Westminster Hall Debate: Care and Nutrition of Older People

Speech delivered on Tue 7th Feb 2006

Mr. Paul Burstow: I am grateful for the opportunity to raise the issue of the care and nutrition of older people. I think that the Minister will know of my interest in the subject, because I had the opportunity last week to host the launch in the House of a campaign by Help the Aged and Action on Elder Abuse to help raise awareness and promote action to tackle the hidden scandal that is elder abuse in our country. The Under-Secretary of State for Health, the hon. Member for Birmingham, Hodge Hill (Mr. Byrne), also took part. The campaign is all about pressing for in-depth research to gauge the true level of the problem of abuse. The most recent figures obtained by the Select Committee on Health, during its inquiry in 2004, show that 500,000 elderly people time at any one may be the victims of abuse, including physical, psychological, financial and sexual abuse. Without a clear picture, however, it is impossible to know whether the current policy and practice, which have developed over the past five to 10 years, really are a fit response to the level of need.

Although this morning's title gives scope to raise many issues, I sought the debate primarily to raise two. The first is the nutrition of older people, particularly vulnerable older people in care homes, and the second is the use and management of medication in care homes. Just before Christmas, the British Association for Parenteral and Enteral Nutrition—BAPEN—published a report into the nutrition of older people in a variety of care settings, and the facts speak for themselves. One in 10 care home residents loses up to 5 per cent. of their body weight within a month of being admitted to the home and 10 per cent. of their body weight within six months. Much malnutrition goes undetected; indeed, many regard it as the norm and as part of the aging process—it is not.

Even on the basis of the available research, it is clear that malnutrition in care homes is at epidemic levels. Based on an analysis of people aged 65 and over by the national diet and nutrition survey, BAPEN found that 20.5 per cent of individuals in care homes—one in five residents—were at medium or high risk of falling victim to malnutrition.

David Taylor (North-West Leicestershire) (Lab/Co-op): As the hon. Gentleman might imagine, I am a big NHS proponent, but does he agree and acknowledge that such treatment can, sadly, be found in both NHS hospitals and care homes? I introduced a private Member's Bill in the previous Parliament to establish an older people's rights commissioner to tackle issues such as nutrition and medication. Would he become a sponsor if I introduced it again later this spring?

Mr. Burstow : That is an invitation that I could not possibly refuse. The hon. Gentleman makes a good point about the need for an advocate—particularly for the frail and vulnerable, who might lack capacity to make decisions for themselves—as a complement to some of the legislation on medical capacity. I hope that he would also support my ten-minute Bill, which is currently before the House, and which would extend the application of the Human Rights Act 1998 to all privately run care homes. It does not currently apply in those circumstances, and anyone who crosses the threshold of a privately run care home can no longer exercise their rights under the Act unless they have a contract with the local authority that specifically stipulates otherwise. The Government acknowledge that anomaly, but it needs to be addressed, and that loophole needs finally to be closed.

Mr. Philip Hollobone (Kettering) (Con): I congratulate the hon. Gentleman on securing the debate and on his excellent work on the issue. Before he goes too much further into the issue of nutrition in care homes, may I draw to his attention the excellent work done by the Womens Royal Voluntary Service and the meals on wheels service in Kettering? They provide valuable nutrition for older people who are being cared for in their own homes and who will later go on to institutional care. Without meals on wheels volunteers, this country would be a in a very sorry state indeed.

Mr. Burstow : I can only echo the hon. Gentleman's sentiments. I also have a meals on wheels service in my constituency, and it relies predominantly on voluntary effort to deliver meals. The service makes a huge difference in terms not only of the delivery of food, but of contact; indeed, it is the only contact that some people have, because many of them lead very isolated lives.

As I said, one in five care home residents is at risk of malnutrition. Today, as many as 63,400 frail elderly people in care homes across England could be malnourished—that is 63,400 victims of poor nutrition. In the 21st century, it is a scandal that elderly people in some of these homes are, in effect, starving to death. The personal cost of such poor treatment is incalculable and unacceptable, and it includes poorer health, slower recovery from illness, the risk of complications from illness and, above all, a very poor quality of life. According to BAPEN, the cost to the taxpayer of treating malnutrition in long-term care has been estimated at £2.6 billion a year. That really is a shocking waste of public money.

According to figures from the Commission for Social Care Inspection, more than 2,000 care homes out of the 11,000-odd in England fail to meet the most minimal of national minimum standards for meals and mealtimes. As things stand, the national minimum standards say next to nothing about nutrition. It is only thanks to work by the Caroline Walker Trust and the National Association of Care Catering that a more detailed set of guidance is available to practitioners in the field. I very much welcome the news that the commission will publish a report on nutrition later this year, which is not a moment too soon.

Last month, I had the opportunity to introduce the Care of Older and Incapacitated People (Human Rights) Bill under the ten-minute rule. I drew attention to a case that was reported to me and which illustrates the nutrition problem. It was the case of a care home resident who nearly starved to death. Like many other residents at the same care home, this elderly lady suffered from dementia and needed help with eating, but none was provided. Residents were left to fend for themselves, and relatives were banned from the dining area. When the news came that the care home was to be closed, conditions deteriorated further. Residents were forced to live on a diet of Angel Delight and beans on toast, and sometimes, if they were lucky, pilchards on toast. They were left for up to 16 hours between meals, as cooks went home at 4 pm. When the manager was asked what the residents could eat at night, he told relatives that there was a pot of fish paste in the fridge. Fortunately, the lady in question moved to a new care home, where she received much better attention, and she put on a stone within a month of arriving.

Another lady wrote to me to say that despite years of battling to ensure that her mother was properly looked after, her mother could barely get a spoon to her mouth or reach her drink and had difficulties because she was offered no assistance in doing so. The lady told me that her mum was being fed on tinned corned beef and packets of Smash potato. After a complaint, she was moved on to tinned mince and Smash, and another complaint later led to the provision day after day of a banana for breakfast, tinned stew mixed with tinned soup for dinner and tinned soup for tea. That was a wholly inadequate diet, and relatives were given no explanation—if there was any—for why such a diet was provided. The lady's mother was put in a bed so high that she could not reach the water placed by her bedside—dehydration is also an issue in some care homes.

It was only after the mother was admitted to hospital with breathlessness and chest pains that the lady was told that her mother was malnourished. Although her mother ate "like a horse", as the hospital put it, during her stay in hospital, and gained weight in the process, the care home denied any responsibility and argued that she had not been eating due to lack of appetite. If we were served a constant diet of tinned stew mixed with soup every day, we might lose our appetites too. Not every care home is like that, but those that are should not be tolerated, because they are ruining people's lives, putting lives at risk and, in some cases, killing people.

I want to raise three specific concerns regarding the nutrition of older people: training, nutritional screening and co-ordination. On training, there is no requirement in the national minimum standards for care homes regarding training catering staff, in particular, in the specialist task of meeting the dietary needs of care home residents. I understand from the National Association of Care Caterers that no module is available as part of national vocational qualification level 2 on catering to ensure that staff can meet those special dietary needs. A module exists and was drawn up by NACC in the late 1990s, but City and Guilds, the awarding body, has not seen it as a high enough priority to be made a component of NVQ, despite the demand for such a course throughout the sector. What action will the Minister take to ensure that training on special dietary requirements is available as part of any qualification for caterers in care homes?

David Taylor : Will the hon. Gentleman give way?

Mr. Burstow : I shall ask my second question, then I shall give way one more time, as I need to make some progress as a number of hon. Members want to speak. Will the Minister also intervene to encourage the awarding authorities to make such training a priority for care catering?

David Taylor : Does the hon. Gentleman agree that in recent years there has been a trend, which predates 1997, of enforced sell-off of local authority homes into the private sector, which in some cases has been accompanied by poorer standards of training for staff in privatised homes? That is especially true in relation to nutrition. The problem that he describes is much less apparent, although not invisible, in the remaining homes that are run by local authorities.

Mr. Burstow : I have two reactions to that point. First, I should like to see the commission's report, which will analyse performance by sector precisely on nutrition standards, inadequate as they are. Secondly, we are where we are, and we must ensure that the system delivers good quality, fit-for-purpose services, regardless of whether they are publicly, privately or charitably run. That is the purpose of my contribution, but I entirely take the hon. Gentleman's criticism, which I have heard about and share, about the downsides of the regulated but not very well managed system that we have had for too many years.

After highlighting my concerns about malnutrition in care homes, I have received a great many letters and phone calls. Some have been from angry care home owners, but many have come from care homes wanting to tell me what they do in practice, relatives and residents sharing their personal experiences, and health and care practitioners pointing to good practice.

An example of good practice that I commend came from Southwark primary care trust, which told me about its care home support team, which works with 40 independent sector nursing homes in the borough. The team has introduced systematic assessment of need, which includes intensive training courses for care home staff, with courses on dementia and nutrition, and working with people with swallowing difficulties—an issue that the Parkinson's Disease Society is most concerned about in the upcoming review of national minimum standards. Those examples of good practice should become the norm. Making them the norm is the challenge.

Standard 8 of the national minimum standards for care homes makes nutritional screening a requirement. However, that requirement is part of a bundle of other requirements, which means that a home could meet the overall standard but perform poorly on nutritional screening. Without proper screening it is hardly surprising that one in every 10 new care home residents loses up to 5 per cent. of their body weight within one month of being admitted and up to 10 per cent. of their body weight within six months.

As things stand, there is no agreed screening tool. BAPEN has developed a universal malnutrition screening tool for assessment of individuals across all care settings that is supported by the Royal College of Nursing, the British Dietetic Association and the Royal College of Physicians. NACC has produced its own screening tool for use by care home managers that is designed with individuals with no nutritional or dietary training in mind. Care homes need clear guidance about the assessment tools available and the circumstances in which they should be used. Will the Minister make nutritional screening on admission to care homes a mandatory requirement in the national minimum standards?

I am sure that the Minister will tell me about the review of the national minimum standards, the work of the Food Standards Agency, the efforts of the Commission for Social Care Inspection and the imminent publication of National Institute for Health and Clinical Excellence guidance on the use of nutritional supplements. The review of national minimum standards offers the opportunity to strengthen nutritional requirements. I understand that CSCI is undertaking work on that, as well as developing a toolkit for inspectors, and is due to publish a report on nutrition next month. The FSA is developing recommendations on nutrient-based standards not only for the care sector, but for public institutions across the piece. That work includes developing example menus to assist caterers in menu planning. I understand that the FSA is in discussion with a range of interested parties about its work and will produce a draft report, which will be ready by this summer.

I do not say that there is not a lot going on; indeed, I acknowledge that there is. However, the more I have researched the issue and talked to people, the more the question arises of where the co-ordination of those different strands of work is. Who is pulling them all together? I and many outside, particularly those in BAPEN and NACC, would like to know whether the Minister or her colleagues in the Department of Health will take steps to ensure that the work of the FSA, CSCI, NACC, the Caroline Walker Trust, BAPEN and other interested parties is effectively joined up, to ensure that the future national minimum standards cover all aspects of nutrition and meal provision. Would she or the Under-Secretary of State for Health, the hon. Member for Birmingham, Hodge Hill, be willing to meet me and representatives of NACC and BAPEN to discuss our concerns and their recommendations?

The second issue that I should like to raise is medication, which I mentioned before Christmas in an Adjournment debate to which the Under-Secretary of State responded. This morning, CSCI issued its report on medicine management in care homes. The report is entitled "Handle with Care?", and it follows a report by the National Care Standards Commission that was published in March 2004. That earlier report identified serious deficiencies in the way care homes managed medicine. In the light of the earlier report, today's report makes worrying reading.

"Handle with Care?" states that

"homes are still not placing enough importance on this critical area of care."

According to the report, 45 per cent. of care homes for older people are failing to meet the national minimum standards on medication. Some 5,140 of the 11,543 care homes in England are not managing medicines according to the national minimum standards. In almost one in three London boroughs, fewer than 40 per cent. of homes meet the medicine management standards. The report states that it

"shows that there has been some slight improvement in performance overall"—

it covers not only older people's homes, but children's homes—

"with the exception of nursing homes for older people. But the rate of improvement in such a crucial area of care has been disappointingly slow, with nearly half the care homes for older people and younger adults, providing 210,000 places for residents, still not meeting the minimum standard relating to medication. The primary responsibility for this failure rests with the homes themselves."

Some 210,000 people are living in homes that do not meet the minimum standards on medication, and the buck stops with the homes themselves. I am not here to say that the Government have not delivered, but I point out that the owners need to end their constant denial of problems and failings.

It seems that the reasons why homes are failing to manage medication properly have not changed since NCSC reported. Lessons have not been learnt, and attitudes have not been changed. Indeed, the commission says:

"expenditure on training does not seem to have had an impact on this area of quality."

The commission has found that even homes that meet the standard then struggle, slip and fall back. I first raised the issue of poor medication management in my report "Keep Taking the Medicine" in 2001. I have published two more reports since and contributed to the writing of the Health Committee's report on elder abuse. Five years on, there is still an awful lot to do. The level of over-medication and inappropriate medication in our care homes is shocking. It is a scandal that such poor practice, mistreatment and abuse continue.

When NCSC reported in 2004, it noted:

"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. Little has changed in nursing homes and progress has been "stagnant", according to the latest report. That means that some older people are being managed by means of chemical cocktails of drugs, not for their benefit, but for the benefit of the home. It is chilling to think that if the published research on inappropriate medication is right, as many as 22,233 elderly nursing home residents in England could be under sedation without medical grounds. Indeed, commission's findings suggest that the situation could be far worse.

Action is long overdue. It is time that care homes came out of denial and took action. There is no quick fix, but ensuring that the recommendations of the commission's report are followed through as a matter of urgency must surely be a priority. Perhaps the Minister can explain how those recommendations will be followed up after the commission is abolished in a couple of years' time.

One way in which the standards could be raised and the quality of life of care home residents improved would be the delivery of the national service framework standard for medication review. The standard is clear. People aged 75 and over on fewer than four medications should have an annual medication review, and those on four or more should have a review every six months.

Sandra Gidley (Romsey) (LD): Is it not something of a missed opportunity that because the standard in the national service framework for older people is not the same as the standards to which GPs work to get their quality and outcomes framework points, the system provides no incentive for GPs to deliver what is in the national service framework?

Mr. Burstow : My hon. Friend makes a good point. There is an apparent misalignment between the GP contract and the QOF, and the NSF standard. That has meant that there has been a lack of incentives in the system for people to get to the milestone for the NSF. The evaluation of "Room for Review" guidance on medication reviews, published last year by the Department, pointed to the fact that progress had been patchy—only 8 per cent. of PCTs had met the NSF standard for annual medication reviews for patients over 75, and 5 per cent. had met the target for six-monthly reviews for patients over 75 on four or more medicines.

It is worth bearing in mind that that NSF standard was meant to be achieved by 2002. Two years after that, just 5 per cent. of PCTs were saying that they could meet that standard. As I have pointed out in previous debates—I did so before Christmas—two years after the NSF milestone was missed, 47 per cent. of PCTs were still reporting that they could not conduct six-monthly medicine reviews for over-75s on four or more medicines. That picture of patchy support from PCTs is borne out and repeated in the report published today by the Commission for Social Care Inspection. What is being done to ensure that the missed NSF milestone on medication reviews is finally achieved, and that PCTs engage with care homes to drive up the standards?

To conclude, I sought this debate to highlight two issues: nutrition and medication. Just one care home starving its elderly residents to death or using chemical straitjackets is too many, but the truth is that, through neglect or wilful intent, thousands of homes make the lives of those whom they are supposed to care for a misery. Thousands of homes are making a mockery of the standards, systems and safeguards that are supposed to protect the vulnerable.

I hope that the Minister will demonstrate that the Government understand the challenge and accept that there is still much to do, and that they will give the matter the same level of priority and attention that they have rightly given for many years to our systems for protecting the welfare of children.