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Mr. Tom Clarke (Coatbridge, Chryston and Bellshill) (Lab): Is the Prime Minister aware that my constituents will very much welcome the protection that he is giving to consumers, particularly in his announcements on banking and on fuel bills? On banking, the Government
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have been supportive, and it is perfectly right that consumers should be protected. The leader of the Liberal Democrats did not seem to hear the part of the statement where my right hon. Friend referred to fuel bills. It is right that he should do so, and may I say that he has the moral authority to ask the energy companies to make their contribution—for example, in terms of their competitiveness and accountability?

The Prime Minister: My right hon. Friend has been a great campaigner on behalf of people who have been affected by poverty. Obviously, high fuel bills are a determinant of poverty and that is why we wanted to increase the winter allowance, which was announced in the Budget, why the low income households deal has been done with the utility companies, and why we will not hesitate to take further action to protect people against high fuel bills. It is in the interests of the country that people are protected at a time when oil prices have trebled.

Paul Rowen (Rochdale) (LD): According to the National Audit Office, the chances of an unemployed person getting a job when coming off the jobseeker’s allowance programme vary between one in five and one in 40 depending on their age, sex and where they live. What will the new proposals do to help people in my constituency, for example, where we have lost 4,500 jobs in the past five years and unemployment is on the up? What is the Prime Minister going to do to help those people?

The Prime Minister: Employment is still rising—that is why there are 600,000 to 700,000 vacancies in the economy. Our desire is to help people who are unemployed or moving between jobs to fill the vacancies that are available. The hon. Gentleman will know that in his constituency there is still a high number of vacancies, as there is across the region. Through the welfare reform Bill, we want to make it an obligation on people to undergo a skills test and then for them to be advised as to whether they need to acquire further skills, because we know that the number of unskilled jobs in the economy is falling but the number of skilled jobs is rising. We want to help his constituents and all other unemployed constituents to get the skills that they need for the future.

Anne Snelgrove (South Swindon) (Lab): My right hon. Friend’s proposals mean that Swindon will be an even more prosperous community in future. We are a proud industrial town and we have a proud industrial heritage derived from the railways. Would his proposals to protect historic buildings help the mechanics institute in Swindon, which is in private hands, and is a crumbling but beautiful building that we seek to protect? Will he help us by ensuring that people who are private owners of such buildings are included in that protection?

The Prime Minister: My hon. Friend has been most innovative in citing the new Bill as a means by which we might support what is obviously an historic building of great value in her constituency. We will certainly look at what we can do. Swindon is a community that has benefited from the expansion of investment over recent years. That is why there are more people in jobs there
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than there have been previously, and why people in Swindon will think twice about a Conservative Government who caused so much unemployment.

Mr. Peter Lilley (Hitchin and Harpenden) (Con): Is the Prime Minister aware that his conversion to Conservative policies would be welcome—there is, after all, more joy in heaven over one sinner that repents—if only he understood them. How does he reconcile his welcome proposal for “directly elected representatives to give local people more control over policing priorities and responsiveness” with the very next sentence, which proposes statutory, national, top-down legislation defining how police authorities should employ their resources and ensure their visibility and responsiveness? Is not the difference between karaoke Conservatism and the real thing that he can recite the words but he does not know what they mean?

The Prime Minister: It is pretty clear that the right hon. Gentleman has learned nothing from his years in opposition. While it is right that people are elected at a local level to discharge representative functions in their area, it is also right in certain circumstances to set down minimum national standards. I hope that he will continue to support the setting of a minimum national standard in respect of policing as in other matters.

Mr. Gordon Prentice (Pendle) (Lab): Is the NHS constitution a mission statement or will it give people new rights that can be exercised in the courts?

The Prime Minister: I think that when the NHS constitution is published and subject to debate my hon. Friend will find that it does give patients new rights. I have mentioned access, safety and care—clearly, people want those things when they use the national health service. For the further details, he should wait for the statement by the Health Secretary.

Mr. John Hayes (South Holland and The Deepings) (Con): Why should we believe the Prime Minister on apprenticeships and lifelong learning given his history? When Chancellor, he predicted that by 2006 there would be an average of 320,000 apprenticeships—in fact, there were 235,000—and on lifelong learning the National Institute of Adult Continuing Education reports this week that in just two years the number of adult learning places has been cut by 1.4 million. Does not the Prime Minister realise that in anticipating the future we do not need a crystal ball when we have his dismal record book?

The Prime Minister: I am grateful to the hon. Gentleman for allowing me to point out that apprenticeships were dying out under the previous Conservative Government. There were barely 70,000 in the country when we came
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to power. If the figure was 235,000 a year or two years’ ago, that represents a trebling of apprenticeships under Labour.

Mr. Kevan Jones (North Durham) (Lab): May I warmly welcome the extension of rights to temporary workers, which adds to the protections offered by the minimum wage, the extension of maternity pay and rights at work? Does my right hon. Friend agree that although that is a priority for this Government, it is something that we would never have seen under a previous Tory Government or see even under a future one?

The Prime Minister: My hon. Friend is absolutely right. On all the major advances in rights, including the minimum wage, the social chapter and maternity and paternity pay, we have had very little support from the Conservative party. That is totally in line with the history of the Conservative party that opposed the national health service in the first place.

Mr. James Clappison (Hertsmere) (Con): The Prime Minister has spoken of a migration policy based on an Australian-style points-based system. A fundamental feature of the Australian system is an annual limit on migration. Does he have any such proposals for a limit on migration?

The Prime Minister: I do not think that any party has an annual limit on migration, and no political party has proposed one. We are saying that we reserve the right to set a limit for unskilled and semi-skilled workers, but if skilled workers have a contribution to make to the country, they should be allowed in. Any business that the Conservative party talks to—I know that it wants to put a cap on this figure as well—will tell it that it wants to be able to draw on the skills of the world when it is necessary to do so, and I would have thought that that is the sensible way forward.

Paddy Tipping (Sherwood) (Lab): Did the Prime Minister share my concern that neither Opposition party leader noted the valuable initiatives in his statement about protecting the natural environment? The marine Bill is much appreciated and widely anticipated. It also contains measures to extend access to the countryside and the coastline, something for which working people have campaigned for 100 years and which a Labour Government have delivered.

The Prime Minister: I was surprised that neither the Conservative nor Liberal party welcomed this— [ Interruption. ] The right hon. Member for Witney could not list all the things that we were suggesting. This is an important part of legislation about the environment, and his party says it cares about the environment. Perhaps it should be consistent in its support for the environment.

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Point of Order

1.20 pm

Mr. Kevan Jones (North Durham) (Lab): On a point of order, Mr. Speaker. During his response to the Prime Minister, the right hon. Member for Witney (Mr. Cameron) accused the Prime Minister of distributing speeches in advance to the Press Gallery. I have seen that practice going on for several years. Could you, Mr. Speaker, clarify the position through your good offices? It is a practice that has grown up over time, and we need some clarification.

Mr. Speaker: I am going to look into the matter, and I will make a statement to the House to see whether we can rectify it.

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Management of Dementia in Care Homes

1.21 pm

David Taylor (North-West Leicestershire) (Lab/Co-op): I beg to move,

One third of all people over 65 will be suffering from dementia when they die. Their condition will touch the lives of millions more families and friends, who will provide care and support to the victims of that cruel and relentless disease. Care homes have a large and increasing amount of responsibility for caring for our population of dementia patients. As the all-party parliamentary group on dementia, of which I am a member, has observed, two thirds of the care home population suffer from a form of dementia. Dementia sufferers in care homes are more likely to be in the advanced stages of the disease.

Our recent inquiry and report, “Always a Last Resort”, into the prescription of anti-psychotic drugs to care home residents with dementia reached some startling conclusions that I feel the Government must take into account before publishing their national dementia strategy later this year. I must pay tribute to the Alzheimer’s Society for its support and to the hon. Member for Rugby and Kenilworth (Jeremy Wright) who chaired the inquiry and guided our deliberations with élan and verve. The team also included my hon. Friends the Members for Conwy (Mrs. Williams) and for Blackpool, South (Mr. Marsden), as well as Baroness Thomas of Walliswood and Baroness Greengross from the other place.

The report reached a number of conclusions that informed its five subsequent recommendations to the Government on the issue and my Bill seeks to implement those recommendations. First, we noted the consensus among patient and professional organisations, the regulators and the care home sector that over-prescribing is a massive problem. The evidence testified to the significance of external behavioural symptoms, not only resulting from the condition, but from wider and more complex environmental problems.

In the awful psychological limbo of dementia, communication with the outside world is unavoidably basic. Too often and too quickly it seems that anti-psychotics are prescribed to manage such behavioural symptoms, banding together types of behaviour that can differ in their seriousness. Witnesses repeatedly stated the importance of not trivialising the challenging types of behaviour demonstrated by care home residents with dementia, such as aggression, which can have serious consequences for the individual and the care home environment. However, in many instances quoted to us, anti-psychotics were prescribed to treat behaviour that is neither distressing nor threatening, such as restlessness or being vocal—often basic expressions of need.

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There is justified concern that care homes resort to the use of anti-psychotics as a response to this behaviour, misinterpreting its cause. A mandatory course of training in caring for dementia patients would enable staff to discriminate better between the types of behaviour exhibited by residents with dementia. Indeed, a lack of dementia care training for staff, high staff turnover and inadequate leadership in a care home setting can partly explain the current excessive and inappropriate use of anti-psychotics.

With scant time or training to provide alternative treatments, care homes have a default switch to “quick”, more accessible methods of managing behaviour that is broadly and often inaccurately, categorised as “difficult”. As the Royal College of Nursing points out, inappropriate prescribing of anti-psychotics can be reduced by ensuring an appropriate environment, activities, and the correct staffing levels and skill mix. It clearly follows that care homes themselves need better support from external services to improve the quality of care provided to residents with dementia. That would reduce the widespread use of anti-psychotic drugs through cutting the number of new prescriptions and ensuring that residents with dementia have access to the sort of prescribing process that we expect from our own GP.

As Help the Aged states, care staff are often in the best position to recognise when a treatment is not working for a patient, so we need to develop the link between care home staff and local GP surgeries. That demonstrates with particular clarity the benefits to be gained from training care home staff in dementia treatment. Not only would staff be able to recognise and treat appropriately behaviour in dementia patients that might currently be referred to GPs or treated with anti-psychotics, but alternative treatments that have genuine benefit to dementia patients would also be used more effectively and successfully.

Our report found that people with dementia and their carers are being excluded from decision making, a direct contradiction of the provisions of the Mental Capacity Act 2005. The present system permits care homes and some external providers to prescribe without fully assessing and discussing the individual’s situation, including the risks and benefits of the drugs—a situation that would be both unthinkable and illegal anywhere else in the health or social care system. Of course, there are some circumstances in which the use of drugs is appropriate to treat dementia sufferers. Nevertheless, the use of anti-psychotics should always be the course of last resort—as in the title of our report—taken only in times of severe distress or critical need.

Anti-psychotics are powerful drugs that GPs do not prescribe lightly. They can have destructive side effects, such as increased risk of stroke. The joint National Institute for Health and Clinical Excellence and Social Care Institute for Excellence 2007 guidelines are recognised as both effective and appropriate guidance, but there is significant evidence to show that they are not working in practice, with obstacles to implementation. As one would anticipate from excessive use of and over-reliance on anti-psychotics, inappropriate prescribing is widespread in the care
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home sector. It is estimated that these drugs are wrongly prescribed in 70 per cent. of cases—an incredible figure.

Even dementia patients with very mild behavioural symptoms are being prescribed lengthy courses of anti-psychotics, with no regular checks to establish whether the patient is deriving benefit from such a serious course of treatment. Urgent and immediate action is needed to correct that bad practice through the implementation of existing guidance. It is of concern to me, however, that the Commission for Social Care Inspection washed its hands of that scandal as being “outside their remit”. It is important to acknowledge, as our report does, that more appropriate ways of dealing with challenging behaviour exist and have been deployed to good effect in some care homes. The use of individually tailored care plans and the promotion of care home based activities, for example, should be used in every care home, as every care home will have dementia patients among its residents.

Essentially, the national dementia strategy for England must have plans to reduce the present number of prescriptions, and there are five steps that the Government can take to end the “chemical cosh” approach to elderly care home residents with dementia, which are the requirements spelled out in my Bill: dementia training to be mandatory for all care home staff; care homes to be properly supported by external services, including GPs, community psychiatric nurses, psychologists and psychiatrists, with regular visits to the care home and its residents; the use of anti-psychotics for people with dementia must be included in Mental Capacity Act training for all care home staff; protocols for the prescribing, monitoring and review of anti-psychotic medication for people with dementia must be introduced; and finally, the regulation and audit of anti-psychotic drugs for people with dementia should be compulsory.

It is now almost five years since June 2003, when I introduced a related piece of legislation—my ten-minute Bill advocating the establishment of an older people’s rights commissioner. That has been overtaken by the Equality and Human Rights Commission, whose overarching equality scheme has emerged in the last few weeks. I hope that the EHRC will give high priority to the frail elderly in our population, who far too often have no one to speak for them, who are being disgracefully and unfairly treated when at their most vulnerable with some type of dementia.

We cannot continue to speed the decline of dementia patients through poor management with expensive and often inappropriate anti-psychotic drugs in care homes. We know that the number of people with dementia in the United Kingdom is expected to reach 1 million in 2025. Last year, care homes spent £60 million on anti-psychotic drugs, even though they were not appropriate forms of treatment in most cases.

As the dementia population continues to grow, we must equip care home staff with the skills necessary to identify different forms of behaviour among dementia residents. To do that, we should ensure that the funds saved from accurate and appropriate drug prescription are ploughed back into the continuing care scheme, in order to provide individualised care for all care home
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residents, particularly those in need of the most care, and understanding and support.

The Under-Secretary of State for Health, my hon. Friend the Member for Bury, South (Mr. Lewis), who has responsibility for care services, has said that he wants to bring dementia out of the shadows. I hope that the Bill and our report will pierce the Stygian gloom and illuminate one of the bleakest and darkest recesses of that dire and degenerative chamber that faces one in three of us in this House. There is much good practice out there in dealing with the behavioural symptoms of dementia in a non-pharmacological manner. We need to spread and entrench that in all care home settings. That is currently happening at far too slow a rate and demands urgent action now.

The 1,000 or more people in each of our constituencies with dementia—750,000 people nationally—deserve better. My Bill, like our all-party group report, aims to flag up some suggestions on the way ahead for the crucial national dementia strategy in a few months. In the interests of those hundreds of thousands of our fellow citizens, I commend the Bill to the House.

Question put and agreed to.

Bill ordered to be brought in by David Taylor, Jeremy Wright, Mr. Eric Illsley, Mr. Gordon Marsden, Mrs. Betty Williams, Mr. Paul Truswell, Mr. Gordon Prentice, John Bercow, Lynne Jones, Bob Russell, Mr. David Drew and Colin Burgon.

Management of Dementia in Care Homes

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