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Mr. Peter Bone (Wellingborough) (Con):
I congratulate the hon. Gentleman on securing the debate
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on this exceptionally important issue. One of my constituents has brought this problem up. One drawback seems to be that a lot of people in care homes have some sort of dementia, and therefore the face-to-face review is more difficult, and I get the feeling that because it is more difficult it is not being done.
Mr. Burstow: I fear that that is a problem. All too often, repeat prescriptions are ordered by care staff and inappropriate historic prescriptions continue without being properly checked and vetted. That is why the process really has to engage with the patient and, if necessary, carers and other family members who have authority to take informed decisions and give consent.
The lack of a specific requirement for level 3-type reviews in the NSF and the quality and outcomes framework has reinforced the view in PCTs and among practitioners that patient-centred reviews are "nice to have" but not a "must have".
Part 1 of the evaluation was conducted in January 2004 and published in March 2005, which really does prompt the question, why did it take so long to publish the findings? While I am asking about part 1 of the evaluation of "Room for Review", I hope that the Minister can clear up a mystery surrounding the publication of part 2, on the patient's view. I was told in July that part 2 would be published over the summer. It was not, so I asked another question about when it would be published and I was told this time that due to ethics clearance requirements it would not be published until the end of 2006. Then I got the news, thanks to Mr. Speaker, that I had secured tonight's debate, and the following day my office took a call from the Department, telling me that part 2 would be published on 5 December. So Christmas has come early, and that is good news. But what is going on?
Certainly, part 2 paints a mixed picture of patient experience of medication reviews. Part 1 talks about face-to-face reviews being the gold standard, yet the evidence from part 2 suggests that there is quite a long way to go before the potential of that gold standard is realised. Many of the comments from patients suggest that they had been given the impression—I emphasise, given the impression, and that is how they saw it—that the purpose of the review was cost cutting. One woman is quoted in the evaluation as saying that the reason she was given for being called for a medication review was that the PCT wanted to change her tablets
A man echoed that when he recounted a conversation that he had had with a doctor drawing the review. The doctor told him that
The concern that medication reviews are essentially about reducing NHS expenditure and saving money is a strong theme running through the second part of the evaluation from the patient's perspective, and it clearly is a problem in terms of how we make these reviews something that people feel comfortable with and see the value of from their own point of view.
Another concern that emerges concentrates on who conducts these reviews, and it touches on the intervention by the hon. Member for Kettering (Mr. Hollobone). When it came to GP-led reviews, while most people felt comfortable that their concerns
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were being addressed, points were made as to whether the GP had sufficient knowledge compared with colleagues in secondary care, which really did fuel a suspicion that the reviews were just being done to save money.
Another set of concerns arose about pharmacists who were leading reviews. The main issue was about the fact that pharmacists did not have access to the medical records or knowledge of the individual medical situation, but above all there was a real concern, and a question mark, over whether the pharmacist could get medication changed; if they could not, delays were occurring while people waited for their practice to change their medicines.
With the new pharmacist contract opening up the possibility of a greater role for pharmacists in medicine management, there is a need for clarity. As the medicines partnership points out in its report, the medicine reviews used by pharmacists are not the same as medication reviews. In the executive briefing published yesterday, the medicines partnership said:
"As with the NSF milestone, there was no published definition of what sort of medication review would qualify for QOF purposes. There is potential for overlap between the different medicines review services and some confusion as to which sorts of reviews 'count' towards which targets. This suggests a need to refocus attention from quantity to quality. PCTs need to consider how the various types of medicines review can help them deliver their objectives and priorities, making sure that reviews deliver maximum benefit to patients and that people with the greatest need and greatest potential to benefit have their medicines reviewed.
We consider that it is important for PCTs, GPs, nurses and pharmacists to have a clear picture of how the various forms of review fit together and how they can be used to meet local priorities and support care for people with long term conditions."
To summarise in two words, confusion reigns. That confusion has caused a failure to join the dots between the rise in the prescribing of anti-psychotic drugs, the rise in adverse drug reaction to anti-psychotic drugs and the worrying 35 per cent. increase in the number of non-fatal ADRs among the over-75s and the alarming 83 per cent. increase in fatal ADRs among the over-75s.
A recent report in the British Medical Journal found that significantly older people were admitted most because of ADRs. The cost to admissions authorities is huge, and the consequences for the individual go without saying. The study concluded that the NSF needs to be implemented. Yes, the NSF medicines standards should be implemented. That would be a step in the right direction. Medication reviews would help to safeguard the health and welfare of older people.
To conclude, I have some questions. First, will the Minister confirm that the NSF standard for annual and six-monthly reviews is still the standard that the NHS should be measured against? Secondly, when will the NSF standard be achieved, and how will we know? Thirdly, does he agree that we need to look into the national minimum standards for medicines management in care homes for older people to ensure that medication reviews are triggered in accordance with the NSF standards and that the timing of medication is made clear to managers and staff? Fourthly, will he act now to clear up the confusion identified by the
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evaluation of the medicines partnership and ensure that clear guidance is issued to the NHS, so that everyone is clear what is expected?
I agree with the medicines partnership that there is a need to focus on quality—that is absolutely right—but that is not sufficient if the NHS is to meet the needs of millions of older people in this country, whose quality of life is impaired because they are not getting the right medication, at the right time and in the right place. I hope that the Minister has something helpful and positive to say.
9.42 pm
The Parliamentary Under-Secretary of State for Health (Mr. Liam Byrne): I congratulate the hon. Member for Sutton and Cheam (Mr. Burstow) on securing this debate. He has indeed taken a long interest in the subject.
Medicines are by far the most common form of medical treatment in the UK. People with long-term conditions, many of whom are older, are reliant on those medicines to stay healthy. In fact, 80 per cent. of people over the age of 75 take at least one prescribed medicine and 36 per cent. of them—just over a third—take four or more medicines each day. With that level of medicine prescribing comes the challenge of ensuring that people with long-term conditions, including those who are older, get the maximum possible benefit from that medicine, and the hon. Gentleman made that argument rather eloquently.
Half of all people—not just older people—on regular treatment do not take their medicines as intended for a number of reasons. Problems with medicines may be the cause of as many as 10 to 15 per cent. of hospital admissions. So people need simple information and advice if they are going to get the best benefit from their medicines. They need to know what their medicines are for, how they work and how they need to take them. However, people also have their own health beliefs, which can affect the way they take their medicines. That is why, as the hon. Gentleman said, involving people in decisions about how medication is taken is an important way in which we can help to ensure that they take medicines effectively. That explains why medication review is important. It is good that the hon. Gentleman has secured such a debate on the Floor of the House because the matter sometimes does not get the airtime that it deserves.
A medication review occurs when a health professional reviews a patient's medicines. The health professional ensures that all medicines that would be of benefit are prescribed and that the various treatments work well together and do not cause problems. That might be done if a GP prescribes someone with repeat medicines, but there is also a place for more in-depth reviews in which a health professional sits down with a patient and discusses his or her medicines in detail. That might occur if someone is on an especially complex regime, or if a patient is experiencing problems. Such reviews are important, not least because they allow patients to ask questions about their medicines and to be more involved in any decisions that are taken.
Given the importance of medicines to many people and the importance of medicine reviews, when we published the national service framework for older
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people in 2000, we produced a booklet that focused on the specific issue of medicines and older people. As the hon. Gentleman knows, that drew together the available evidence and made recommendations on how to improve older people's medicine taking.
Within that, we set a specific milestone on medication reviews. We recognised that the more medicines people take, the more likely they are to experience difficulties, so the scheme had two elements. First, by 2002, all people aged 75 and over were expected to have medicine reviews at least annually, and, secondly, those taking four or more medicines were to be reviewed at least every six months. Although it was largely for the NHS, working with other stakeholders locally, to implement the NSF on older people, we have nationally supported the improvement of medicine-taking in several ways. Before the publication of the NSF, medication reviews were not systematically undertaken or recorded.
Let me outline several of the measures that we have taken to support the policy. We have supported several primary care trusts to identify what works best and to share that learning with others through the national medicines management collaborative. About half of PCTs have participated in that programme to implement local medicine management schemes so that people get more help in using their medicines from not only their GPs, but pharmacists and others.
One of the measures used for assessing improvement was the proportion of people aged over 65 who were on four or more regular medicines and had received a documented medication review in the previous 12 months. There was a significant increase in activity and, in some cases, the reported rate of reviews more than doubled.
Another measure was the percentage of patients in care homes who had had a documented review of their medicines in the previous year. I am aware that some people believe that people in care homes do not have their medicines reviewed regularly, or sufficiently regularly, but the data from the collaborative work showed that the situation was slightly different. The increase in activity for patients in care homes was similar to that for those living at home, although the two groups had slightly different starting positions. The extent of patient involvement in medication reviews was measured for PCTs in wave 4 of the programme. It increased from 22 per cent. to 62 per cent. in a single year.
After drawing on this learning, guidance on medication reviews was widely disseminated through "Room for Review: A guide to medication review", which was published by the medicines partnership in conjunction with the national medicines management collaborative in 2002. The document set out a framework on how medication reviews should work, together with supporting tools and advice for managers and health care professionals.
Two years later, the medicines partnership commissioned an evaluation of the impact of "Room for Review", first to determine the extent to which the guidance had been adopted by PCTs and, secondly, to assess the experience and opinions of a sample of patients who had had a medication review. As the hon. Gentleman knows, the original plan was to publish both parts of the evaluation together. However, there were
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unexpected delays in publishing the part involving patients because of the two practical issues—the need to obtain ethics committee approval and the need to identify a suitable sample of patients through GPs. The medicines partnership did not wish to withhold the findings, so it went ahead and disseminated the survey of PCTs in March 2005. Part 2 was published yesterday.
I am glad that I have helped to ensure that Christmas has come early for the hon. Gentleman. From the survey of PCTs undertaken in 2004, we know that the majority of PCTs had a written strategy and that more than 60 per cent. of them had agreed local guidelines. About 45 per cent. of the PCTs that responded to that survey indicated that they were achieving or likely to achieve the older people's NSF target. Just 30 per cent. of PCTs said they were unlikely to achieve the target. If the survey were carried out now the figures would be very different, and I shall come on to the results of the GP quality and outcomes framework data later. The relationship between the national service framework and the quality and outcomes framework is important. The NSF indicator is still very much in force, but the way in which it has been implemented through the QOF target has become slightly more flexible to make sure that there is local managerial flexibility for doctors who implement it.
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