There are residential dementia homes in Britain where standards are low, indifference reigns, and where we would prefer any loved relative not to be placed. Perhaps, according to the rule of thirds, one in three units falls into this category. But in how many are older patients with dementia sworn at, ridiculed as "past their sell-by date", denied normal food, deliberately left outside in cold weather, inadequately clothed, strapped on to commodes for hours, or physically assaulted?
The answer, surprisingly, is that we do not know - for two reasons. First, recent investigations have shown such practices can go on for years, without relatives, managers or other visiting staff knowing about it. Second, even when abuse does come to light, there is great variety in how it is investigated - even within the NHS. The problem can be seen conveniently as entirely to do with the unit, or even an individual; alternatively, a wide-ranging review of the trust (rarely beyond) may result. There is no national reporting system for these episodes and their investigations, so general lessons for the NHS cannot be learned.
Without data, anything said about the institutional abuse of vulnerable people in the NHS is anecdotal. But one summer, as part of an independent team reviewing one such episode, three things struck me.
The first was that nearly everyone involved, at every level of the organisation, seemed decent, honourable, hard working and kind. The second impression was of the pain caused to staff by the process of independent review. A pall of misery hung over the reviewers as well; I felt tainted. But the main impression was one of mystery. If my impression is correct that almost all NHS staff are basically kind, how does the culture in a unit develop in so deviant a way and why do remarkably similar episodes continue to happen across the country?
I now think that abuse - in the original meaning of the word as "using incorrectly or improperly" - is not just in isolated pockets in the NHS, but widespread in the service and beyond. NHS staff dealing with dementia, and perhaps others too, are at risk of abusing because they themselves are continually abused.
They are abused by being obliged to work in inadequate buildings, in inadequate numbers, with inadequate support, inadequate disciplinary boundaries, and inadequate training. They deal with patients with dreadful, progressive disorders who present emotional challenges often ignored. Working with inadequate numbers of colleagues is the worst abuse. Staff want to do their best, but they rarely can because there is no economy of scale in personal care and attention.
Who is abusing the staff? Their managers. Why? Because they are abused, too. Again, they are given huge responsibilities, inadequate support and inadequate training; task after task is piled on them by their superiors, often in a very strong, "no whinge" culture. Judged almost entirely by their budgetary control, they strive to please by constant working and reworking of "skill-mix", whittling down the number and quality of their staff.
Who is abusing the managers? Trust boards. Why? Because they are abused, too. Purchaser, regional and NHS executive imperatives pour down, each priority being piled on others. Now, impossibly, "clinical governance" joins responsibility for the quality of treatment and care to its opposite - cheapness. Trust chief executives who show a regional chief executive anything other than calm competence in the face of chaos are not destined for greatness.
Who is abusing the NHS executive? Ministers. And who is abusing them? Press and MPs. And who is buying the newspapers and voting? We are, and it is our relatives who are abused by NHS staff. Thus does the wheel of abuse turn.
Why, then, is any unit ever free of abuse? My optimism about NHS frontline staff as basically decent and well-meaning extends to all those involved in this chain, including ministers and even the press.
If all this is right, what can we do? Perhaps We are so immured in abuse we don't know when we're being abused, let alone when we are abusing others. The first step may be to speak up when we feel abused. Whingeing? Perhaps, but there are worse crimes. We should resist passing on abuse ourselves, if necessary by deceit. Subversive? Arguably, but there are worse crimes. Finally, we must praise more, vote for polite parties, and eschew abusive newspapers and TV. We won't reduce the risk of extreme collective abuse by fiddling with the system; only by increasing resistance to it.
• Alastair Macdonald is professor of old age psychiatry at Guy's, King's and St Thomas's Medical Schools, London. The original article on which this is based was published in the Journal of Dementia Care
