The Welsh NHS Confederation response to the inquiry into the use of anti-psychotic medication in care homes.

Contact:

Callum Hughes, Policy and Research Officer, Welsh NHS Confederation.

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Date created:

April 2017

Introduction

1. The Welsh NHS Confederation welcomes this opportunity to respond to the Health, Social Care and Sport inquiry into the use of anti-psychotic medication in care homes.

2. The Welsh NHS Confederation represents the seven Local Health Boards and three NHS Trusts in Wales. We support our members to improve health and well-being by working with them to deliver high standards of care for patients and best value for taxpayers’ money. We act as a driving force for positive change through strong representation and our policy, influencing and engagement work.

Overview

3. Anti-psychotics are a group of medications usually used in the treatment of mental health conditions such as schizophrenia. They are sometimes inappropriately prescribed to control the behavioural and psychological symptoms of dementia, where their use is commonly associated with a significantly increased risk of harm. Reducing the number of people with a dementia diagnosis inappropriately receiving such medication in care homes has been identified as a key action in the Welsh Government’s Draft Dementia strategy.

4. To deliver on such a commitment, work must be done to ensure the effective provision of multi-disciplinary teams within care homes. This means ensuring the provision of effective integration frameworks between neighbouring Local Health Boards and Local Authorities, and also between Local Health Boards and individual care homes. There is also a need to reshape our relationship with dementia patients so that we treat them as partners in these changes and utilise the insights gained through direct experience of living with dementia to further our understanding of the condition and the role played by anti-psychotics within this process.

5. An ageing population and an increasing number of people with multiple long term conditions has meant that utilising medication has become a way of managing often complex behavioural and psychological issues. Where dementia is concerned, it is estimated that between 40,000 - 50,000 people in Wales are currently living with the condition[i]. Against this background, we welcome the Health, Social Care and Sport Committee’s interest in this area.

6. Our response will address the terms of reference to the inquiry in turn.

The availability of data on the prescribing of anti-psychotics in care homes, to understand prevalence and patterns of use;

7. The lack of a central point of data makes it difficult to benchmark the level of anti-psychotic prescribing at a care home level as such data is linked back to the prescribing GP, of which there may be many covering one care home. This makes it difficult to identify patterns of use.

8. As such, the only data available to our members in relation to the use of anti-psychotic medication across the relevant Local Health Board would be available only as a result of a manual audit of GP records or an analysis of individual care home prescribing records. However, this can be more difficult for Health Boards with large population bases.

9. Numerous audits have been carried out by Local Health Boards and are ongoing. One of the key findings has been that the use of anti-psychotics is best undertaken during a holistic patient review, including the patient’s need for an anti-psychotic by the GP or pharmacist during the regular polypharmacy medication review, rather than being reviewed in isolation.

Prescribing practices, including implementation of clinical guidance and medication reviews;

10. The use of pharmacological interventions to treat the behavioural and psychological symptoms of dementia should only be used when patients are severely distressed, or there is an immediate risk of harm to self or others. The cerebrovascular risk of anti-psychotics needs to be discussed, and target symptoms should be identified quickly so that changes to a patient’s medication can be made. Furthermore, the decision to use anti-psychotics should be made only after an individual risk-benefit analysis and monitored closely, with reviews every three months at least.

11. However, it must also be remembered that, while in some cases the clinical view is that medication to relieve severe anxiety may be in a person’s best interest, this must be part of a regularly reviewed care plan and not simply considered a convenient and accessible method of subsiding challenging behaviour as and when it arises. These prescribing practices are in accordance with the NICE-SCIE guideline on supporting people with dementia and their carers in health and social care settings.

12. Clinicians within Local Health Boards are broadly aware of such guidelines, but there can be resistance from care homes to reducing or stopping the use of anti-psychotics for fear of relapse. It is encouraging however that our members have reported a number of cases where patients who previously resisted reducing or stopping their anti-psychotic medication have done so in a safe and controlled manner following a discussion with a Nurse Prescriber. Referrals and admissions have reduced significantly the use of anti-psychotic medication in these cases. However, it could be argued that routine prescribing reviews are not the most effective use of a Consultant Psychiatrist’s time. An alternative would be for a non-medical prescriber, or an in-reach nurse, to undertake these reviews with an emphasis on educating staff members around medication reduction and support for care homes, thus allowing more time to be freed up for more urgent reviews.

13. It is encouraging also that there have been examples of our members setting up polypharmacy medication pro-forma/review sheets which can be modified by individual practices. These documents will allow care home workers to monitor patient progress and record recommendations for change for patients taking in excess of four different types of medicine. Moreover, reviews have been carried out by specialised teams focusing on the prescription of anti-psychotic medication for elderly people in accordance with NICE guidelines, the Medicines and Healthcare Products Regulatory Agency (MHRA) recommendations and Local Health Board guidance.

The provision of alternative (non-pharmacological) treatment options;

14. Strategies designed to manage behaviours that often lead to the prescription of anti-psychotic medication services need to be implemented as a whole system approach. This process starts with ensuring the provision of less restrictive and safe therapeutic environments in line with prudent healthcare principles, examples of which may include pleasant outside space or quiet rooms.

15. However, for some care homes and cognitive stimulation groups, it is significantly more challenging to adopt such measures due to an insufficient number of permanent staff members currently employed in local care homes. Reduced occupational therapy resources often mean that opportunities for alternative treatments become even more challenging, despite the fact that our members have made it clear that such functions could be delivered and promoted more effectively by an in-reach worker.

Training for health and care staff to support the provision of person-centred care for care home residents living with dementia;

16. It is encouraging that inpatient dementia wards, in some areas, have activity co-ordinators whose responsibility it is to personalise therapy and patient activities to reduce stress and agitation. It is also encouraging that similar teams have been set up to offer a practical, hands-on approach to integrating non-pharmacological approaches in addressing behavioural challenges for patients living with dementia. Such teams have offered advice and consultation to care home staff to emphasise the importance of exploring alternative treatments in accordance with NICE guidelines.

17. A considerable proportion of training for health and care staff to support the provision of care for residents living with dementia is now done online. It is encouraging that such online resources have incorporated pre-existing materials from the relevant Local Authority and third sector partners, thus developing the integration agenda. There are also a number of projects currently ongoing between GP practices and care homes with a view to identifying residents who show early signs of dementia and the various ways in which carers can respond to their condition. Alternative ways of working have developed in other areas, such as the introduction of a dementia checklist for managing the behavioural and psychological symptoms associated with dementia, and there are a number of good examples of such specialist care being delivered within care homes.

18. However, while it is encouraging to see e-learning on such a scale, a lack of capacity in some areas has meant that it is difficult to provide specialist teaching for staff members to support the provision of care for patients living with dementia. Moreover, while it is undisputed that there are a number of effective initiatives ongoing, there remains considerable space for sharing good practice and training. In particular, there is a great opportunity for Local Authorities and care homes to closer align their ways of working to develop enhanced care settings. This would also be improved by an in-reach role where the training procedures could be repeated, relationships with homes improved and focused on the reduction in the prescribing of anti-psychotic medication.

Identifying best practice, and the effectiveness of initiatives introduced so far to reduce inappropriate prescribing of anti-psychotics;

19. A number of reviews have taken place across Wales in recent years aimed at reducing the prescription of anti-psychotic medication. The results are, broadly speaking, encouraging, though significant challenges around workforce capacity and the sustainability of such measures remain.

20. One of our members in particular is currently piloting the adoption of a new strategy aimed at improving communication on discharge from hospital and ensuring that an indication and a review date is included on any transfer of care documentation to be handed to the patient. This strategy has been brought about following a previous ambitious effort to enhance collaborative ways of working between GPs, pharmacists, care homes, nurses and consultants – while the model was successful in bringing about a reduction in the prescribing of anti-psychotic medication, it was not sustainable and was subsequently discontinued. It is promising however that the Local Health Board in this instance has agreed that an indication and review date will be added to every anti-psychotic prescription for challenging behaviour in dementia.

21. It is encouraging also that a number of Local Health Boards have recently undertaken medication reviews in care homes when requested. These practices have proven particularly effective for patients immediately after their hospital discharge or upon the request of a nurse assessor visiting a particular care home. Reviews are conducted in the care home and in front of the patients themselves, thus involving them as much as possible in their own care and with access to the GP record so that changes in a patient’s medication can be quickly reconciled and implemented. Additionally, primary care cluster/local pharmacist roles have been developed as extra clinical pharmacist support which has brought about a greater focus on care home medication reviews. Polypharmacy toolkits such as NOTEARS and STOPP START have been developed and utilised to support medicine optimisation in the medication review process too.

The use of anti-psychotic medication for people with dementia in other types of care settings;

22. It is important to note at the outset that the emphasis on the need to avoid hospital admission means that the likelihood of an individual being prescribed anti-psychotics to keep them at a care home invariably increases. It follows therefore that training for care agencies could be improved to enable home carers to be better able to manage the behavioural problems associated with patients living with dementia without asking for medication.

23. Two Local Health Boards have distributed information leaflets to carers with a view to raising awareness of the risks and benefits of using anti-psychotic medication for patients living with dementia. Both have been recognised as best practice and consideration will be made for ways of monitoring service user feedback. Also, mental health liaison practitioners have been made available in some Local Health Boards to improve the management of dementia patients on non-mental health wards.

Conclusion

24. It is positive to see that a range of approaches are being taken to address the ineffective use of anti-psychotic medication in care homes across Wales. It is suggested that frameworks be established to allow for improved communication and the co-ordination of best practice and learning between Local Health Boards and between care homes to maximise learning opportunities. This will enable consistent and standardised practices. It is suggested also that this work be undertaken in conjunction with dementia care mapping to identify and gather examples of good practice and wellbeing.