Select Committee on Health Second Report

5  Physical abuse


50. The over-prescription of medications, particularly of anti-psychotic medication for people with dementia, is sometimes used in the care environment as a tool for managing service users and ensuring that the care of people with dementia is easier for the staff. Anti-psychotic drugs have a sedating and calming effect; they are used to reduce psychotic thinking and behaviour, or to pacify a person. In general, older people tend to be more sensitive to the effects of these medications. Between 1999 and 2002 there was a 6.2% increase in community prescriptions of anti-psychotic drugs — a rise of 129,000 prescriptions in four years.[42]

51. We were told that in care homes there was a particular risk of over- or under-prescribing when the older person had diminished capacity to offer informed consent. The responsibility for the administration of medicines for older people in care homes rests with care staff, but many lack sufficient experience or knowledge of the management of medicines. This may lead to errors occurring, particularly when the care workers have not received adequate training in the safe practice of administering medicines. The problem can be exacerbated when the staffing levels in the care homes are insufficient.

52. Evidence from the Alzheimer's Society stated: "Over-prescription of neuroleptics is a common form of physical abuse — often used to sedate people with dementia in care homes and hospitals." The Society acknowledged that in some cases these drugs could be helpful in reducing symptoms such as hallucinations, but they believed that the levels of prescribing far exceeded the numbers of older people who would benefit from these drugs.[43] The drugs were, in their view, being prescribed as a management tool for behaviour such as wandering, agitation and uncooperativeness that could be dealt with by other methods if staff were well trained in dealing with people with dementia. The negative consequences of neuroleptics are well documented yet the prescription rates continue to rise. Furthermore, their use is not monitored, meaning that many older people in care homes are sedated for no medical reason.[44]

53. A police investigation took place into the potential unlawful killing of a patient in 1998 at Gosport War Memorial Hospital. As part of their investigation, the police commissioned expert medical opinion relating to five patient deaths in 1998. In February 2002, the police decided not to proceed further, but based on the information gathered during their investigations, were sufficiently concerned about the care of older people at Gosport Hospital to share their concerns with CHI. CHI undertook a detailed review of the systems in place to ensure good quality patient care, and concluded that a number of factors contributed to a failure of the trust's systems:

·  insufficient local prescribing guidelines were in place governing the prescription of powerful pain-relieving and sedative medicines;

·  the lack of a rigorous, routine review of pharmacy data led to a failure to question high levels of prescribing on wards caring for older people;

·  the absence of adequate trust-wide supervision and appraisal systems meant that poor prescribing practice was not identified; and

·  there was a lack of thorough multidisciplinary total patient assessment to determine care needs on admission.[45]

54. Dame Deirdre Hine, for CHI, told us that Gosport Hospital had been referred to her organisation following police concern over prescribing on some wards:

    That concern [related to] the quantity, the combination, the lack of review and the lack of recording of medicines and to what is called 'anticipatory prescribing' particularly of sedatives, which I think is a general problem, both in care homes and in perhaps wards caring for older people in hospital and that is where patients are given sedatives to ensure that they have a quiet night and therefore the staff have a quiet night. [46]

55. A recent study of 22 South London nursing homes, accommodating 935 residents aged over 65, established that 24.5% of them were prescribed anti-psychotic drugs. Of these, 82% were found to be inappropriate. Most prescriptions were inappropriate for more than one reason including the absence of any condition that would respond to medication, a lack of documentation, a failure to adopt a dose reduction and a failure to review medication within the past six months.[47]

56. Evidence from the NCSC highlighted the issue of inappropriate prescribing and administration of medication. Their analysis of the problem suggested that for older people only 40% of residential care homes met the standards for administering and handling medication.[48] NCSC told us that 12% of providers failed to meet the National Minimum Standards on medication.[49] We gather there are substantial regional variations within this figure. The NCSC has subsequently incorporated many of these points in a report published after we concluded taking evidence.[50] We hope that the Government will set out in its response to our report its views on the NCSC's report.

57. Concerns about medication are by no means new. In 1997, the Royal College of Physicians reported that: "Over 90% of older patients in continuing care accommodation receive medication and polypharmacy is frequent … the use of sedation is all too common and can result in a high incidence of over-sedation, confusion and anticholinergic effects."[51] The College called for a low threshold of referral for the opinion of a geriatrician or psychiatrist of old age if there was a need for frequent or continued use of psychotropic medication.

58. The Department acknowledged that there was understandable concern about inappropriate and excessive prescribing of anti-psychotic drugs for people with dementia, especially those in care homes. It pointed out, however, that care professionals could face considerable dilemmas when they needed to administer medication to individuals when consent was difficult to obtain.[52]

59. We accept that prescribing and administration of drugs is not, of itself, indicative of abuse. BUPA pointed out that all medication was prescribed, other than for those in hospital, by the person's own GP who decided what drugs a care home resident should take and decided on the dosage.[53] As BUPA indicated, care regulators do not have jurisdiction over the prescribing habits of attending doctors, although it is acknowledged that there may be discussion between care staff that will be influential.

60. It is our view that the NCSC is in a strong position to identify inappropriate prescribing and medication review failures. We note the comment from the Department that the regulations governing care homes are important in ensuring that people with dementia do not inappropriately receive anti-psychotic drugs, and that the NCSC can report any evidence of over-prescription or maladministration of drugs to the police and the relevant professional bodies for further action.[54]

61. One of the milestones in the National Service Framework (NSF) for Older People, is that by April 2002 "all people over 75 years should normally have their medicines reviewed at least annually and those taking four or more medicines should have a review 6 monthly."[55] Research has suggested that 6,208 out of 8,748 GP practices in England, almost 71%, had missed this milestone.[56] By July 2003 fewer than 29% of GP practices had put in place mechanisms to undertake this monitoring.[57]

62. Professor Ian Philp, National Director of Older People's services, with responsibility for implementing the NSF, told us that medication management was the most important quality issue.[58] He referred to a range of measures that were intended to strengthen greatly medicines management. In many cases, particularly for people in the care home setting, there were indications that an improvement had been made since the survey of 2002, which showed that only one in five people over 75 years of age had an annual review. He acknowledged that whilst progress was evident, much work remained to be done.

63. We note that although the new General Medical Services (GMS) contract for GPs, to be implemented in April 2004, contains a number of quality indicators that will enable practices meeting them to gain additional remuneration, the care of older people is not one such indicator.[59] However, we consider that recommendations on the prescribing practice of general practitioners, particularly in relation to older people, are likely to emerge from the Shipman Inquiry.

64. We are concerned that, not only in care homes but also in other care settings, abuse of older people can be associated with poor standards of prescribing and poor compliance with the rules on the supply, administration and disposal of drugs. These procedures must be in accordance with high standards and under effective scrutiny if these routes to abuse are to be closed.

65. We believe that the incorrect prescription of medication is a serious problem within some care homes, and that medication is, in many cases, being used simply as a tool for the easier management of residents. We recommend that the Government should vigorously pursue the National Service Framework target that all people over 75 years of age should normally have their medicines reviewed at least annually, and those taking four or more medicines should have a review every six months.

66. We recommend that a review of the medication of care home residents should be conducted by their GP every three months, or on request by the home, whichever is more frequent, regardless of the number of medicines being prescribed. Additionally, we recommend that action should be taken to ensure GPs comply with the NSF milestone and that procedures are implemented to monitor effective compliance.

67. We recommend that consultants with an interest in medicine and psychiatry of older people should be encouraged to develop services to residential and care homes in the community. Further, we recommend that an appropriate schedule of clinical standards related to old age services should be developed for recognition within the GMS contract to enable GPs who wish to develop special interest in the care of older people to do so.

68. We recommend that the National Care Standards Commission and its successor body should ensure that medication systems within care homes and domiciliary care reflect good practice and that good practice procedures that exceed the national minimum standard are publicised.

69. We also recommend that the results of investigations by CHI and its successor body relating to inappropriate medication management in the NHS should be widely disseminated and that evidence of unacceptable practice should trigger sanctions. We believe that close co-operation between CHAI and the National Patient Safety Agency would aid the discovery and dissemination of such practices.


70. We have discussed the use of medication as a form of chemical restraint, but actual physical restraint of older people, for example by the use of furniture, physical confinement, or electronic tagging is obviously also completely unacceptable. However, we received little evidence on this category of abuse.

71. The NCSC stated that inappropriate management of behaviour or inappropriate forms of restraint were a form of physical abuse and might constitute criminal offences. Examples include:

·  Restrictions of liberty, which amount to false imprisonment (for example, locking someone in their room);

·  Misuse of equipment or furniture beyond its intended purpose (for example, misuse of bedrails or 'Buxton' chairs[60]); and

·  Unsafe or outmoded restraint practices which risk physical injury to the service user (for example, techniques that restrict breathing and risk the suffocation of the service user).[61]

72. Care homes providing nursing are in the charge of first-level registered nurses, who are accountable for their professional conduct to the Nursing and Midwifery Council. The inappropriate use of restraint, if detected, would be a matter for reporting to the Council whose Disciplinary Committee would adjudicate on the matter.

73. Formal guidance on restraint has been issued to the caring professions. NCSC inspectors review the policy and practice on restraint in each care home inspected and are expected to pursue any shortcoming on policies and procedures vigorously.

74. Given that physical restraint can be exercised in both overt and subtle ways, we recommend that the National Care Standards Commission and its successor body publish its findings on physical restraint as a thematic study in order that all agencies can benefit from the findings.


75. Some additional protection for the rights of older people may result from measures contained in the Domestic Violence, Crime and Victims Bill. This bill aims to increase protection for those who experience domestic violence and to provide clarity for the police when called to such incidents. The bill includes measures addressing the non-accidental death of a child or vulnerable adult in the presence of a small number of people, where it cannot be established which person was responsible. (The bill is being introduced following a number of cases where a child has died in the care of adults and it has been impossible to prove which particular adult caused the death.) A new offence of causing or allowing the death of a child or vulnerable adult will be created, where the death results from the unlawful act of a member of the same household, and either the defendant was the person who caused the death, or they were aware of a significant risk of serious physical harm by another member of the household. The prosecution will not have to prove who actually caused the death.[62] The bill also provides for additional support for victims and witnesses.

76. We welcome the measures contained in the Domestic Violence, Crime and Victims Bill, which we hope will provide some additional protection for older people.

42   Paul Burstow, Keep Taking the Medicine 2, 2003, p 3 (based on data from the Prescription Pricing Authority from the Prescription Cost Analysis System). Back

43   Ev 174 Back

44   Ev 174  Back

45   CHI, Portsmouth Healthcare NHS Trust at Gosport War Memorial Hospital, Executive Summary, July 2002, p vii


46   Q 124 Back

47   Paul Burstow, Keep Taking the Medicine 2, p 4 (based on Oborne, C. Alice et al "An Indicator of Appropriate Neuroleptic Prescribing in Nursing Homes." Age and Ageing vol 31 (2002), pp 435-439); Q 124 Back

48   Ev 108 Back

49   Q101  Back

50   The National Care Standards Commission, The Management of Medication in Care Services 2002-03, March 2004 Back

51   The Royal College of Physicians, Medication for Older People 2nd edn. (1997) Back

52   Ev 131 Back

53   Ev 158 Back

54   Ev 131 Back

55   Department of Health, National Service Framework for Older People, March 2001, p 24 Back

56   Paul Burstow, Keep Taking the Medicine 2, 2003, p 4 Back

57   HC Deb, 15 July 2003, Col 232W Back

58   Q 184  Back

59   See GMS contract documents, Department of Health website Back

60   Buxton Chair - a chair that is used to restrain patients and restrict their movements. It can be tilted backwards to prevent attempts to leave it and also has a table which can be locked across the patient's lap. Back

61   Ev 108 Back

62   Justice. Domestic Violence, Crime and Victims Bill: Briefing for Grand Committee Stage in House of Lords, 2004, p 4 Back

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