Medication
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.
Restraint
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.
Violence
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
Back
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
