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Medicine Reviews (Older People)
Motion made, and Question proposed, That this House do now adjourn.—[Tony Cunningham.]
9.26 pm
Mr. Paul Burstow (Sutton and Cheam) (LD): I am grateful for the opportunity to raise the subject of medication reviews for older people. I do so because I believe that if good practice in medication review were to be the norm across the NHS, it could transform the lives of millions of people.
At the moment, there are more than 3.6 million people over 75 taking at least one medication and 1.6 million taking four or more medications. On the evidence that I have, it is clear that most of them have never benefited from a review of their medication in the way that is envisaged in the national service framework for older people. Getting the dosage right, understanding the complex interplay of different medicines and making sure that medicines are taken at the right time can make a huge difference to people's health and quality of life. For some, simply getting medication right can be like turning the light back on—it can make a huge difference. For others, getting the medication right can be a matter of life or death.
My purpose in having a debate on this issue is to press the Minister for more concerted action to realise the full potential of medication reviews. What do I mean by medication review? That is a good question, because there is no single agreed definition of what constitutes a medication review. However, there is a proposed definition. It comes from the medicines partnership and has been endorsed by the Department of Health. It says that a medication review is:
"A structured, critical examination of a patient's medicines with the objective of reaching an agreement with the patient about treatment, optimising the impact of medicines, minimising the number of medication related problems and reducing waste."
I have long been concerned about the impact that poor medication practice can have on the quality of life of older people. In particular, I still do not believe that enough is being done to stamp out the inappropriate use of medication in care homes. At its worst, the use of medication becomes restraint by chemical means, and that is elder abuse.
According to the most recent figures from the Commission for Social Care Inspection, more than 5,700 of the 13,000 care homes in England either did not meet or almost met the national minimum standard for medication last year. Let us be clear that we are talking about a minimum standard. I acknowledge that those figures are a modest improvement on the previous year, but try telling that to the residents living in one of the homes who do not meet the minimum standard.
I was even more worried to note that the National Care Standards Commission—the predecessor of the Commission for Social Care Inspection—pointed out in its report on medication that:
"The majority of prescribed medicines will be supplied by a GP on a repeat basis at the request of care staff and not the service user."
That places care staff in a powerful position to influence prescribing for good or for ill. In a briefing for today's debate, the Parkinson's Disease Society points out the
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need to review the medicine management standards, especially standard 9.1, which deals with self-medication. It wants to see greater clarity over the issue of timing of medication, and I strongly agree.
In 2003, a study in the British Medical Journal concluded that older people in care homes received poorer medical care than those living at home, in terms of over-use of inappropriate or unnecessary drugs, poor monitoring of chronic disease and under-use of beneficial drugs. That is one of the reasons why regular medication review should be part of the process and why I welcomed the national service framework for older people medication standards.
Although I support the standards, it must be said that international evidence suggests that annual reviews of prescriptions for elderly people, as proposed in the NSF, are inadequate. Harm can be done, and is done, in far less than a year. There is a huge gap between the intention of the Government's policy, which is to be applauded, and its implementation over the last few years since the NSF was published. That gap has been caused by a lack of clarity and insufficient incentives to deliver what is expected; in particular, the new GP contract does not provide the necessary incentives for more frequent reviews.
Among the indicators in the quality and outcomes framework—QOF—for the contract, two specifically incentivise regular review of medication. The first is:
"A medication review is recorded in the notes in the preceding 15 months for all patients being prescribed four or more repeat medicines."
That is worth seven points. The second is:
"A medication review is recorded in the notes in the preceding 15 months for all patients being prescribed repeat medicines."
That is worth eight points. So the QOF says 15 months, yet the NSF talks about 12 months for people on fewer than four medications and six months for people on more than four medications. Neither actually sets out what qualifies as a medication review. Am I the only one who thinks there is a problem?
Every time I have raised the issue with Ministers through written questions and in debate I have been left with the distinct feeling that the NSF medicine review standard has been quietly dropped. That impression was reinforced in February when the Minister of State, Department for Transport, the hon. Member for South Thanet (Dr. Ladyman), who was then a Minister in the Department of Health, told me:
"The quality and outcomes framework (QOF) indicator for medication reviews for people prescribed repeat medicines was developed by a group of independent experts who were commissioned by the British Medical Association and the NHS Confederation. The group developed QOF indicators using its own search of the evidence and did not necessarily use existing national service framework (NSF) standards. Although this means that the QOF indicators and NSF standards may not match entirely, meeting the QOF indicator will go a long way to helping practices meet the NSF standard and vice versa."—[Official Report, 3 February 2005; Vol. 430, c. 1119W.]
That really beggars belief. It is optimistic, but when the Department was signing off the QOF why did not it ensure that the NSF standard would be achieved? What is the point of producing the NSF standard if it is not being used in that way?
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Mr. Philip Hollobone (Kettering) (Con): I congratulate the hon. Gentleman on securing this debate. Let me assure him that he is not the only one with those concerns. There is a growing number of elderly people in my constituency. If there were to be more regular medication reviews, how would that burden affect already overstretched local GP services?
Mr. Burstow: I shall probably come to that later in my remarks. There could be an additional burden on GPs and also on pharmacists, and some useful evaluation of the relevant guidelines has been conducted.
On the point that I was raising about the QOF and the NSF, I was reassured recently by a written answer from the Minister who will reply to the debate. He told me that the NSF standard had not been superseded. That is good news, but the truth is that the standard has not been achieved either. In a written answer, the Minister told me:
the milestones set in the NSF for older people—
the national medicines management collaborative programme—
"suggest that there have been significant and sustained improvements in the number and quality of medication reviews."—[Official Report, 16 June 2005; Vol. 435, c. 642W.]
Where is the evidence to support that contention? Certainly the evaluation of the implementation of the "Room for Review" guidance on medication reviews published by the medicines partnership earlier this year does not point to significant and sustained improvement.
Part 1 of the evaluation found that only 8 per cent. of primary care trusts had met the NSF standard for annual medication reviews for patients aged over 75. Worse still, just 5 per cent. had met the target for six-monthly reviews for patients over 75 who were on four or more medicines. The NSF milestone for medicine reviews was 2002. That is when this was meant to be in place, albeit with the potential burdens that would arise from it.
Even in 2004, 47 per cent. of PCTs were reporting that they would not be able to conduct six-monthly medicine reviews for over-75s on four or more medicines. Delve a little deeper into part 1 of the evaluation and one finds that even in those PCTs that said they were doing it, not every GP practice was actually conducting and taking part in medication reviews. More worrying still, the evaluation found that in the PCTs that had implemented medication reviews, only a minority of reviews were conducted face to face. That type of patient-centred review was therefore being considered by PCTs as "aspirational"—as a gold standard—and therefore limited to more complex patients.
As I am sure the Minister will know, "Room for Review" defined four levels of medication review—levels 0 to 3. Of these, level 3 involved the patients in face-to-face discussion about their medicines and therefore offered the opportunity to explore the patient's views and experiences of using medicines and allowed them to share in the decision-making process about future prescribing—
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