofsted.gov.uk
web: www.ofsted.gov.uk
Ofsted inspects and regulates the educational, economic and social wellbeing of children, young people and adult learners. This includes the care and local services.

Parliamentary and Health Service Ombudsman
Millbank Tower
Millbank
London SW1P 4QP
complaints helpline: 0345 015 4033
email: phso.enquiries@ombudsman.org.uk 
web: www.ombudsman.org.uk 
Carries out independent investigations into complaints about unfair or improper actions or poor service by the NHS and UK government departments that cannot be resolved at local level.

United Kingdom Council for Psychotherapy (UKCP)
2nd Floor, Edward House
2 Wakley Street
London EC1V 7LT
tel: 020 7014 9955
email: via website
web: www.ukcp.org.uk 
The main membership organisation solely for psychotherapists. The aim of the UKCP is to promote and maintain the profession of psychotherapy and high standards in the practice of psychotherapy in the UK, for the benefit of the public. Although registration is currently voluntary, the UKCP is working towards statutory registration.

Victim Support
National Centre
Hallam House
50-60 Hallam Street
London W1W 6JL
tel: 020 7268 0200
helpline: 0845 3030 900
email: supportline@victimsupport.org.uk 
web: www.victimsupport.org.uk 
Victim Support is a charity that gives free advice and support to people affected by crime. The website provides a list of local offices.

WITNESS
32-36 Loman St
London SE1 0EH
tel: 020 7922 7799 helpline: 08454 500 300
email: info@professionalboundaries.org.uk 
web: www.popan.org.uk 
WITNESS is a charity that aims to promote safe boundaries between professionals and the public to prevent abuse.