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Medicine Reviews (Older People)

I am grateful for the opportunity to raise the subject of medication reviews for older people. I do so because I believe that if good practice in medication review were to be the norm across the NHS, it could transform the lives of millions of people. At the moment, there are more than 3.6 million people over 75 taking at least one medication and 1.6 million taking four or more medications. On the evidence that I have, it is clear that most of them have never benefited from a review of their medication in the way that is envisaged in the national service framework for older people. Getting the dosage right, understanding the complex interplay of different medicines and making sure that medicines are taken at the right time can make a huge difference to people’s health and quality of life. For some, simply getting medication right can be like turning the light back on—it can make a huge difference. For others, getting the medication right can be a matter of life or death. My purpose in having a debate on this issue is to press the Minister for more concerted action to realise the full potential of medication reviews. What do I mean by medication review? That is a good question, because there is no single agreed definition of what constitutes a medication review. However, there is a proposed definition. It comes from the medicines partnership and has been endorsed by the Department of Health. It says that a medication review is"““A structured, critical examination of a patient’s medicines with the objective of reaching an agreement with the patient about treatment, optimising the impact of medicines, minimising the number of medication related problems and reducing waste.””" I have long been concerned about the impact poor medication practice can have on the quality of life of older people. In particular, I still do not believe that enough is being done to stamp out the inappropriate use of medication in care homes. At its worst, the use of medication becomes restraint by chemical means, and that is elder abuse. According to the most recent figures from the Commission for Social Care Inspection, more than 5,700 of the 13,000 care homes in England either did not meet or almost met the national minimum standard for medication last year. Let us be clear that we are talking about a minimum standard. I acknowledge that those figures are a modest improvement on the previous year, but try telling that to the residents living in one of the homes who do not meet the minimum standard. I was even more worried to note that the National Care Standards Commission—the predecessor of the Commission for Social Care Inspection—pointed out in its report on medication that:"““The majority of prescribed medicines will be supplied by a GP on a repeat basis at the request of care staff and not the service user.””" That places care staff in a powerful position to influence prescribing for good or for ill. In a briefing for today’s debate, the Parkinson’s Disease Society points out the need to review the medicine management standards, especially standard 9.1, which deals with self-medication. It wants to see greater clarity over the issue of timing of medication, and I strongly agree. In 2003, a study in the British Medical Journal concluded that older people in care homes received poorer medical care than those living at home, in terms of over-use of inappropriate or unnecessary drugs, poor monitoring of chronic disease and under-use of beneficial drugs. That is one of the reasons why regular medication review should be part of the process and why I welcomed the national service framework for older people medication standards. Although I support the standards, it must be said that international evidence suggests that annual reviews of prescriptions for elderly people, as proposed in the NSF, are inadequate. Harm can be done, and is done, in far less than a year. There is a huge gap between the intention of the Government’s policy, which is to be applauded, and its implementation over the last few years since the NSF was published. That gap has been caused by a lack of clarity and insufficient incentives to deliver what is expected; in particular, the new GP contract does not provide the necessary incentives for more frequent reviews. Among the indicators in the quality and outcomes framework—QOF—for the contract, two specifically incentivise regular review of medication. The first is:"““A medication review is recorded in the notes in the preceding 15 months for all patients being prescribed four or more repeat medicines.””" That is worth seven points. The second is:"““A medication review is recorded in the notes in the preceding 15 months for all patients being prescribed repeat medicines.””" That is worth eight points. So the QOF says 15 months, yet the NSF talks about 12 months for people on fewer than four medications and six months for people on more than four medications. Neither actually sets out what qualifies as a medication review. Am I the only one who thinks there is a problem? Every time I have raised the issue with Ministers through written questions and in debate I have been left with the distinct feeling that the NSF medicine review standard has been quietly dropped. That impression was reinforced in February when the Minister of State, Department for Transport, the hon. Member for South Thanet (Dr. Ladyman), who was then a Minister in the Department of Health told me:"““The quality and outcomes framework (QOF) indicator for medication reviews for people prescribed repeat medicines was developed by a group of independent experts who were commissioned by the British Medical Association and the NHS Confederation. The group developed QOF indicators using its own search of the evidence and did not necessarily use existing national service framework (NSF) standards. Although this means that the QOF indicators and NSF standards may not match entirely, meeting the QOF indicator will go a long way to helping practices meet the NSF standard and vice versa.””—[Official Report, 3 February 2005; Vol. 430, c. 1119W.]" That really beggars belief. It is optimistic, but when the Department was signing off the QOF why did not it ensure that the NSF standard would be achieved? What is the point of producing the NSF standard if it is not being used in that way?