Examination of Witnesses (Questions 100-119)
NATIONAL HEALTH
SERVICE
15 OCTOBER 2007
Q100 Mr Bacon: I would like to move
on to neuroleptic drugs, which were mentioned before. Do you agree
with Professor Clive Ballard, the Alzheimer's Society's Director
of Research, when he says that in most cases the prescription
of these drugs is inappropriate?
Professor Banerjee: Sorry,
is that in the Report?
Q101 Mr Bacon: No, it is not in the
Report. I am reading an article in which Professor Clive Ballard
is quoted as saying that, in most cases, although not necessarily
all, the prescription of neuroleptic drugs is inappropriate.
Professor Banerjee: That
is absolutely the point. Yes, I would agree with Clive. The prescription
of neuroleptic drugs for people with psychosis maybe entirely
appropriate. People with dementia develop psychosis, and it is
important that they have their psychosis treated, because psychoses
can be terribly distressing for individuals—that is a recognised
co-morbidity in dementia. The problem is with the management of
behavioural disturbance, such as agitation in dementia, which
is not caused by psychosis. I would agree with Clive entirely
that it is important to work out what the antecedent of the behavioural
disorder is. If it is depression, we can treat the depression;
if it is psychosis, we can treat the psychosis with anti-psychotic
medications; if it is caused by the person being in pain, we can
treat the pain; if it is caused by a urinary tract infection,
we can treat that, and so on. If the individual continues to suffer
severe agitation, which is causing them distress in their dementia,
that is the point at which it is important to try psychological
and social ways of managing them—to see whether there are
different ways of feeding or being that can help them. But there
is a group of people who, after all that, remain intensely distressed
by the problems that they have and who may be a risk to themselves—
Q102 Mr Bacon: And for whom neuroleptic
drugs are then appropriate?
Professor Banerjee: And for
whom neuroleptic drugs would be appropriate, and I think that
Professor Ballard would agree with that.
Q103 Mr Bacon: I am sure he would.
Do you agree that there is a group of people for whom neuroleptic
drugs are prescribed far too soon, effectively, in Mr Touhig's
words, as a way of sedating those who might be a bit difficult?
Indeed, that might even be done covertly through food. Is it correct
that that happens?
Professor Banerjee: The covert
administration of medication?
Q104 Mr Bacon: Is that something
you have heard about?
Professor Banerjee: There
is a literature on the covert administration of drugs, absolutely.
It happens in NHS facilities, as well as in other places. The
important issue is that the places where it is most likely to
happen are in the community, with individuals living in their
own homes, or in care homes. Clive Ballard's work focuses largely
on care homes, and there are particular issues in care homes.
The solution to this—there needs to be a solution, because
it is an important problem in the health system, and we are becoming
increasingly aware of it and of the fact that there are non-pharmacological
answers to it—is for specialist mental health services to
have time and capacity, because these drugs are generally not
initiated by specialist mental health services, unless you have
met all the criteria we have gone through. We need to have specialist
mental health services that are able to go into care homes and
advise on non-pharmacological treatments and, when and if those
treatments are instigated, to make sure that they are initiated
at a low dose, reviewed regularly and stopped as soon as possible.
That needs to be done, and it is specialist mental health care
liaison going into care homes that can help us to tackle this.
By themselves, GPs find such behaviours and issues very difficult
to deal with, so there may be recourse to such drugs when other
things might be helpful. Having good quality liaison going into
homes would enable those other treatment options to be tried before
drugs are.
Q105 Mr Bacon: Thank you for that.
I have just two more questions. Is it correct that patients with
dementia are three times more likely to have a stroke if they
are medicated and twice as likely to have an early death?
Professor Banerjee: People
with dementia are more likely than the general population to have
strokes anyway—
Q106 Mr Bacon: But if they are medicated
and on drugs?
Professor Banerjee: Sorry.
There is a set of warnings about neuroleptic medication, which
came out through analyses of data sets. It is by no means certain
that the increased risk is associated with any particular sort
of neuroleptic drugs, although there is an inherent risk in taking
medications of all sorts. These drugs should be used only when
their benefits outweigh the risks of their use. The people prescribing
such drugs need to be aware of those benefits and risks. Speaking
as a specialist mental health practitioner, I can say that those
involved in old-age psychiatry and the services that we provide
are aware of those risks.
Q107 Mr Bacon: Finally, Mr Nicholson,
in the helpful DVD that that the NAO sent us, which described
some of the people who had been carers and some of the people
who have been suffering from dementia, one of the points that
was made strongly was that respite breaks are absolutely fundamental
for people who are caring at home. Such caring is, of course,
a huge cost to people's lives individually, but it is not a cost
to the taxpayer. It is a huge cost that you are not having to
pay for, because all this work is being done at home by families.
Never mind the fact that there is also
a big care issue here for those people; in the most accounting-like
ways of looking at this issue, if one looks at it purely with
financial spectacles, surely it would be very cost-effective to
have more respite available, because there are all those people
out there who are caring who you do not have to pay. What are
you going to do to increase the amount of respite care?
David Nicholson: One of the
things that we have to do is to persuade commissioners, primary
care trusts and local authorities to invest in this area, to enable
such respite care to happen. One of the important pieces of work
is this business case, which sets out exactly the situation that
you have described; how much you save by investing upstream. We
will certainly be driving that message through. Also, our experience
shows us that in different places different types of respite care
are required. Some carers will tell you that they do not want
their relative to go away to a particular unit for a period; they
would rather have some help in the home. So we do not have to
be dogmatic about this issue, but we would certainly see PCTs
and social care organisations responding to this need for more
respite care as part of this strategy.
Q108 Mr Williams: Following on from
what Mr Bacon has just said, is the suggestion just apocryphal
that some nursing homes use these drugs more as a management tool
in some cases than to meet a medical need, or is that just a popular
misconception?
Professor Banerjee: A management
tool? Do you mean a tool for the management of behaviour?
Q109 Mr Williams: Yes, to tranquillise
patients and to make them convenient and malleable.
Professor Banerjee: That
is absolutely the concern that people have.
Q110 Mr Williams: It is a concern
that they have, but is it a concern that you have? Have you seen
instances of such treatment?
Professor Banerjee: I find
it very difficult to understand the motivations of individuals
in particular homes at particular times. If you look at the evidence
as a whole—again, Clive Ballard's work is very clear on
this—you will see that there are many more of these medications
being prescribed than one would expect, given the level of disturbance
and given the level of psychosis.
Q111 Mr Williams: Why do you think
that is?
Professor Banerjee: I think
that it is to control behavioural disturbances.
Q112 Mr Williams: That is right.
So, the answer to my question was just a simple yes, was it not?
They are used as a management tool and people are just robbed
of their dignity and their human rights, propped in a chair, tranquilised
and left where they are least inconvenient. Is that a completely
false portrayal of what happens in many cases?
Professor Banerjee: I know
some excellent care homes where that really is not the case. I
also have worked with people who have benefited tremendously from
treatment. I just think that treatment needs to be given only
to those people who really need it.
Q113 Mr Williams: That cannot be
so, because you said that you cannot understand the amount of
these medicines that are being dispensed, because the amount seems
to be more than would be needed. You cannot have it both ways.
David Behan: There is an
important distinction to make between the prescription of medication,
which is done outside the care home, and the management of that
medication, which is done within the care home. Certainly, there
are no staff who work in or are responsible for care homes where
they prescribe the medication.
To go back to the regulator, the CSCI (Commission
for Social Care Inspectorate), what we are aware of is that compliance
with medicines management as a standard is an issue that needs
constant attention. Approximately six out of 10 care homes are
meeting the medicines management standard; in other words, four
out of 10 are not. So that is a cause for concern—whether
the management is of the drugs that you are referring to or of
other forms of medication. But I think that it is quite important
to distinguish between where the prescription takes place and
where the management and administration of that medication takes
place.
Q114 Mr Williams: I come to the question
that I was originally going to ask until I listened to Mr Bacon.
You referred to the fact that there is a director who is responsible,
or who is the prime mover, in relation to cancer. We have a high
priority for heart problems and for strokes, but dementia costs
more than all three put together. Yet, according to the briefing
that we were given for this meeting in addition to the Report,
the NAO tells us, "Dementia is not specifically considered
in any of the Department's key policy initiatives". That
is pretty damning, isn't it? Why not?
David Nicholson: I think
that it reflects the relative priority of improving dementia services
over the past—
Q115 Mr Williams: It reflects the
Department's priority. "Dementia is not specifically considered
in any of the Department's key policy initiatives", so when
you say that it is not considered a priority, that means that
you do not consider it a priority.
David Nicholson: I did not
consider it a priority until August, when our Minister—
Q116 Mr Williams: When you found
that you were coming to this Committee to answer to it.
David Nicholson: Sorry, it
was not me who identified it as a priority, it was the Government.
It was the Minister.
Q117 Mr Williams: It was a coincidence
that it was in August, was it? When did you first get a copy of
the Report to read?
David Nicholson: When it
came out. No, I saw a draft, probably. The Report makes a compelling
case, and we are responding to that and saying, "Yes, we
need to do something about this particular compelling case."
Mr Williams: Well, goody, goody!
David Nicholson: But there
were compelling cases for cancer, coronary heart disease, waiting
times—
Q118 Mr Williams: Yes, and you did
something about them.
David Nicholson: Yes, we
did, because the whole point of having priorities—
Q119 Mr Williams: This is bigger
than the lot of them put together in the use of your resources,
and you are still only thinking about doing something about it.
David Nicholson: Just because
you spend a lot of money on it does not necessarily mean that
it is a priority. There is a whole series of issues: what is the
clinical evidence? What can improve the services? What is the
state of the services at the time? What are the priorities of
the Government? That is what we have been reflecting on. Coronary
heart disease, cancer and waiting times were identified by the
Government as priorities and were reflected in the general population.
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