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Westminster Hall

Tuesday 7 February 2006

[Mr. Joe Benton in the Chair]

Care and Nutrition (Older People)

Motion made, and Question proposed, That the sitting be now adjourned.—[Mr. Dhanda.]

9.30 am

Mr. Paul Burstow (Sutton and Cheam) (LD): Good morning to you, Mr. Benton, and to other hon. Members. I am grateful for the opportunity to raise the issue of the care and nutrition of older people. I think that the Minister will know of my interest in the subject, because I had the opportunity last week to host the launch in the House of a campaign by Help the Aged and Action on Elder Abuse to help raise awareness and promote action to tackle the hidden scandal that is elder abuse in our country. The Under-Secretary of State for Health, the hon. Member for Birmingham, Hodge Hill (Mr. Byrne), also took part. The campaign is all about pressing for in-depth research to gauge the true level of the problem of abuse. The most recent figures obtained by the Select Committee on Health, during its inquiry in 2004, show that 500,000 elderly people at any one time may be the victims of abuse, including physical, psychological, financial and sexual abuse. Without a clear picture, however, it is impossible to know whether the current policy and practice, which have developed over the past five to 10 years, really are a fit response to the level of need.

Although this morning's title gives scope to raise many issues, I sought the debate primarily to raise two. The first is the nutrition of older people, particularly vulnerable older people in care homes, and the second is the use and management of medication in care homes. Just before Christmas, the British Association for Parenteral and Enteral Nutrition—BAPEN—published a report into the nutrition of older people in a variety of care settings, and the facts speak for themselves. One in 10 care home residents loses up to 5 per cent. of their body weight within a month of being admitted to the home and 10 per cent. of their body weight within six months. Much malnutrition goes undetected; indeed, many regard it as the norm and as part of the aging process—it is not.

Even on the basis of the available research, it is clear that malnutrition in care homes is at epidemic levels. Based on an analysis of people aged 65 and over by the national diet and nutrition survey, BAPEN found that 20.5 per cent of individuals in care homes—one in five residents—were at medium or high risk of falling victim to malnutrition.

David Taylor (North-West Leicestershire) (Lab/Co-op): As the hon. Gentleman might imagine, I am a big NHS proponent, but does he agree and acknowledge that such treatment can, sadly, be found in both NHS hospitals and care homes? I introduced a private Member's Bill in the previous Parliament to establish an
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older people's rights commissioner to tackle issues such as nutrition and medication. Would he become a sponsor if I introduced it again later this spring?

Mr. Burstow : That is an invitation that I could not possibly refuse. The hon. Gentleman makes a good point about the need for an advocate—particularly for the frail and vulnerable, who might lack capacity to make decisions for themselves—as a complement to some of the legislation on medical capacity. I hope that he would also support my ten-minute Bill, which is currently before the House, and which would extend the application of the Human Rights Act 1998 to all privately run care homes. It does not currently apply in those circumstances, and anyone who crosses the threshold of a privately run care home can no longer exercise their rights under the Act unless there is a contract with the local authority that specifically stipulates otherwise. The Government acknowledge that anomaly, but it needs to be addressed, and that loophole needs finally to be closed.

Mr. Philip Hollobone (Kettering) (Con): I congratulate the hon. Gentleman on securing the debate and on his excellent work on the issue. Before he goes too much further into the issue of nutrition in care homes, may I draw to his attention the excellent work done by the Womens Royal Voluntary Service and the meals on wheels service in Kettering? They provide valuable nutrition for older people who are being cared for in their own homes and who will later go on to institutional care. Without meals on wheels volunteers, this country would be a in a very sorry state indeed.

Mr. Burstow : I can only echo the hon. Gentleman's sentiments. I also have a meals on wheels service in my constituency, and it relies predominantly on voluntary effort to deliver meals. The service makes a huge difference in terms not only of the delivery of food, but of contact; indeed, it is the only contact that some people have, because many of them lead very isolated lives.

As I said, one in five care home residents is at risk of malnutrition. Today, as many as 63,400 frail elderly people in care homes across England could be malnourished—that is 63,400 victims of poor nutrition. In the 21st century, it is a scandal that elderly people in some of these homes are, in effect, starving to death. The personal cost of such poor treatment is incalculable and unacceptable, and it includes poorer health, slower recovery from illness, the risk of complications from illness and, above all, a very poor quality of life. According to BAPEN, the cost to the taxpayer of treating malnutrition in long-term care has been estimated at £2.6 billion a year. That really is a shocking waste of public money.

According to figures from the Commission for Social Care Inspection, more than 2,000 care homes out of the 11,000-odd in England fail to meet the most minimal of national minimum standards for meals and mealtimes. As things stand, the national minimum standards say next to nothing about nutrition. It is only thanks to work by the Caroline Walker Trust and the National Association of Care Catering that a more detailed set of guidance is available to practitioners in the field. I very much welcome the news that the commission will publish a report on nutrition later this year, which is not a moment too soon.
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Last month, I had the opportunity to introduce the Care of Older and Incapacitated People (Human Rights) Bill under the ten-minute rule. I drew attention to a case that was reported to me and which illustrates the nutrition problem. It was the case of a care home resident who nearly starved to death. Like many other residents at the same care home, this elderly lady suffered from dementia and needed help with eating, but none was provided. Residents were left to fend for themselves, and relatives were banned from the dining area. When the news came that the care home was to be closed, conditions deteriorated further. Residents were forced to live on a diet of Angel Delight and beans on toast, and sometimes, if they were lucky, pilchards on toast. They were left for up to 16 hours between meals, as cooks went home at 4 pm. When the manager was asked what the residents could eat at night, he told relatives that there was a pot of fish paste in the fridge. Fortunately, the lady in question moved to a new care home, where she received much better attention, and she put on a stone within a month of arriving.

Another lady wrote to me to say that despite years of battling to ensure that her mother was properly looked after, her mother could barely get a spoon to her mouth or reach her drink and had difficulties because she was offered no assistance in doing so. The lady told me that her mum was being fed on tinned corned beef and packets of Smash potato. After a complaint, she was moved on to tinned mince and Smash, and another complaint later led to the provision day after day of a banana for breakfast, tinned stew mixed with tinned soup for dinner and tinned soup for tea. That was a wholly inadequate diet, and relatives were given no explanation—if there was any—for why such a diet was provided. The lady's mother was put in a bed so high that she could not reach the water placed by her bedside—dehydration is also an issue in some care homes.

It was only after the mother was admitted to hospital with breathlessness and chest pains that the lady was told that her mother was malnourished. Although her mother ate "like a horse", as the hospital put it, during her stay in hospital, and gained weight in the process, the care home denied any responsibility and argued that she had not been eating due to a lack of appetite. If we were served a constant diet of tinned stew mixed with soup every day, we might lose our appetites too. Not every care home is like that, but those that are should not be tolerated, because they are ruining people's lives, putting lives at risk and, in some cases, killing people.

I want to raise three specific concerns regarding the nutrition of older people: training, nutritional screening and co-ordination. On training, there is no requirement in the national minimum standards for care homes regarding training catering staff, in particular, in the specialist task of meeting the dietary needs of care home residents. I understand from the National Association of Care Caterers that no module is available as part of national vocational qualification level 2 on catering to ensure that staff can meet those special dietary needs. A module exists and was drawn up by NACC in the late 1990s, but City and Guilds, the awarding body, has not seen it as a high enough priority to be made a component of NVQ, despite the demand for such a
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course throughout the sector. What action will the Minister take to ensure that training on special dietary requirements is available as part of any qualification for caterers in care homes?

David Taylor : Will the hon. Gentleman give way?

Mr. Burstow : I shall ask my second question, then I shall give way one more time, as I need to make some progress as a number of hon. Members want to speak. Will the Minister also intervene to encourage the awarding authorities to make such training a priority for care catering?

David Taylor : Does the hon. Gentleman agree that in recent years there has been a trend, which predates 1997, of enforced sell-off of local authority homes into the private sector, which in some cases has been accompanied by poorer standards of training for staff in privatised homes? That is especially true in relation to nutrition. The problem that he describes is much less apparent, although not invisible, in the remaining homes that are run by local authorities.

Mr. Burstow : I have two reactions to that point. First, I should like to see the commission's report, which will analyse performance by sector precisely on nutrition standards, inadequate as they are. Secondly, we are where we are, and we must ensure that the system delivers good quality, fit-for-purpose services, regardless of whether they are publicly, privately or charitably run. That is the purpose of my contribution, but I entirely take the hon. Gentleman's criticism, which I have heard about and share, about the downsides of the regulated but not very well managed system that we have had for too many years.

After highlighting my concerns about malnutrition in care homes, I have received a great many letters and phone calls. Some have been from angry care home owners, but many have come from care homes wanting to tell me what they do in practice, relatives and residents sharing their personal experiences, and health and care practitioners pointing to good practice.

An example of good practice that I commend came from Southwark primary care trust, which told me about its care home support team, which works with 40   independent sector nursing homes in the borough. The team has introduced systematic assessment of need, which includes intensive training courses for care home staff, with courses on dementia and nutrition, and working with people with swallowing difficulties—an issue that the Parkinson's Disease Society is most concerned about in the upcoming review of national minimum standards. Those examples of good practice should become the norm. Making them the norm is the challenge.

Standard 8 of the national minimum standards for care homes makes nutritional screening a requirement. However, that requirement is part of a bundle of other requirements, which means that a home could meet the overall standard but perform poorly on nutritional screening. Without proper screening it is hardly surprising that one in every 10 new care home residents loses up to 5 per cent. of their body weight within one month of being admitted and up to 10 per cent. of their body weight within six months.
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As things stand, there is no agreed screening tool. BAPEN has developed a universal malnutrition screening tool for assessment of individuals across all care settings that is supported by the Royal College of Nursing, the British Dietetic Association and the Royal College of Physicians. NACC has produced its own screening tool for use by care home managers that is designed with individuals with no nutritional or dietary training in mind. Care homes need clear guidance about the assessment tools available and the circumstances in which they should be used. Will the Minister make nutritional screening on admission to care homes a mandatory requirement in the national minimum standards?

I am sure that the Minister will tell me about the review of the national minimum standards, the work of the Food Standards Agency, the efforts of the Commission for Social Care Inspection and the imminent publication of National Institute for Health and Clinical Excellence guidance on the use of nutritional supplements. The review of national minimum standards offers the opportunity to strengthen nutritional requirements. I understand that CSCI is undertaking work on that, as well as developing a toolkit for inspectors, and is due to publish a report on    nutrition next month. The FSA is developing recommendations on nutrient-based standards not only for the care sector, but for public institutions across the piece. That work includes developing example menus to assist caterers in menu planning. I understand that the FSA is in discussion with a range of interested parties about its work and will produce a draft report, which will be ready by this summer.

I do not say that there is not a lot going on; indeed, I acknowledge that there is. However, the more I have researched the issue and talked to people, the more the question arises of where the co-ordination of those different strands of work is. Who is pulling them all together? I and many outside, particularly those in BAPEN and NACC, would like to know whether the Minister or her colleagues in the Department of Health will take steps to ensure that the work of the FSA, CSCI, NACC, the Caroline Walker Trust, BAPEN and other interested parties is effectively joined up, to ensure that the future national minimum standards cover all aspects of nutrition and meal provision. Would she or the Under-Secretary of State for Health, the hon. Member for Birmingham, Hodge Hill, be willing to meet me and representatives of NACC and BAPEN to discuss our concerns and their recommendations?

The second issue that I should like to raise is medication, which I mentioned before Christmas in an Adjournment debate to which the Under-Secretary of State responded. This morning, CSCI issued its report on medicine management in care homes. The report is entitled "Handle with Care?", and it follows a report by the National Care Standards Commission that was published in March 2004. That earlier report identified serious deficiencies in the way care homes managed medicine. In the light of the earlier report, today's report makes worrying reading.

"Handle with Care?" states that

According to the report, 45 per cent. of care homes for older people are failing to meet the national minimum standards on medication. Some 5,140 of the 11,543 care
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homes in England are not managing medicines according to the national minimum standards. In almost one in three London boroughs, fewer than 40 per cent. of homes meet the medicine management standards. The report states that it

it covers not only older people's homes, but children's homes—

Some 210,000 people are living in homes that do not meet the minimum standards on medication, and the buck stops with the homes themselves. I am not here to say that the Government have not delivered, but I point out that the owners need to end their constant denial of problems and failings.

It seems that the reasons why homes are failing to manage medication properly have not changed since NCSC reported. Lessons have not been learnt, and attitudes have not been changed. Indeed, the commission says:

The commission has found that even homes that meet the standard then struggle, slip and fall back. I first raised the issue of poor medication management in my report "Keep Taking the Medicine" in 2001. I have published two more reports since and contributed to the writing of the Health Committee's report on elder abuse. Five years on, there is still an awful lot to do. The level of over-medication and inappropriate medication in our care homes is shocking. It is a scandal that such poor practice, mistreatment and abuse continue.

When NCSC reported in 2004, it noted:

That places care staff in a powerful position to influence prescribing for good or for ill. Little has changed in nursing homes and progress has been "stagnant", according to the latest report. That means that some older people are being managed by means of chemical cocktails of drugs, not for their benefit, but for the benefit of the home. It is chilling to think that if the published research on inappropriate medication is right, as many as 22,233 elderly nursing home residents in England could be under sedation without medical grounds. Indeed, the commission's findings suggest that the situation could be far worse.

Action is long overdue. It is time that care homes came out of denial and took action. There is no quick fix, but ensuring that the recommendations of the commission's report are followed through as a matter of urgency must surely be a priority. Perhaps the Minister can explain how those recommendations will be followed up after the commission is abolished in a couple of years' time.

One way in which the standards could be raised and the quality of life of care home residents improved would be the delivery of the national service framework
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standard for medication review. The standard is clear. People aged 75 and over on fewer than four medications should have an annual medication review, and those on four or more should have a review every six months.

Sandra Gidley (Romsey) (LD): Is it not something of a missed opportunity that because the standard in the national service framework for older people is not the same as the standards to which GPs work to get their quality and outcomes framework points, the system provides no incentive for GPs to deliver what is in the national service framework?

Mr. Burstow : My hon. Friend makes a good point. There is an apparent misalignment between the GP contract and the quality and outcomes framework, and the national service framework standard. That has meant that there has been a lack of incentives in the system for people to get to the milestone for the NSF. The evaluation of "Room for Review" guidance on medication reviews, published last year by the Department, pointed to the fact that progress had been patchy—only 8 per cent. of PCTs had met the NSF standard for annual medication reviews for patients over 75, and 5 per cent. had met the target for six-monthly reviews for patients over 75 on four or more medicines.

It is worth bearing in mind that that national service framework standard was meant to be achieved by 2002. Two years after that, just 5 per cent. of PCTs were saying that they could meet that standard. As I have pointed out in previous debates—I did so before Christmas—two years after the NSF milestone was missed, 47 per cent. of PCTs were still reporting that they could not conduct six-monthly medicine reviews for over-75s on four or more medicines. That picture of patchy support from PCTs is borne out and repeated in the report published today by the Commission for Social Care Inspection. What is being done to ensure that the missed NSF milestone on medication reviews is finally achieved, and that PCTs engage with care homes to drive up the standards?

To conclude, I sought this debate to highlight two issues: nutrition and medication. Just one care home starving its elderly residents to death or using chemical straitjackets is too many, but the truth is that, through neglect or wilful intent, thousands of homes make the lives of those whom they are supposed to care for a misery. Thousands of homes are making a mockery of the standards, systems and safeguards that are supposed to protect the vulnerable.

I hope that the Minister will demonstrate that the Government understand the challenge and accept that there is still much to do, and that they will give the matter the same level of priority and attention that they have rightly given for many years to our systems for protecting the welfare of children.

9.52 am

Tony Baldry (Banbury) (Con): I have been a north Oxfordshire Member of Parliament for more than two decades. During that time I have visited the nursing homes and residential care homes in my constituency on many occasions. After more than 20 years, many friends and neighbours have ended up in nursing homes and one goes and sees them.
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I do not recognise the picture that the hon. Member for Sutton and Cheam (Mr. Burstow) paints of care homes that do not care for their residents, but I think that there is a reason for that. I represent a relatively "healthy and wealthy" area of England, and I suspect that every nursing home in my constituency has a fair number of residents who pay privately. The homes cross-subsidise residents with local authority placements, and have done so for many years. One of our difficulties is that nursing home proprietors, whether they belong to the voluntary or the private sector, have to manage with the funds with which they are provided. Often, because of the pressures on local government finance and social service budgets, their margins are very tight.

When it comes to nursing care standards, nursing homes are in competition with every other part of the NHS for nurses. Pretty well every nursing home on my patch has had recourse to creative schemes to recruit and train nurses from overseas, and I suspect that it must be difficult to recruit sufficiently well-trained staff in other parts of the country that are not as attractive or as wealthy as north Oxfordshire. I am not an expert, and I rose to my feet to speak about a different issue, but I suspect that there are two pressures that we need to consider: the unit cost per week of providing care in a nursing home for an elderly person and the need to ensure that there are sufficient well-trained nursing staff in our nursing homes. In areas of the country that do not have considerable cross-subsidy from residents who pay the full private rate, those pressures could be much greater.

I want to raise a slightly different issue, however, and I hope that the hon. Gentleman will not mind my doing so. It concerns a point that he made in respect of the statement on the White Paper on community care the other day, so we are probably at one. Tomorrow, all six Oxfordshire Members are going to see the Secretary of State about funding in Oxfordshire. Our concern is that the Oxford Radcliffe NHS trust has a £15 million deficit. One of the reasons for that is the continuing confusion as to what services are provided free within the NHS and what services are provided by social services, means-tested outside the NHS. If one were to visit the John Radcliffe hospital or the Horton hospital today and do an audit, one would find a number of patients who do not need to be there—they no longer need to be in acute general hospitals. They are not sufficiently well that they can go home, but their treatment at the John Radcliffe or the Horton has finished; they no longer need expensive acute beds. However, because of the confusion about services, the NHS is unable to move such patients into the non-NHS sector of continuing care. The situation is a nightmare and it is getting worse.

A recent judicial review on the matter caused further confusion. As a lawyer, I am fortunate, as I am supposed to be able to construe definitions and documents. However, I find the definition of when care should be provided within the NHS and when it should be provided outside almost impossible to construe. As the complexities of people's care needs increase, that becomes even harder to do.

When I was first elected to Parliament in the mid-1980s and I went around residential care homes at Christmas and other times, most of the people there were spry widows in their 70s. They were mentally alert and were there because their husbands had died, and
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they needed some care. Now I go into residential elderly care homes and find that practically every resident has Alzheimer's or some form of dementia. I often take my pug dogs with me, and the truth is that the residents are far more interested in seeing my dogs than they are in seeing me—the pugs are much better looking, and they go off on chocolate biscuit search and rescue missions. Those people are very poorly, and it is difficult to explain to their families that the nature of their illness is such that care should not be provided free at the point of use through the NHS, but has to be means-tested and contributed to in the social services sector. Unless we have much greater clarity about which services are provided by the NHS and which are provided on a means-tested basis in the social services sector, we will continue to have an increasing number of blocked beds in our acute hospitals to the overall detriment of NHS financing.

There also still seems to be complete confusion about community hospitals with interim beds. For many people who do not need to go for long-term care in a residential care home, an interim bed would be brilliant. However, it is quite clear that the Thames Valley strategic health authority does not like community hospitals, simply because they are funded by the NHS. The Thames Valley strategic health authority would far prefer all community health to be provided by Oxfordshire social services. The Secretary of State made it clear in her statement last week that she wants existing community hospitals to be protected, so far as is possible. That will be difficult when strategic health authorities, in trying to balance their books, can say, "Look, we can shift this off to some other funder." That square will not be circled by joint social services and health commissioning bodies, because there will still be tension about who pays for what.

There will be considerable difficulties and tensions until there is greater clarity. It is unfair that a lot of people find themselves going through the whole appeal process to determine whether they should be entitled to continue in care funded by the NHS, and where it should happen. Collectively, Parliament must get to grips with a new definition. If we expect people to make a means-tested contribution to their long-term care at some stage, it behoves us to introduce a much clearer definition.

Mr. Burstow : I have listened carefully to the hon. Gentleman and agree with much of his analysis of the problem. Will he also note that the definitions are based solely on guidance that is administrative in nature, has no statutory force and yet appears to have redrafted the legal position and changed the law? That has led the courts to be concerned about whether the guidance is flawed.

Tony Baldry : As the hon. Gentleman knows, because he follows the subject, there have been a number of matters of judicial review, and the Department has been criticised for the lack of clarity. The courts cannot themselves give a statutory definition where none exists. If we are to have beds in acute hospitals that are not blocked, as well as a vibrant and confident care home sector, we need greater clarity about what is provided free by the state through the national health service and what services are provided by local social services and are means-tested.
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10.2 am

Sandra Gidley (Romsey) (LD): I congratulate my hon. Friend the Member for Sutton and Cheam (Mr. Burstow) on securing the debate. I apologise, as I assumed that there would be greater interest and have not prepared a lengthy speech, but I am sure that when the Minister responds we will be able to ask her plenty of questions.

It is timely that the CSCI report on medications has been published today. My hon. Friend has said some of what I wanted to say about the report, but it is disappointing that two years on we seem to be no further forward. That seems to be the story when we consider the provision of services for older people. It is worth remembering that older people do not live only in care homes or hospitals. These days, the Government are driving towards looking after more older people at home, which is quite right. That is where they want to be. Many aspects of care in the home need to be considered.

Underpinning all those issues is the national service framework for older people, which was produced in March 2001. It had the dubious distinction of being the first NSF without any attached funds, which immediately created a number of challenges, because anybody trying to achieve the NSF targets had to scrabble for funding. It was also one of the last NSFs to have targets attached. I was curious to see how we were progressing against those targets, so I tabled a number of parliamentary questions and received the perhaps not unsurprising answer that the Government were not collecting routine data on the matters for which targets had been set. It is difficult to determine how progress is being measured, so I decided to carry out my own survey in 2004, which revealed that many targets had not been met, even those that were supposed to have been achieved a year previously. I am disappointed that there has been no comprehensive analysis of the success or failure of the NSF, other than a glossy booklet assuring us that all is well. Clearly, all is not well.

The Government rightly acknowledge that most people would like care at home. There is a problem with that, because although the Government have increased the funding for care at home, it has generally gone into more intensive packages. The casualty has been the funding for lower-level interventions, which may cause significant improvements in quality of life and health. Standard 8 of the national service framework is about the promotion of health and active life in older age. It acknowledges the benefits of a healthy diet but says little about two significant problems that, if addressed, could improve the overall picture.

First, people who are much older get quite tired. It is an effort to cook and they have less time and energy for food preparation. There is a strong case for teaching them new ways to cook. Those in their generation are used to meat and two veg, which involves quite a lot of food preparation. They tend to resort to tinned foods, which may not be as high in nutritional value. Secondly, where a partner dies, two people would previously have been used to rubbing along together quite nicely, and one might have taken responsibility for food preparation. When someone is left to cope with that on their own, as well as with everything else, there is another need for education.
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My hon. Friend has highlighted some of the problems that will arise if we do not address nutrition among the elderly. I also want to quote from a lecture given by Professor Marinos Elia to the Westminster diet and health forum. He pointed out:

He went on to say:

He said that protein-energy malnutrition probably affected 13 per cent. of those aged over 65, and concluded:

There seems to be some evidence that such action would be useful.

Standards for care homes have been mentioned, but they are fairly basic and centre around having three meals a day at certain intervals. Although they are welcome, there is no mention of basic things such as the need for five portions of fruit and vegetables a day. That is a Government strategy and has been the subject of a Government campaign, but it does not seem to appear in the guidance for care homes. Although my hon. Friend mentioned the failures of the system, it is disappointing that the statistics have not improved since last year. We have to ask what effect CSCI is having in driving those standards upwards. On the basis of the evidence of the past year, it would seem to be very little.

The European Nutrition for Health Alliance has produced some statistics as well. It points out:

Clearly the problem is getting worse with increasing age—a factor that has not been mentioned today. The statistics concerning loss of weight when people enter a nursing home have already been mentioned.

Age Concern has also put together some work on the subject. It says that a range of studies has put the prevalence of malnutrition in care homes at levels between 60 per cent. and 100 per cent. I cannot believe that the level is 100 per cent., because there are homes in which the food is excellent, and I know which ones I would like to go to when I am older, if the standards remain the same. Clearly, however, the problem is widespread and wholesale.

What are the Government doing to assess the problem? I was interested in a parliamentary question that my hon. Friend asked in November 2005:

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I am afraid to say that the answer was a bit waffly; it did not really answer the question. It stated:

It then gave the URL where those details could be found. I decided last night to have a look to see what wealth of information was out there. I typed the words "nutrition and older people" into the search engine, and I found only one hit: a study of diet and nutrition in older people comparing the Afro-Caribbean population and other people. I think it considered 30 people in each cohort, which is not great. I tried some more combinations, such as "nutrition in care homes" and "nutrition for geriatrics", and found zero hits for both.

It would be interesting if the Minister could tell us what research is going on into this important subject. I am sure that the cost-benefit analysis must show that a little investment on the problem will reap dividends. If people go into hospital with malnutrition, they are at risk of developing bedsores and other illnesses, which create a demand on health services and facilities.

Medication in care homes is a significant problem that is generally underestimated. I would like briefly to mention the recent death of a care home patient who had been in a home for less than a fortnight. That home was owned by a GP, who I am pleased to say has now been removed from the register. The GP persuaded the patient to register, saying that it would be easier to register with the local practice. People do not think anything of that in such situations; they want to keep everyone happy. The patient was prescribed very high doses of sedatives, such that they could not eat and went into a steep decline; it can be proved that that was linked to the medication.

That case raises questions about whether a GP who owns a care home should be allowed to prescribe, or whether there should be some sort of arm's-length prescribing process. I am sure that it is not a common problem, but for the protection of medics and the public, it deserves some attention.

Mr. Burstow : My hon. Friend makes some important points about the dearth of Government research, not least in respect of nutrition. Does she share my concern that there appears to be a dearth of research on the use of medication in care settings—particularly care homes—to understand why prescribing in some cases appears to be inappropriate and to identify courses of action that could change that?

Sandra Gidley : My hon. Friend makes a good point about medication in care homes. I have seen that situation at first hand, because I used to work as a pharmacist, and I saw the prescriptions for each home. Things are better than they used to be when I first qualified 20 years ago. At that time, a person could have a pot of 500 sedatives prescribed, which could then be given out willy-nilly. At least that process is now carried out on a named-patient basis. I have seen homes undergo a change of ownership where the prescribing patterns change radically, sometimes for the better and, sadly, sometimes for the worse. There seems to be no overview of the process or the appropriateness of prescribing. The subject needs more research.
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I have read my hon. Friend's paper, and a lot of it seemed based on small-scale research with an extrapolation upwards. That can be dangerous, and it would be much better to have an accurate picture of what is going on with clearer guidelines as to when sedation is appropriate. In my opinion, sedation is inappropriate in many cases and is used for the convenience of the care staff, rather than the benefit of the patient. That is one of the biggest hidden scandals and abuses in today's society.

I would like to mention hospitals. I have mentioned that those over 80 admitted to hospital have a five times higher prevalence of malnutrition than those under 50, but many are admitted in an emergency and the food that is given is often inappropriate. A lot of thought has recently gone into food in hospitals, but sometimes it is perhaps not enough. It does not matter what the food is like, because the problem that returns time after time—it happens in the care home sector as well—is the lack of basic help for the patient to eat or drink. That form of abuse is endemic in the system.

The Minister will be aware of the "Panorama" programme a few months ago in which reporters went undercover into a hospital in the south of England. The programme showed how drinks were put out of patients' reach and food was taken away after a meal with no thought as to whether patients had been able to feed themselves. Sometimes people's arms were in plaster and no thought was given to basic care. There is a real need for a return to basic nursing standards, which seem to be forgotten time and time again.

Sadly, we are dealing with a generation that does not complain. People do not complain because they do not want to be picked on or treated wrongly if they make a fuss. But we owe a lot to that generation. It deserves our attention because it is a generation that deserves better.

10.18 am

Mr. John Baron (Billericay) (Con): I add my congratulations to the hon. Member for Sutton and Cheam (Mr. Burstow) on securing this important debate. He has raised some very important issues. Caring for those who can no longer care for themselves is one of the greatest challenges facing us, as has been recognised in the good contributions made.

Nutrition is clearly of great importance to the well-being of any elderly person, whether in a care home or private accommodation. That was recognised by the Government in their 1998 study, "National diet and nutrition survey: people aged 65 and over", which revealed that those living in care homes were more likely to be underweight and also reported that one in six residents were deficient in folate—a B vitamin—or were anaemic. Most care homes do a good job, but there are undoubtedly cases of under-nourishment in older people. Such cases are still many and varied, which in many respects is what today's debate is about. According to Age Concern, a range of studies have put the prevalence of malnutrition in care homes at between 60 and 100 per cent. Clearly, that is a matter of great concern.

I do not propose to repeat everything that has been said about nutrition. Many good points have been made. I will endorse one point made earlier: of course nutrition is terribly important, but it is also important
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that elderly patients have access to that nutrition. In some cases, older people require special assistance to help them eat. That issue needs to be recognised, as does the issue of those suffering from Alzheimer's, who may become confused about whether they have eaten.

In the light of those concerns, what estimate has the Minister made of the scope of nutritional problems facing many elderly people both inside and outside care homes? Is she entirely confident that that Commission for Social Care Inspection has the capability to enforce rigorous standards? I would like her to consider those points in her response. I intend to keep my speech relatively short, so that there is plenty of time for her to respond.

Problems with nutrition in care homes are mirrored in the use of medication. As we have heard, CSCI's report yesterday revealed that almost half of all nursing and care homes fail to meet national minimum standards for how they give medication prescribed by their doctors. Those results are deeply disturbing. It is vital that patient confidence is restored. The report highlighted significant geographical variations in performance and indicated that council-run homes perform significantly worse that voluntary and private homes. It went on to say that there had been few improvements since a similarly critical report in 2004. What measures are the Government going to introduce to ensure that patients in care homes receive the medication prescribed by their doctors?

Fear of abuse is a chilling problem that affects elderly people in some care homes and private homes, as was well set out by the hon. Gentleman. Many of the activities involved, including physical attacks, sexual abuse and fraud, are already criminal and would be recognised as such. However, elder abuse also includes psychological bullying and neglect. It does not help the situation that because older people are often vulnerable and suffering from mental or physical illness, unique barriers stand in the way of reporting such abuse. Help the Aged has estimated that a staggering 500,000 people are believed to be being abused at any one time in the UK, and yet nearly 40 per cent. of the public have not even heard the term "elder abuse". Raising awareness and promoting vigilance is therefore a vital step towards tackling the problem.

I am concerned that, although the Department of Health has published guidance for local authorities on the protection of vulnerable patients, there is no legal requirement for local authorities to adhere to its recommendations. I am conscious that the Government are expected to announce today—they might have already done so this morning—proposals for the registration, further training and vetting of the approximately 750,000 care workers who look after elderly people. We have asked questions of the Department of Health about the vetting of staff working with vulnerable adults and the operation of the protection of vulnerable adults list, but as yet, we have not received any answers. Will the Minister address that point?

It is important that the Government's proposals, whatever they may be, which affect a large number of workers in the social care sector, are properly thought through. Otherwise, there will be a risk that the latest initiative will serve to add to the bureaucracy and cost, without necessarily achieving its aims of helping and
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protecting older people. I look forward to hearing what the Minister has to say about that. With that in mind, perhaps she will explain her Department's response to the campaign led by Help the Aged and Action on Elder Abuse. I joined the hon. Member for Sutton and Cheam at the campaign launch. Will the Minister outline what is being done to tackle this serious problem?

Taking advantage of the broad nature of the debate, if I may, I should like to address another serious problem facing elderly people. It is one that the Government have so far failed even to acknowledge in replies to my letters or when it has been raised at the Dispatch Box. I refer to the shortage of basic chiropody services for elderly people who cannot look after their own feet. Although nail cutting and routine chiropody treatments might seem insignificant to a large number of people, healthy and comfortable feet are especially important for elderly people. It is an issue not only of independence, dignity and mobility, but of helping to prevent dangerous falls.

Last year, I raised the case of an 82-year-old lady who was partially sighted, suffered from angina and emphysema, had suffered three strokes, and was unable to bend to attend to her feet. She was told that she was no longer eligible for NHS podiatry care after she changed her GP. Before the KT23 statistical measures were discontinued, they showed that 17 per cent. fewer people were being seen by NHS chiropody departments in 2004–05 compared with eight years previously.

Tony Baldry : My hon. Friend's point goes back to the point that I was making. He is jolly lucky that podiatry care is being provided. In Oxfordshire now, one does not get operated on for a hernia, and varicose veins are not operated on on the NHS, even if, like one of my constituents, one has to stand every day at work in great pain. That is because the primary care trusts, under substantial financial pressure, have had to move the line on what they think the NHS should be funding and what should be funded from social services or one's own resources.

Mr. Baron : My hon. Friend makes a valid point, and I will return to it briefly. I think that it illustrates that there is a black hole between health and social care. We need some joined-up thinking to bridge that gap, but I will come to that later.

I tried to explore the scope of the problem with regard to the lack of chiropody care in the NHS and undertook a survey of NHS services over the summer of last year. The results were quite disturbing. Some 85 per cent. of the chiropody departments or services surveyed—this was a nationwide survey—claimed that the budget for their service had not kept up with increases in demand. On average, respondents needed a 25 per cent. increase in staffing. Four out of 10 respondents told us that the level of need required for access to the service had been raised in the past five years—a point referred to by my hon. Friend. In other words, the barrier to entry had been raised. In a separate development, East Elmbridge and Mid Surrey primary care trust recently announced that some 3,000 people, or 30 per cent. of its patient base, were being discharged. I fear that it is not alone in discharging such a large number of people.
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As PCTs have the freedom to vary their eligibility criteria and level of need for access to services, I am concerned that a postcode lottery in access to basic chiropody care has been developing largely unnoticed. This issue highlights a wider problem, as my hon. Friend mentioned. Many elderly chiropody patients are falling through the gap that undoubtedly exists between health and social care. Nail cutting may not be the most complex medical operation or the most pressing health need, but its importance must been seen in the context of social factors such as independence, dignity and mobility.

The arbitrary distinction between health and social need has allowed chiropody departments to divest themselves of their responsibilities, preferring to focus resources on, for example, the national service framework for diabetes. So far, social services have failed to pick up the tab and the responsibility, and many people are needlessly suffering as a result. May I invite the Minister to acknowledge the scale of the problem facing chiropody patients? What are the Government going to do about it? So far, there has not even been any recognition of the problem. How do the Government propose to monitor what is happening in that field now that the KT23 statistics are no longer collected? If one were being uncharitable, one might suggest that it was very convenient that the figures were no longer being collected and that the Government did not wish to acknowledge the issue at hand.

Finally, I should like to bring the Minister back to the issue of the gap between health and social care, as illustrated by the lack of chiropody services in the NHS. One key way of tackling that black hole between health and social care would be to instruct NICE to draw up holistic standards and entitlements regarding care, recognising health and social care needs and benefits. That would ensure that patients did not fall into that gap, and that for all those suffering from long-term medical conditions, the whole care pathway was catered for. That is one key reform that must be introduced if we are to bridge the gap. I cite chiropody only as one example of what is happening in the system and of where so many patients are being failed. I ask the Minister to address those issues, and I look forward to hearing her response.

10.30 am

The Minister of State, Department of Health (Jane Kennedy) : It is a rare pleasure not only to serve under you, Mr. Benton, but to have half an hour to respond to a debate.

A number of hon. Members have contributed to what has been an interesting and useful debate. I compliment the hon. Member for Sutton and Cheam (Mr. Burstow) on securing the debate. I know his interest in the area and his commitment to improving the experience and quality of life of people in care homes. I welcome the opportunity to state the Government's position. The Under-Secretary of State for Health, my hon. Friend the Member for Birmingham, Hodge Hill (Mr. Byrne), is engaged elsewhere, and regrets that he cannot be present to engage in this debate with the hon. Gentleman. Of course, I shall draw my hon. Friend's attention to the length of time that the hon. Gentleman has left me to reply, although I am going to enjoy it none the less.
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Given the concerns expressed by the hon. Gentleman and the hon. Member for Romsey (Sandra Gidley) about care for the elderly, I invite them to visit Liverpool, where the Liberal Democrat-run city council consistently refuses to fund the realistic costs of homes for the elderly, so that beautiful and caring homes, such as Christopher Grange in my constituency, continue to stay in business only by relying on charitable support and reducing to the absolute minimum their staff's wages. Christopher Grange is run by the Catholic Church, and it has a loyal complement of staff who stay with it even under circumstances such as those. It might be of interest to the hon. Gentleman and his hon. Friend to see the difficulties that private homes and those provided by the charitable sector, such as Christopher Grange, have while operating under Liberal Democrat policies in Liverpool.

Mr. Burstow : I should not intrude on a local concern raised by a constituency Member, but may I ask the Minister to consider that when many of us from all parts of the House express concerns about the adequacy of funding settlements and resources for the care home sector, one response that Ministers often offer us is that the delivery of good outcomes and quality of care is a question not only of resources?

Jane Kennedy : I am glad that the hon. Gentleman made that point, because it allows me to reply that CSCI has rung its hands about the state of care for the elderly in Liverpool and criticised the local authority for not passing on to the elderly sector in social services the resources that the Government have provided to the city. I have been longing to get that off my chest. Notwithstanding that, however, the Under-Secretary of State for Health, my hon. Friend the Member for Birmingham, Hodge Hill, would without doubt be willing to meet the hon. Gentleman to discuss his concerns further.

Peter Bottomley (Worthing, West) (Con): This is not quite a point of order, but it is quite close. Given that no Labour Back Benchers are speaking in this debate, should not the Minister be speaking from two chairs? She might be able to move slightly to the right to make her point as an MP, and then move to the left as a Minister to respond to it.

Jane Kennedy : I thought about that, but I might have fallen over my chair if I had tried it.

The hon. Member for Sutton and Cheam questioned why we did not have an older people's rights commissioner in England. I draw to his attention the fact that we already have a national director for older people, Ian Philp, who is responsible for the implementation and oversight of the national service framework for older people. We would look to him for advice and guidance on those areas. When older people begin to need support at home or elsewhere, whether it comes from family members or health and social care professionals, we should strive to help them maintain their independence and quality of life. We should do so because that is what we would want for ourselves and those close to us.

As hon. Members have said, caring for older people can be challenging, as I know from personal experience. The House may not know this, but it may be interested
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to learn that I used to be a care assistant in a residential home for the elderly in Liverpool, working for social services. I know exactly the pressures and demands on staff, requiring not only expert clinical skill, but an ability to empathise with individuals who require support at a time in their life when they are most vulnerable.

The hon. Member for Banbury (Tony Baldry) rightly described the difficulties that people at that stage of their lives often experience. Care must be delivered in a way that maximises their independence, respects their autonomy and meets their quality requirements. We take very seriously the standard of care delivered to older people, and that is why we published in 2001 the national service framework to which Members have referred this morning.

That framework, like others, has the twin aims of raising standards of care and reducing inconsistencies between localities in the levels of care. The hon. Member for Sutton and Cheam asked why the national minimum standards say nothing about nutrition and the training of catering staff and others. However, the regulations and the national minimum standards do cover nutrition and they are being reviewed. As he said, there was no doubt that I would draw the House's attention to that. There will be full public consultation as we take the review forward, and plenty of opportunity for him and others to give their views on what they think should be included in the national standards.

Sandra Gidley : The standards and milestones in the national service framework stopped at 2004, and there has been no indication about how the Government plan to take forward the framework. The Minister mentioned consultation. Will she speak further about when the framework will be updated?

Jane Kennedy : As I said, we are reviewing the framework. I think that the hon. Lady is wrong about the standards ending in 2004, but we shall review the framework and we want to improve on it. The whole purpose of the review is to ensure that the standards that we have set are the best that we can achieve. We can always do better.

Mr. Baron : Having the standards in place is right, but if there is no enforcement of standards or no check on their enforcement, they can be useless. What assurance can the Minister give that there will be consideration not only of the standards, but of how they are enforced?

Jane Kennedy : The hon. Gentleman made that point in his speech. The Commission for Social Care Inspection can take enforcement action and it does. It is charged with the inspection of care homes and with working with the sector to achieve performance improvements. It has the necessary powers to take action. The commission has the powers that it needs, and it uses them. If I have the opportunity, I shall come on to the report that it published this morning.

Sandra Gidley : The Minister will be aware that not all the NSF milestones are those that will be monitored by CSCI, such as the provision of joined-up stroke services and protocols in GP surgeries. How are those monitored by the Government?

Jane Kennedy : I think that the hon. Lady is mixing up the NSF and the standards. The national minimum
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standards are also being reviewed, and the NSF will be updated in the light of that review. The next step will be a report from Ian Philp, which we expect to receive in 2006 and which will also cover her point.

Mr. Baron : I am fully aware—I raised this in my speech—that CSCI is there. The question that I asked is whether the Minister can ensure that it has the capability and resources to ensure that these issues are dealt with, because at the moment there is a question mark over that area, as is shown by the reports that we are seeing about malnutrition in care homes.

Jane Kennedy : The hon. Gentleman makes a fair point, and it is one that can always be made. We believe that the commission has the resources that it needs to fulfil its statutory obligations, but we keep the issue of resources constantly under review.

Mr. Burstow : I am grateful to the Minister for giving way so often. The hon. Member for Billericay (Mr.   Baron) referred to the ability of inspectors to get traction on some of these issues. One point made in the medication report today is that there is a

which it says suggests that there is no

That relates to medication standards, but I fear that inspectors face the same dilemma in other cases, because the nuclear option of closing a home is not really an option. That is the problem.

Jane Kennedy : The hon. Gentleman makes a fair point, and I want to invite the Under-Secretary of State for Health, my hon. Friend the Member for Birmingham, Hodge Hill, to reflect on the range of issues raised this morning and the force with which they have been made.

Let me deal with some of the other points. The hon. Member for Billericay made a firmly argued point about chiropody and said that he had had no response from the Government. There is no excuse for that; we should respond when hon. Members raise issues with us. I acknowledge the force of what the hon. Gentleman said and will invite my hon. Friend the Under-Secretary, assuming that he has responsibility for this matter, to respond to him more fully. The hon. Gentleman has previously brought to my hon. Friend's attention the gap between the NHS and social services in respect of podiatry services. The White Paper "Our health, our care, our say" addresses the joint commissioning of services and, crucially, the development of more services in the community, which will include improved chiropody services. However, I personally do not have a great deal of knowledge of that area, so I shall draw it to my hon. Friend's attention.

Mr. Baron : I appreciate that this is not the Minister's area of responsibility, so obviously I do not expect a detailed answer now. Nevertheless, when she raises the issue with the Under-Secretary, will she ensure that the issue of taking a holistic approach to the care pathway is
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also addressed? In my view and that of many other hon. Members, without a holistic view of the whole pathway, particularly when dealing with patients with long-term medical conditions, we shall continue to fail. People will continually fall into the gap between health and social care. I cited chiropody as an example, but as the Minister knows, that happens in many other areas.

Jane Kennedy : I could not disagree with what the hon. Gentleman has just said. We are firmly behind the concept of the patient pathway in improving the whole patient experience, from beginning to end. As the Minister with responsibility for patient safety and for quality, I receive the letters from Members of Parliament when patients fall into the gap that he described, so I, too, take an interest in ensuring that services are coherent and comprehensive.

The hon. Member for Banbury argued cogently about the complexity of the definition of what comprises nursing or residential care. He described the pressures that that is causing in Oxfordshire and said that he would meet my right hon. Friend the Secretary of State for Health later this week. The Under-Secretary of State for Health, my hon. Friend the Member for Birmingham, Hodge Hill, will read his comments with interest. The hon. Gentleman talked about people in acute hospitals who should not be there. More intermediate care has been available in the past five years. We have worked hard to develop that, and the new national framework for continuing care will be issued for consultation in April, so further work is in the pipeline. Delayed discharges have often been discussed. The number of delayed discharges was reduced by 67 per cent. between September 2001 and September 2005, so I hope that he will take some encouragement from that.

The hon. Member for Sutton and Cheam talked about misalignment of the national service framework standards and GPs' incentives to review medicines. By the end of the first year—2004–05—the majority of GPs were carrying out medication reviews for people who were prescribed repeat medicines under the quality and outcomes framework.

Mr. Burstow indicated dissent.

Jane Kennedy : The hon. Gentleman shakes his head, but that is my information. I will happily look into the matter if he is convinced that we have got it wrong.

Mr. Burstow : I shake my head not because the statistics do not show what has been stated, but because the definition used in the quality and outcomes framework for a medication review is not the standard that was set for the national service framework, and the national service framework is therefore not being adhered to.

Jane Kennedy : I accept the hon. Gentleman's point; we shall have to study the matter further.

Promoting healthy, active ageing is a key element of the national service framework. Improving diet and nutrition in older people is, of course, an integral part of maintaining health and determining a person's well-being. It is also fundamental to the principles of dignity
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and respect. We recognise that patients should be involved, wherever possible, in all decisions about their care, including nutrition. The hon. Member for Romsey suggested that five portions of fruit and vegetables a day should be one nutritional requirement for older people. I say to her that older people are adults and, like any of us, can be encouraged to participate in healthy eating programmes, but we cannot insist on that. Clearly, choice is what is important.

Care home residents regard the food that they are given as one of the most important factors in determining their quality of life and their ability to maintain their health and well-being. We acknowledge that fact in the national minimum standards. Failure to eat through physical inability or depression, or because the food is inadequate or unappetising, can lead to malnutrition, with serious consequences for health. Older people are entitled to nutritious, varied, balanced, culturally sensitive and attractively presented meals at times that suit them. I take the point that hon. Members have made about cooks not being available after 4 o'clock.

The national minimum standards state clearly what we expect. As I have said, the Commission for Social Care Inspection inspects and regulates care homes and has statutory powers to take action if those standards are not being met. As I have shown, the principles of respect and dignity are expressed in a practical way in the national minimum standards, through which registered providers of care, assisted by regulators, can ensure that their services are person-centred, appropriate and effective and that their care staff are trained, supervised and supported so that they are competent to deliver high-quality care.

I shall make one or two further comments on the review. The hon. Gentleman said that there was no screening tool in respect of nutrition for people entering care homes. All stakeholders, including CSCI and the FSA, will have an opportunity to contribute to the review that we are undertaking on the national minimum standards. All the contributions that they make, including his point, will be considered seriously.

I should make a point about the report that CSCI has issued today. We acknowledge the findings in its follow-up study—this is the second study that it has conducted—and I am disappointed that care homes appear to have made so little progress towards meeting the national minimum standards on medicines management since its last report. However, CSCI has the responsibility for inspection, as well as the powers it needs to take any necessary and appropriate enforcement action to secure improvements in standards of care in care homes. Ultimately, it has the powers to close poorly performing care homes. I read the review of the report with interest. While being briefed for today's debate, I was a little disappointed to learn that it appeared that CSCI had briefed the hon. Gentleman on the details of the report in advance of briefing Ministers—that is a cause of some consternation.

The national minimum standards leave providers in no doubt about how the Government expect people to be cared for and treated. Providers should respect that older and vulnerable people have preferences and needs that should be met on an individual basis, and care and treatment should provide safeguards to promote health and well-being. It should be respected that a good
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quality of life is essential to health and well-being. No one should be deprived of a decent quality of life through neglect, omission, malice or ignorance.

Apart from analysis of calls to the Action on Elder Abuse helpline—the hon. Member for Billericay asked me to respond specifically to that—and local data collections on the back of the "No Secrets" guidance, there are no credible national statistics on the incidence and nature of abuse. I have noticed that in recent publicity linked to the campaign on awareness of abuse of older people, Help the Aged has claimed—the hon. Member for Sutton and Cheam pointed this out—that about 500,000 people experience abuse at any one time. We do not recognise that figure. The Government have consistently expressed reservations about it; it was derived from a small community-based study that took a very wide definition of abuse or harm. Importantly, the figure also does not recognise all that we have done since 1997 to prevent and tackle abuse.

However, I accept that a lack of knowledge about the nature and prevalence of abuse is a serious flaw. To help remedy that, we have provided AEA with funding of £280,000, with £150,000 for data capture to take stock of the information that is currently being collected by councils. AEA will advise on the validity and reliability of the information, and make recommendations on what data can be routinely and accurately collected. We are awaiting the final report from AEA, which will be published in due course.

Of course, it is important to acknowledge that the vast majority of care staff are dedicated to their work, as I know, having worked alongside them. They are committed to the welfare of those whom they look after. I am grateful to all those working in care homes, in individuals' own homes as home helps or equivalents, and in other settings, who provide a high-quality service.

It is important to return to the CSCI report that was published today, because it raises matters of serious concern. The report makes a number of recommendations on issues such as staff training and the development and monitoring of patients to safeguard them from abuse through medication mismanagement, and to maximise their well-being. In the coming year, CSCI will also carry out themed inspections into medication management, sampling homes for controlled drugs management, and its inspectors will pay particular attention to medication management in care homes. Through all this activity, the commission will strive to ensure that it works collaboratively and supportively with its stakeholders in the sector to ensure that the messages from its report are acted upon. The hon. Gentleman made a valid point about the nuclear option of closing a home that has become a haven for many residents.

The hon. Gentleman also said that it appears that there has been little improvement in managing medicines. We will look carefully at CSCI's recommendations, and a deeper analysis of where exactly homes are failing would be helpful. We will feed CSCI's report into the review of the standards and regulations.

The national service framework for older people recommended that medication reviews be carried out for all people over 75 at least once a year, and that those taking four or more medicines should have a review every six months. In that context, we have also
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supported a number of primary care trusts to identify and share good practice in medicines management through the national medicines management collaborative. Nearly half of all PCTs have participated in this programme to implement local medicines management schemes so that people get more help from their GPs, pharmacists and others in using their medicines.

One of the measures used for assessing improvement was the proportion of people aged 65 years and over on four or more regular medicines who had had a documented medication review carried out in the last 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 have had a documented review of their medicines in the last year. I am aware that some people believe that people in care homes do not have their medicines reviewed regularly, but that is not what the data from the collaborative show. There was a similar increase in activity for patients in care homes, compared with those living at home, albeit from a lower starting position.

From a survey of PCTs undertaken in 2004, we know that the majority of PCTs had a written strategy—I know that things can be put on paper, but they have to be put into practice—and 60 per cent. of PCTs had agreed local guidelines for medication reviews.

Mr. Baron : A similarly critical report was published in 2004, and this latest CSCI report highlights that very little progress appears to have been made since then. I ask the Minister to give that issue added urgency this time around, as little seems to have been done over the past couple of years.

Will the Minister also ask the Under-Secretary of State for Health, the hon. Member for Birmingham, Hodge Hill, to write to me in response to the issues that she has referred to him, specifically including chiropody and the gap between health and social care?

Jane Kennedy : I am happy to take my revenge on my hon. Friend the Under-Secretary by assuring the hon. Gentleman that he will write to him.

In conclusion, I hope that I have demonstrated our commitment to ensuring that all our older people are treated safely, effectively and with respect for their dignity. Through the older people's NSF and other initiatives I have outlined today, we have done much to root out discrimination of older people. However, we are aware that there is more work to be done to ensure that older people are treated with sensitivity, and today's report serves to underline that.

Many reforms are already under way. The improvements described in the White Paper will build on them. By looking at people's whole lives rather than individual problems, and by fitting services around their needs, we will help them live healthier, more independent lives. That is what we would all wish.

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