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Elder Abuse

Volume 474: debated on Tuesday 1 April 2008

I am grateful for the opportunity to raise the serious issue of elder abuse. This is not the first time that I have brought these concerns to the House, nor will it be the last. Over the past 10 years, I have urged Ministers to pay greater attention to elder abuse. I do not want to pretend in this debate that nothing has changed over those 10 years—an awful lot has done. I acknowledge that the Government have done much to develop standard setting, with the introduction of the protection of vulnerable adults scheme and a range of other initiatives that have improved the situation. Clearly, there has been improvement, but there is still much to be done if we are to expose and expunge the scourge of elder abuse from our society.

Today I want to focus on one issue: the use of medication as a chemical restraint. Before doing so, however, I must say that I am a firm believer in serendipity. As Members will know, MPs apply for a debate over a number of weeks and hope that their name will eventually come out of the hat in the lottery for the selection of Adjournment debates. I was therefore pleased when I received the news last Wednesday that this debate had finally risen to the point where it secured a slot. I was even more pleased when, 24 hours later, I learned that three of the issues that I had planned to discuss were being progressed: the closing of a loophole in the Human Rights Act 1998 that prevents a resident in a private care home who is funded by the state from benefiting from the protections of the Human Rights Act; issues around complaints; and the question of research on the prevalence of elder abuse in residential institutions.

That is all welcome news, particularly the news that, at long last, the loophole in the Human Rights Act will be closed, at least partially. It would be churlish to do anything other than welcome that news, and I applaud the fact that the Minister is to introduce amendments to achieve that end. However, I understand from the press release issued last week that the gap will be closed only for residents of care homes who are funded by the state; self-funders will not be protected by the Act. Therefore, when a self-funder crosses the threshold of an independent care home, the writ of the Act apparently will not apply.

I urge the Minister to set out the rationale for that decision, and explain why it is not possible to close the loophole completely. Extending the Act is just the beginning—it is essential but not sufficient. I have heard the Minister make the point in debate that what is required is a cultural change to bring every home up to the standard of the best. Will he therefore say a bit more today about how he intends to go about winning the hearts and minds of care home owners, managers and staff?

Turning to complaints, it is welcome that self-funders will have a right to refer complaints to an independent adjudicator, but, clearly, the devil is in the detail of such a scheme. Just how independent and powerful will the adjudicator be when it comes to settling disputes? Finally, on research, I have argued in debates over the years that we need to commission research into the prevalence of elder abuse in institutional care settings. Indeed, last year’s research funded by the Department and by Comic Relief revealed that elder abuse is a problem in the community, as some 342,400 people over the age of 66 are victims. That was a stark warning and reminder of the scale of the challenge that society faces in dealing with the issue. Research is certainly welcome, but it must not be a substitute for action, which is what I am calling for today.

For several years, I have taken an interest in the inappropriate and even abusive use of anti-psychotic medication in care homes. This is not simply a matter of poor standards in some of our institutions. It demands more than just a response from providers, commissioners and regulators. There is a growing body of evidence from studies and other research about the abusive prescribing and administration of drugs. That really ought not to be a matter just for regulators and commissioners but for the criminal justice system, the police and the courts.

A slap on the wrist from a regulator or social services is not sufficient to deal with the abusive and inappropriate use of medication. Frankly, people should go to prison. Prescribing anti-psychotic drugs to manage the behaviour of elderly people with dementia is a shocking abuse, because the evidence is clear, and has been for rather a long time, that the drugs cut lives short, increase the risk of stroke and have other harmful side effects that create the justification for further prescribing. The drugs create many of the symptoms that are used as a pretext for prescribing drugs in ever greater doses.

Some 100,000 care home residents are prescribed such drugs at any one time, according to research by the Alzheimer’s Association. Based on research presented to the Alzheimer’s Research Trust, I estimate that as many as 23,500 care home residents die prematurely as a result of taking anti-psychotic drugs, which are not even licensed for the treatment of dementia. I understand the difficulties in the ethics of testing drugs on people who are unable to give their consent, and Parliament has debated the issue. Nevertheless, a large part of our population is prescribed such drugs off-licence. That is not illegal: doctors can prescribe licensed drugs for an unlicensed purpose on their own authority. The General Medical Council makes it clear in its guidance to doctors on prescribing off-licence drugs that they must satisfy themselves that the drugs are safe, that good records are kept and that regular medicine reviews take place. However, on the face of it, the GMC’s guidance is routinely ignored by GPs. Prescribing anti-psychotic drugs has become the accepted norm, despite clear guidance issued by the National Institute for Health and Clinical Excellence and by the Social Care Institute for Excellence. Inappropriate and abusive prescribing is an infringement of human rights and should be prosecuted under the Mental Capacity Act 2005 as assault, ill treatment or wilful neglect.

When it comes to the administration of medicines in care homes, the most recent figures—there should be some out in the next couple of months—show that more than 4,000 care homes fall short of the minimum standard. We need to be clear about the fact that we are talking about a minimum standard. When the Commission for Social Care inspection looked at the matter, it concluded:

“People are given the wrong medication, someone else’s medication, medication in the wrong doses, or no medication at all.”

It found many care homes failing to attain or sustain the minimum standard—they get to the standard but then slip back—and that was a recurring theme in several inspections. Indeed, one only has to look at inspection reports to see that recurring deficiency.

The reports on care homes document concerns such as poor storage and record keeping, failure to safeguard residents, inadequate training and supervision, and lack of medicine reviews. Some homes are repeat offenders. How can doctors safely prescribe anti-psychotic medication for residents in homes that are habitual failures when it comes to the minimum standards of medicine management? That brings me to medicine reviews. In 2001, the Government published the national service framework for older people. It promised that by 2002, everyone over 75 should have their medicines reviewed at least annually, and people who take four or more medicines should have reviews every six months. Research by the Medicines Partnership, an agency that works with the Government, states that there remains a lack of clarity in the definition of medication or medicine review. That lack of clarity has led to various interpretations in different parts of the country by different practitioners and, therefore, to inevitable confusion and inconsistency in the application of medicine review practice.

Seven years after the undertaking in the national service framework, what is happening? Is there a clear definition? That is a question to which I do not have an answer. It is not obvious that there is a clear definition against which systematic audits are done to ensure that we gain traction. Does the Minister know how many medicine reviews take place every year? Apparently, that information is not collected centrally, and it is hard to obtain it locally. A lot can happen to someone when they are prescribed a range of anti-psychotic medicine for six months, which is one reason why, in the USA, monthly medicine reviews take place when an older person in residential care is prescribed four or more drugs, with quarterly reviews for those who are prescribed fewer than four. Surely, that should be the standard is this country, too.

Since 1999, the number of anti-psychotic drugs prescribed to people over 60 has risen by 38 per cent. That contrasts with the fact that the population of over-60s in this country over the same period has risen by just 6 per cent. What is going on with prescribing practice for those drugs? Prescribing is wrong if it aims to manage behaviour such as wandering, poor self-care, restlessness, impaired memory, depression without psychosis, unco-operativeness, and agitation. Those are all symptoms of dementia, but they are not a justification for prescribing. However, that is exactly what happens. Using drugs chemically to restrain vulnerable older people with dementia is no different from putting them in a straitjacket. It kills people.

NICE says that there is a two to threefold increase in the risk of death, and a twofold increase in the risk of stroke. Despite all the evidence, we lack the systems and safeguards to protect vulnerable people. Where are the robust clinical governance arrangements to audit prescribing practice? Why are commissioners and regulators so tolerant—one might even say complacent? Anti-psychotic drugs should not be prescribed to people with mild to moderate dementia. Even in severe dementia, the benefits are, at best, limited.

Will the Minister take steps to ban the use of anti-psychotic drugs in the treatment of people with mild dementia? Some people argue that without medication care homes could not cope, but research evidence demonstrates that there is an alternative, on which I think the Minister and I agree—person-centred care in care homes. When staff are trained and supported, with the emphasis on alternatives to drugs for the management of agitated behaviour, older people’s quality of life can be transformed, and they may live longer. When I raised the issue at Health questions recently, the Secretary of State told me that the national dementia care strategy, which will be published later this year, has a part to play. That is the right approach, so will the Minister confirm that the strategy will be clear and unequivocal about ending the dependency on anti-psychotic drugs to manage dementia?

The guidance from NICE and the Social Care Institute for Excellence is clear about how to respond when dementia causes significant distress, or challenging behaviour develops. Drugs do not help. If the guidance is clear, what is missing? I believe that the answer is leadership. We need leadership by commissioners and regulators to put in place robust audit and action to stamp out bad medicine practice; leadership by the Crown Prosecution Service to send a message that abusive medication is a criminal offence; leadership by clinicians, care home owners, managers and staff to blow the whistle on bad practice and face up to the legacy of lethal prescribing; and, above all, there must be leadership from politicians and Ministers to do everything in their power to protect vulnerable older people from ill-treatment. I hope that the Minister will respond positively, as everyone with an elderly parent or grandparent expects nothing less.

I congratulate the hon. Member for Sutton and Cheam (Mr. Burstow) on securing this important debate, and on the incredibly effective way in which he has raised issues concerning the dignity, care and protection of older people in a variety of ways while he has been in the House. As the Minister responsible for many of those issues, I genuinely welcome his passion. I also pay tribute to him for his balanced contribution, which recognised that some of the issues are complex, and concern the behaviour of clinicians and regulators. Gently, I say to him that his contribution to the debate is very different from his press release which stated:

“Government fail to act on warnings.”

When politicians complain about spin, and then spin themselves, it is no wonder that the public are sometimes a little sceptical. However, seriously, the hon. Gentleman is passionate about these issues, and not enough hon. Members talk about the needs of older people.

I shall reflect on the specific issues that the hon. Gentleman raised. First, the Government have a good record on the regulatory system. Soon after coming into office, we put in place, for the first time, national minimum standards for what is expected from care providers. We introduced a new regulatory system to ensure that providers’ performance is monitored robustly, and that has led to a significant rise in standards throughout the country, particularly in residential and nursing care. Of course, there are still homes that do not meet the appropriate standards, so we still have work to do.

The Government also introduced the “No Secrets” guidance on the protection of vulnerable adults, which was, for the first time, a framework. We asked local agencies in every local community to work together to ensure that, in line with the guidance, we had a much better system of adult protection than we had ever had previously. As the hon. Gentleman said, we made some significant announcements last week about how we want to toughen protection for vulnerable older people. We should reflect on the fact that the changing nature of society makes that a top public policy priority. As people live longer and longer, family members and carers are under pressure to fulfil the responsibilities. Demographic change—the ageing population—is increasingly a challenge for families, communities, Parliament and Government.

Last week, we announced a £2 million project in partnership with Comic Relief over three years to consider the risk of abuse faced by older people, specifically in institutionalised settings, but also more generally where older people are not treated with the dignity—that is not quite the same as abuse, but there is a continuum—that they should expect, whether on NHS wards, in residential nursing homes or in domiciliary care services. That prevalence study will take place over the next three years with the support of Action on Elder Abuse, and I should pay tribute to that organisation’s tremendous work in highlighting elder abuse. I was fortunate enough to speak at its annual conference on Monday where there was an impressive gathering. Its chief executive, Gary Fitzgerald, does a tremendous job in ensuring that the issue has the profile that it deserves.

Action on Elder Abuse also supported the study published last year, to which the hon. Gentleman referred, on the risk to older people of being abused in their own homes behind closed doors, because the other change in society is that an increasing number of older people are choosing to remain in their own homes for as long as possible. The debate about protecting older people tends to be skewed towards residential and nursing homes, but we must keep an eye on the fact that more and more people will be cared for at home. There is a question about domiciliary care agencies, their relationship with carers and so on.

In the design of the prevalence study published last year, dementia sufferers were excluded. Clearly, in relation to institutional settings, people with dementia will have to be included. When designing the new study, will work be done to try to reach people with dementia in the community?

The hon. Gentleman makes an important point and, interestingly, that will be one of the characteristics and key components of the new prevalence study. We estimate, as he knows, that approximately two thirds of people in nursing care have dementia, so one of the challenges of the prevalence study is to consider how to empower, enable and protect people in those circumstances. Older people who have different conditions and circumstances pose a separate challenge.

I shall address the hon. Gentleman’s specific comments about extension of the Human Rights Act 1998, which I must be clear about. When that Act was introduced, Parliament’s and Government’s intention was that publicly funded residents of private residential and nursing homes, as well as those in publicly provided residential and nursing care, should be covered. Subsequently, a House of Lords ruling put that in a lot of doubt. Therefore, the Government will seek to amend the Health and Social Care Bill to ensure that we reinstate Parliament’s original intention, which was that the Human Rights Act should cover publicly funded residents of private establishments.

To deal directly with the hon. Gentleman’s comment, the 1998 Act is about the relationship between the state and the citizen. It is, therefore, entirely inappropriate to talk about extending the Act to include people who fund their own care. However, more significant safeguards to protect self-funders are needed. The hon. Gentleman will know that the transformation programme for adult social care begins today in every local authority area and that one of the new emphases is a responsibility to self-funders. Too often in local authority areas, self-funders are told that they are on their own. One of the key elements of the transformation programme is the provision of much higher-quality information and advice to self-funders and their families, and a much greater focus on the needs of all citizens—not just those who are publicly funded—who use social care. The Human Rights Act is not the mechanism to deal with people who are funding their own care because it is about the relationship between the state and the citizen.

The hon. Gentleman referred to our announcement last week that we will act to help people who fund their own care. At the moment, if those people have a complaint against a care provider, their complaint is considered only by the organisation that they are complaining against and there is no right of independent appeal beyond that process. We will introduce proposals to help such people, but we are not in a position yet to share the details with the hon. Gentleman. However, the proposals will ensure that self-funders who are dissatisfied with the handling of their complaint have the right to seek a review by an independent organisation. Following discussion and negotiation, we need to decide which is the most appropriate and expert organisation to fulfil that role.

Will the Minister give serious consideration to ensuring that whoever discharges that adjudication role is fully subject to the Human Rights Act so that someone could take them to court if they fail to enforce human rights?

In view of some of the things that I am reported to have said over the weekend, if I start speaking for the Ministry of Justice in debates such as this it may be one step too far. We need to consider the end point. If people are state-funded and are unhappy with their provider, they can refer to the local authority’s complaint procedure. Ultimately, they can go to the local government ombudsman if they are still dissatisfied. We must examine the chain for people to get proper and appropriate redress. However, I shall not make any specific commitments on that today.

I urge the hon. Gentleman to contribute to our review of “No Secrets”, which is starting now and will go on for the next few months. We will put out a consultation document in the summer, and I urge him to respond to it. I offer to meet him to discuss his views. We need to focus on prevention and early intervention in relation to crime and safety, to encourage a new wave of innovative practice, to increase responsiveness and local accountability, to empower local and vulnerable people and those who have not previously been adequately safeguarded, and to develop new forms of support and encouragement so that people can improve their own health and safety. I urge him to be part of the debate about where we go next with “No Secrets”, and I will meet him specifically to consider his views, as he has taken a particular interest in the issues.

On the question of medication, the Government have done a number of things, but we need to reflect on the emerging evidence and, if appropriate, act in the short term. However, we will have to act following the publication of the national dementia strategy in the autumn. If we are to have a credible, robust national strategy to improve the quality of life and standard of care for people with dementia and their families, we cannot avoid tackling the issue. If measures can be taken in advance of the publication of that strategy, I am more than willing to consider them.

The hon. Gentleman may be aware that, on 26 March, I met the hon. Member for Rugby and Kenilworth (Jeremy Wright), who is the chairman of the all-party group on dementia. He is another hon. Member who does an excellent job championing what was once an unfashionable cause. Last August, we said that we would bring dementia out of the shadows, and we have been able to do that with the assistance of parliamentarians on both sides of the House. As the hon. Member for Sutton and Cheam will be aware, the all-party group is about to publish a report. The hon. Member for Rugby and Kenilworth was good enough to give me some advance notice of the kind of issues that were likely to be raised and the recommendations. We focused on a number of specifics. One of the major messages was the need for the training of front-line staff. There was a need for friends and families to be more involved in the oversight of care, to ensure consultation when crucial decisions are made about medication. There will also be a recommendation along the lines of a three-monthly review of medication for all residents. I cannot be specific about how the Government will respond to such recommendations, but we will take the all-party report seriously and respond to it, both in the short and long term. That will be a key element of the first ever national dementia strategy in the autumn.

The hon. Member for Sutton and Cheam might be interested in some specific statistics. Through the new general medical services contract, medication reviews for patients being prescribed four or more repeat medicines were included as one of the performance indicators in our quality and outcomes framework. In 2005-06, 95.8 per cent. achieved an acceptable level for that indicator. In the year ending 31 March 2007, 7 per cent. of homes inspected against the national minimum standards for care homes for older people failed the medication standard. Some 33 per cent. almost met the standard—I will give him more details about what that might mean—59 per cent. met the standard, which is a significant majority but nowhere near enough, and 2 per cent. exceeded the standard. That represents some minor improvement, but the figures are pretty stubborn: in the previous year, 8 per cent. failed the standard, 33 per cent. almost met it, 58 per cent. met it and 1 per cent. exceeded it. A hard core of providers are not meeting acceptable standards.

One of the difficult issues in this debate is professional judgment. I am not a doctor and some of the judgments are made by professionals using best available clinical evidence and acting, as they would see it, in the best interests of the patients. Ministers cannot possibly second-guess some of those clinical judgments. However, I agree with the hon. Gentleman that it is not acceptable for a modern health and social care system, as a first instinct, to drug inappropriately people who, as a consequence of dementia, are exhibiting potentially challenging behaviour. The approach is about cultural change, training and regulation.

Commissioning also has an important role to play in protection. If private homes are not fulfilling their responsibilities with regard to dignity or appropriate care, local authorities should stop commissioning services from them. There is not a magic bullet or a quick fix; we must do a whole series of things to ensure that people with dementia are not inappropriately drugged in a way that none of us would find acceptable for members of our own family. The Government will say more about that as we develop a national strategy this autumn.