House of Commons debate: Medicine Reviews (Older People)

Speech by Paul Burstow MP on Mon 5th Dec 2005

Mr. Paul Burstow (Sutton and Cheam) (LD): 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

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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?

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Mr. Philip Hollobone (Kettering) (Con): I congratulate the hon. Gentleman on securing this debate. Let me assure him that he is not the only one with those concerns. There is a growing number of elderly people in my constituency. If there were to be more regular medication reviews, how would that burden affect already overstretched local GP services?

Mr. Burstow: I shall probably come to that later in my remarks. There could be an additional burden on GPs and also on pharmacists, and some useful evaluation of the relevant guidelines has been conducted.

On the point that I was raising about the QOF and the NSF, I was reassured recently by a written answer from the Minister who will reply to the debate. He told me that the NSF standard had not been superseded. That is good news, but the truth is that the standard has not been achieved either. In a written answer, the Minister told me:

"Historic data for both measures"—

the milestones set in the NSF for older people—

"collected from the 146 PCTs taking part in the programme"—

the national medicines management collaborative programme—

"suggest that there have been significant and sustained improvements in the number and quality of medication reviews."—[Official Report, 16 June 2005; Vol. 435, c. 642W.]

Where is the evidence to support that contention? Certainly the evaluation of the implementation of the "Room for Review" guidance on medication reviews published by the medicines partnership earlier this year does not point to significant and sustained improvement.

Part 1 of the evaluation found that only 8 per cent. of primary care trusts had met the NSF standard for annual medication reviews for patients aged over 75. Worse still, just 5 per cent. had met the target for six-monthly reviews for patients over 75 who were on four or more medicines. The NSF milestone for medicine reviews was 2002. That is when this was meant to be in place, albeit with the potential burdens that would arise from it.

Even in 2004, 47 per cent. of PCTs were reporting that they would not be able to conduct six-monthly medicine reviews for over-75s on four or more medicines. Delve a little deeper into part 1 of the evaluation and one finds that even in those PCTs that said they were doing it, not every GP practice was actually conducting and taking part in medication reviews. More worrying still, the evaluation found that in the PCTs that had implemented medication reviews, only a minority of reviews were conducted face to face. That type of patient-centred review was therefore being considered by PCTs as "aspirational"—as a gold standard—and therefore limited to more complex patients.

As I am sure the Minister will know, "Room for Review" defined four levels of medication review—levels 0 to 3. Of these, level 3 involved the patients in face-to-face discussion about their medicines and therefore offered the opportunity to explore the patient's views and experiences of using medicines and allowed them to share in the decision-making process about future prescribing—

Mr. Peter Bone (Wellingborough) (Con): I congratulate the hon. Gentleman on securing the debate

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on this exceptionally important issue. One of my constituents has brought this problem up. One drawback seems to be that a lot of people in care homes have some sort of dementia, and therefore the face-to-face review is more difficult, and I get the feeling that because it is more difficult it is not being done.

Mr. Burstow: I fear that that is a problem. All too often, repeat prescriptions are ordered by care staff and inappropriate historic prescriptions continue without being properly checked and vetted. That is why the process really has to engage with the patient and, if necessary, carers and other family members who have authority to take informed decisions and give consent.

The lack of a specific requirement for level 3-type reviews in the NSF and the quality and outcomes framework has reinforced the view in PCTs and among practitioners that patient-centred reviews are "nice to have" but not a "must have".

Part 1 of the evaluation was conducted in January 2004 and published in March 2005, which really does prompt the question, why did it take so long to publish the findings? While I am asking about part 1 of the evaluation of "Room for Review", I hope that the Minister can clear up a mystery surrounding the publication of part 2, on the patient's view. I was told in July that part 2 would be published over the summer. It was not, so I asked another question about when it would be published and I was told this time that due to ethics clearance requirements it would not be published until the end of 2006. Then I got the news, thanks to Mr. Speaker, that I had secured tonight's debate, and the following day my office took a call from the Department, telling me that part 2 would be published on 5 December. So Christmas has come early, and that is good news. But what is going on?

Certainly, part 2 paints a mixed picture of patient experience of medication reviews. Part 1 talks about face-to-face reviews being the gold standard, yet the evidence from part 2 suggests that there is quite a long way to go before the potential of that gold standard is realised. Many of the comments from patients suggest that they had been given the impression—I emphasise, given the impression, and that is how they saw it—that the purpose of the review was cost cutting. One woman is quoted in the evaluation as saying that the reason she was given for being called for a medication review was that the PCT wanted to change her tablets

"not for my benefit, but to bring me into line with the PCT."

A man echoed that when he recounted a conversation that he had had with a doctor drawing the review. The doctor told him that

"capsules are dearer so they've got to give you the cheapest medication they've got."

The concern that medication reviews are essentially about reducing NHS expenditure and saving money is a strong theme running through the second part of the evaluation from the patient's perspective, and it clearly is a problem in terms of how we make these reviews something that people feel comfortable with and see the value of from their own point of view.

Another concern that emerges concentrates on who conducts these reviews, and it touches on the intervention by the hon. Member for Kettering (Mr. Hollobone). When it came to GP-led reviews, while most people felt comfortable that their concerns

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were being addressed, points were made as to whether the GP had sufficient knowledge compared with colleagues in secondary care, which really did fuel a suspicion that the reviews were just being done to save money.

Another set of concerns arose about pharmacists who were leading reviews. The main issue was about the fact that pharmacists did not have access to the medical records or knowledge of the individual medical situation, but above all there was a real concern, and a question mark, over whether the pharmacist could get medication changed; if they could not, delays were occurring while people waited for their practice to change their medicines.

With the new pharmacist contract opening up the possibility of a greater role for pharmacists in medicine management, there is a need for clarity. As the medicines partnership points out in its report, the medicine reviews used by pharmacists are not the same as medication reviews. In the executive briefing published yesterday, the medicines partnership said:

"As with the NSF milestone, there was no published definition of what sort of medication review would qualify for QOF purposes. There is potential for overlap between the different medicines review services and some confusion as to which sorts of reviews 'count' towards which targets. This suggests a need to refocus attention from quantity to quality. PCTs need to consider how the various types of medicines review can help them deliver their objectives and priorities, making sure that reviews deliver maximum benefit to patients and that people with the greatest need and greatest potential to benefit have their medicines reviewed.

We consider that it is important for PCTs, GPs, nurses and pharmacists to have a clear picture of how the various forms of review fit together and how they can be used to meet local priorities and support care for people with long term conditions."

To summarise in two words, confusion reigns. That confusion has caused a failure to join the dots between the rise in the prescribing of anti-psychotic drugs, the rise in adverse drug reaction to anti-psychotic drugs and the worrying 35 per cent. increase in the number of non-fatal ADRs among the over-75s and the alarming 83 per cent. increase in fatal ADRs among the over-75s.

A recent report in the British Medical Journal found that significantly older people were admitted most because of ADRs. The cost to admissions authorities is huge, and the consequences for the individual go without saying. The study concluded that the NSF needs to be implemented. Yes, the NSF medicines standards should be implemented. That would be a step in the right direction. Medication reviews would help to safeguard the health and welfare of older people.

To conclude, I have some questions. First, will the Minister confirm that the NSF standard for annual and six-monthly reviews is still the standard that the NHS should be measured against? Secondly, when will the NSF standard be achieved, and how will we know? Thirdly, does he agree that we need to look into the national minimum standards for medicines management in care homes for older people to ensure that medication reviews are triggered in accordance with the NSF standards and that the timing of medication is made clear to managers and staff? Fourthly, will he act now to clear up the confusion identified by the

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evaluation of the medicines partnership and ensure that clear guidance is issued to the NHS, so that everyone is clear what is expected?

I agree with the medicines partnership that there is a need to focus on quality—that is absolutely right—but that is not sufficient if the NHS is to meet the needs of millions of older people in this country, whose quality of life is impaired because they are not getting the right medication, at the right time and in the right place. I hope that the Minister has something helpful and positive to say.

9.42 pm

The Parliamentary Under-Secretary of State for Health (Mr. Liam Byrne): I congratulate the hon. Member for Sutton and Cheam (Mr. Burstow) on securing this debate. He has indeed taken a long interest in the subject.

Medicines are by far the most common form of medical treatment in the UK. People with long-term conditions, many of whom are older, are reliant on those medicines to stay healthy. In fact, 80 per cent. of people over the age of 75 take at least one prescribed medicine and 36 per cent. of them—just over a third—take four or more medicines each day. With that level of medicine prescribing comes the challenge of ensuring that people with long-term conditions, including those who are older, get the maximum possible benefit from that medicine, and the hon. Gentleman made that argument rather eloquently.

Half of all people—not just older people—on regular treatment do not take their medicines as intended for a number of reasons. Problems with medicines may be the cause of as many as 10 to 15 per cent. of hospital admissions. So people need simple information and advice if they are going to get the best benefit from their medicines. They need to know what their medicines are for, how they work and how they need to take them. However, people also have their own health beliefs, which can affect the way that they take their medicines. That is why, as the hon. Gentleman said, involving people in decisions about how medication is taken is an important way in which we can help to ensure that they take medicines effectively. That explains why medication review is important. It is good that the hon. Gentleman has secured such a debate on the Floor of the House because the matter sometimes does not get the airtime that it deserves.

A medication review occurs when a health professional reviews a patient's medicines. The health professional ensures that all medicines that would be of benefit are prescribed and that the various treatments work well together and do not cause problems. That might be done if a GP prescribes someone with repeat medicines, but there is also a place for more in-depth reviews in which a health professional sits down with a patient and discusses his or her medicines in detail. That might occur if someone is on an especially complex regime, or if a patient is experiencing problems. Such reviews are important, not least because they allow patients to ask questions about their medicines and to be more involved in any decisions that are taken.

Given the importance of medicines to many people and the importance of medicine reviews, when we published the national service framework for older

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people in 2000, we produced a booklet that focused on the specific issue of medicines and older people. As the hon. Gentleman knows, that drew together the available evidence and made recommendations on how to improve older people's medicine taking.

Within that, we set a specific milestone on medication reviews. We recognised that the more medicines people take, the more likely they are to experience difficulties, so the scheme had two elements. First, by 2002, all people aged 75 and over were expected to have medicine reviews at least annually, and, secondly, those taking four or more medicines were to be reviewed at least every six months. Although it was largely for the NHS, working with other stakeholders locally, to implement the NSF on older people, we have nationally supported the improvement of medicine-taking in several ways. Before the publication of the NSF, medication reviews were not systematically undertaken or recorded.

Let me outline several of the measures that we have taken to support the policy. We have supported several primary care trusts to identify what works best and to share that learning with others through the national medicines management collaborative. About half of PCTs have participated in that programme to implement local medicine management schemes so that people get more help in using their medicines from not only their GPs, but pharmacists and others.

One of the measures used for assessing improvement was the proportion of people aged over 65 who were on four or more regular medicines and had received a documented medication review in the past 12 months. There was a significant increase in activity and, in some cases, the reported rate of reviews more than doubled.

Another measure was the percentage of patients in care homes who had had a documented review of their medicines in the past year. I am aware that some people believe that people in care homes do not have their medicines reviewed regularly, or sufficiently regularly, but the data from the collaborative work showed that the situation was slightly different. The increase in activity for patients in care homes was similar to that for those living at home, although the two groups had slightly different starting positions. The extent of patient involvement in medication reviews was measured for PCTs in wave 4 of the programme. It increased from 22 per cent. to 62 per cent. in a single year.

After drawing on this learning, guidance on medication reviews was widely disseminated through "Room for Review: A guide to medication review", which was published by medicines partnership in conjunction with the national medicines management collaborative in 2002. The document set out a framework on how medication reviews should work, together with supporting tools and advice for managers and health care professionals.

Two years later, medicines partnership commissioned an evaluation of the impact of "Room for Review", first to determine the extent to which the guidance had been adopted by PCTs and, secondly, to assess the experience and opinions of a sample of patients who had had a medication review. As the hon. Gentleman knows, the original plan was to publish both parts of the evaluation together. However, there were unexpected delays in publishing the part involving patients because of the two practical issues—the need to obtain ethics committee

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approval and the need to identify a suitable sample of patients through GPs. Medicines partnership did not wish to withhold the findings, so it went ahead and disseminated the survey of PCTs in March 2005. Part two was published yesterday.

I am glad that I have helped to ensure that Christmas has come early for the hon. Gentleman. From the survey of PCTs undertaken in 2004, we know that the majority of PCTs had a written strategy and that more than 60 per cent. of them had agreed local guidelines. About 45 per cent. of the PCTs that responded to that survey indicated that they were achieving or likely to achieve the older people's NSF target. Just 30 per cent. of PCTs said they were unlikely to achieve the target. If the survey were carried out now the figures would be very different, and I shall come on to the results of the GP quality and outcomes framework data later. The relationship between the national service framework and the quality and outcomes framework is important. The NSF indicator is still very much in force, but the way in which it has been implemented through the QOF target has become slightly more flexible to make sure that there is local managerial flexibility for doctors who implement it.

Mr. Burstow: That is one of my main concerns, and a key issue in the executive summary of both parts of the evaluation. At the heart of the problem is the fact that a clear working definition of a medication review was not in place when the QOF and the NSF were set. Without such a definition, it is difficult to know what one is measuring and thus be confident that progress is under way.

Mr. Byrne: May I write to the hon. Gentleman on that point, as it merits more consideration than I can provide this evening?

I have talked about the efforts to support PCTs in establishing medicine reviews. We have also ensured that through the new general medical services contract steps are in place to encourage medication reviews. Across the country, about 90 per cent. of GP practices reported that at least 80 per cent. of their patients who were prescribed four or more repeat medicines had had a medication review in the preceding 15 months recorded in their notes. Over four fifths of GP practices reported that at least 80 per cent. of their patients who were prescribed repeat medicines had had a medication review in the preceding 15 months, which is an achievement.

Alongside the role of PCTs and GPs, we should consider the role of local pharmacists. We have gone to some lengths to underpin the important contribution that pharmacists make through the new community pharmacy contract. In the first six months, pharmacy owners have focused on the delivery of essential services. Even so, by the end of October, more than 20,000 people had had the benefit of a face-to-face consultation with their pharmacist to discuss their medicines and resolve problems. It was clear from the national consultation that we undertook as we developed the health White Paper that the role of community pharmacists was considered important by local communities. We will reflect on that in the White Paper to be published at the turn of the year.

Mr. Burstow: Will the Minister ensure that further consideration is given to the need to make sure that,

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with patients' permission, pharmacists have access to patient records so that they can take their history into account when they look at medicines that are being prescribed?

Mr. Byrne: That may, or may not, appear in the White Paper—time will tell.

From the medicines partnership evaluation that was published yesterday we know that patients welcome medication reviews. To gain the full benefit, they say that they need to be better prepared for the review. We must ensure that there is shared understanding of the purpose of the review to create an environment in which patients are empowered to ask questions about their medicines. We have taken that on board by supporting the medicines partnership in producing a guide to medicine use reviews, which patients can use to prepare and identify the questions that they want to ask before they consult their pharmacist. Copies will be available by the end of the month.

We have also commissioned NICE, the National Institute for Health and Clinical Excellence, to develop a clinical guideline that sets out best practice in involving patients in decisions about prescribed medicines.

The hon. Gentleman highlighted the role of the Commission for Social Care Inspection in ensuring that medication reviews were carried out in care homes in accordance with statutory regulations and national minimum standards. Where inspections are uncovering instances of inappropriate or over-prescribing of medicines, enforcement action is being taken. I am aware that in the past the hon. Gentleman raised the specific issue of the inappropriate or over-prescribing of anti-psychotic medicines. These medicines have an important role to play in the management of a range of conditions and they have a good safety record, but it is vital that they are used with care and in appropriate clinical situations. The role of non-pharmacological therapies is considered where that is an appropriate course of action.

CSCI inspectors routinely check records to ensure that medicines are properly controlled and correctly administered. Where the CSCI finds evidence of over-prescribing or inappropriate administration of medicines, such evidence is reported to the police and

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the professional bodies of those involved in such activities. The CSCI also employs pharmacist inspectors who can be called on for advice.

Furthermore, I understand that a report that focuses specifically on the management and administration of medication in care homes and in children's homes is expected to be published by the CSCI early in the new year. That report will be important because it will help to identify in much greater detail how care homes are performing against medication national minimum standards. It will also incorporate an analysis of complaints about medicines that the commission has received from care homes. I know that that will be of great interest to the hon. Gentleman.

In summary, the milestone in the national service framework for older people raised the profile of the importance of effective medicine-taking, and in particular the benefit of regular medication review. Significant action has been taken by primary care trusts and others to put in place the infrastructure to deliver those medication reviews. From the first year of the new general medical services contract, we can see and celebrate the progress that has been made, with the vast majority of people taking regular medicines.

Mr. Burstow: The Minister has been generous with his time. Will he undertake to consider the requests that I made at the end of my remarks, particularly the issue of the clarity of medication reviews, which was identified by medicines partnership in the report that has been available only since yesterday?

Mr. Byrne: I shall look into that. There are different types of medication review, and it is for the clinician to determine which is the most appropriate for an individual patient. Sometimes that will involve a face-to-face consultation, but that will not necessarily be the right solution for many patients. I will happily come back to the hon. Gentleman with more detail on that.

We have seen a great deal of progress since of the advent of the older people's national service framework. It is part of a broad package of improved care for older people that we have seen unfold over the past seven years. That is a reform programme that we intend to continue.