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Management of Dementia in Care Homes

Volume 475: debated on Wednesday 14 May 2008

I beg to move,

That leave be given to bring in a Bill to regulate the prescription of anti-psychotic drugs for people with dementia in care homes; to require the introduction of protocols for the prescribing, monitoring and review of such medication; to make dementia training, including the use of anti-psychotics, mandatory for care home staff; to require care homes to obtain support from specified external services; and for connected purposes.

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.

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 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 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

David Taylor accordingly presented a Bill to regulate the prescription of anti-psychotic drugs for people with dementia in care homes; to require the introduction of protocols for the prescribing, monitoring and review of such medication; to make dementia training, including the use of anti-psychotics, mandatory for care home staff; to require care homes to obtain support from specified external services; and for connected purposes: And the same was read the First time; and ordered to be read a Second time on Friday 17 October, and to be printed [Bill 109].