Elder Abuse

HC Deb 13 February 2002 vol 380 cc92-113WH

11 am

Mr. Paul Burstow (Sutton and Cheam)

I am grateful for the opportunity to speak on this subject, which seems almost taboo in this country, both because it is hard to get any reliable statistics to measure the extent of the abuse and because many remain in denial about the existence of such abuse. However, the evidence that does exist suggests that elder abuse happens on a scale that requires a significant shift in Government thinking and a change in professional practice.

Let us start by defining our terms. Action on Elder Abuse, an organisation that campaigns on the issue, defines elder abuse as a single or repeated act or lack of appropriate action occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person. The charity goes on to define five main types of abuse.

They are: Physical: for example, hitting, slapping, burning, pushing, restraining or giving too much medication or the wrong medication…Psychological: for example, shouting, swearing, frightening, blaming, ignoring or humiliating a person…Financial: for example, the illegal or unauthorised use of a person's property, money, pension book or other valuables…Sexual: for example, forcing a person to take part in any sexual activity without his or her consent—this can occur in any relationship…Neglect: for example, where a person is deprived of food, heat, clothing or comfort or essential medication.

Given those definitions, how widespread is elder abuse? Action on Elder Abuse offers evidence in its report entitled "Listening is not enough", which states that in the first two years of its national freephone service, more than one in four of the calls were about abuse in care homes. That figure should be set in context: just one in 20 older people live in care homes, and that pattern has continued beyond the first two years of the service. Research has also found that abuse increases with age.

Will the Minister tell us whether the Department has any plans to commission a national study of the level of elder abuse so that we can get a clear fix on the scale of the problem, not only in formal care settings but in the community at large? Such research is long overdue; research in the United States of America, commissioned by the US Congress, confirmed that the reported level of abuse in that country was merely the tip of the iceberg. I suspect that the findings would prove the same in this country, too.

I want to raise four concerns, of which I have given the Minister notice. The first relates to the resources available to the National Care Standards Commission to do its job properly. In 1983 there were eight nursing homes per inspector; in 1999 there were 20 homes per inspector.

The second issue is the low number of trained staff and the limited target set for raising the level of training. Currently, only two in 10 care staff have recognised qualifications. The Government have set the target that by 2005, half of care home staff should have NVQ2.

Thirdly, there is no offence of neglect of a vulnerable adult, and there is no legal means of dealing with informed consent when people no longer have the mental capacity to make decisions for themselves. Fourthly, standards of medication for older people are inadequate.

The resources available to the National Care Standards Commission are the subject of the first of my concerns. The British Medical Journal published a paper last year on the quality of care in the private sector and in national health service facilities for people with dementia. Using a system of evaluation based on dementia care mapping, researchers from the Institute for Ageing and Health came to the conclusion that the quality of care needed radical improvement or much improvement in all homes, and that no home showed even a fair standard of care. Research revealed that in a six-hour daytime period, 60 per cent. of the time was spent asleep, socially withdrawn or not actively engaged in any form of basic or constructive activity. Only 50 minutes was spent talking or communicating in other ways with staff or residents, and less than than 12 minutes was spent actively engaged in everyday constructive activities. This is not about room sizes or the width of doorways; it is about the quality of the life experience of the residents in those care homes. As the researchers emphasised, inspection teams do not use direct observation, so how can they fully evaluate the care environment of older people?

In 1983 there were 28,000 nursing home beds. That increased sevenfold to 196,000 by 1999. In the same period, the number of inspectors increased from 100 to 300. The human resources available to carry out the meaningful inspection of care homes, and residential and nursing homes, is a serious cause for concern. I hope that the Minister can spell out in detail today some of the issues that I have raised in written parliamentary questions to which I have not yet received an answer, including details about the establishment of the National Care Standards Commission and the ratios that the Government hope to achieve for all care settings.

That is not the only concern. On 29 January the Minister wrote to the chair of the National Care Standards Commission, Anne Parker, with guidance on the implementation of regulations and national minimum standards. What message was the Minister trying to send? Certainly, the message received by groups such as the Coalition for Quality in Care was that the Minister condoned low standards, particularly in the physical environment, for an unacceptably long period. What message does that send to care home owners who already comply with or exceed the national minimum standards? What message does it send to care home residents? As the Institute for Ageing and Health demonstrated in its British Medical Journal paper, it is not good enough to limit the scope of the commission's work to the prevention of "dangerous and unsafe practice." As if to underline that point, Counsel and Care, another charity, published a report last month entitled "Showing Restraint", which makes depressing reading.

All restraints, used inappropriately, are an affront to the dignity of older people. They create barriers between the residents and the staff taking care of them. They undermine residents' confidence and autonomy. They emphasise the power of staff and the powerlessness of residents. They promote incontinence and dependency. In some cases they increase the risk of injury and death. Examples of restraint include removing a person's walking aid, setting a heavy table in front of a resident's chair to stop them getting up, and tightly tucking in blankets, which can immobilise a resident as effectively as straps.

A care home becomes abusive to its residents when the convenience of the staff is a greater priority than the dignity and well-being of the people in their care. Neither I nor Counsel and Care claim that elder abuse happens in every care home or care setting. There are many dedicated home owners and care home staff who do a challenging job, often in difficult circumstances, but that should not be an excuse for not turning the spotlight on this issue.

Far too prevalent is the insidious abuse experienced by residents because of poor standards and low expectations of the sort recorded by the Institute for Ageing and Health in its BMJ paper. I wrote to the institute to test whether it was confident about its findings and believed that they were representative of a wider problem. It confirmed that that was its strong view, but said that there was a need for further research to underpin the evidence produced by the original research.

Just as care home residents can become institutionalised, so too can the staff, accepting poor standards and tolerating bad practice. Will the Minister give a clear guarantee that the National Care Standards Commission has the necessary human resources to get to grips with the issues surrounding the quality of life in care homes and other care settings and to undertake even an abbreviated form of the recorded observation used by the Institute for Ageing and Health? If the commission is to focus on preventing dangerous and unsafe practice, how will the poor standards and low expectations reported by the BMJ be tackled?

That brings me to my second concern—the training of care staff and the status of elderly care. As long ago as 1997, the United Kingdom Central Council for Nursing, Midwifery and Health Visiting said that it was concerned about the increasing number of cases that it saw involving abuse of older people. In the year 1999–2000, more than one in four cases of misconduct by nurses involved nurses in nursing homes. Action on Elder Abuse also found that as many as three out of four alleged abusers were care workers or nurses.

Those figures, set against the findings of a study by the university of Paisley, which examined the attitudes of nurses and health care professionals to nursing the elderly, paint a disturbing picture. That research found that the care of the elderly is given the lowest status among care professionals. Elderly care is seen by many of those surveyed by Paisley university as a place to put staff who cannot do anything else. That is not my view; those are not my words. That was the result of the research.

Poor quality is frequently, but not always, associated with low fee levels which lead, in turn, to reduced staff levels, higher staff turnover and poorly trained staff. Low levels of training and high staff turnover are a serious cause for concern. In a recent debate on the state of the care system, I referred to a statement by the Association for Residential Care. It said—and this time I shall complete the quote: With some supermarkets offering £8 per hour to stock shelves overnight it is hard to attract staff to a complex and often stressful job for much less money. In some parts of the country the only people applying for vacancies are those that Mcdonald's and Tesco have already rejected and, if employed, they come with high numeracy and literacy training needs, quite apart from any induction training and value based training needs. Numeracy and literacy training needs are an issue for many care home providers. There are many thousands of dedicated people working in the sector, and their work is often overlooked and undervalued. Good staff really make a difference to the lives of the people they care for. Nevertheless, the economics of care are such that the pool of people willing to work in the care home sector is small and lacking in basic skills.

Inspections rely on good record keeping, so the skills gap must be closed, to ensure that the records can be relied on to give a true picture. Most hands-on care is provided by care assistants with limited or no formal training. It is disturbing to know that research in the United States has shown a strong and clear link between the level of abuse in a care home and the level of training. As Counsel and Care points out, the attitude of staff to residents can hugely affect the degree of freedom and choice that the residents enjoy. Standard 28 of the national minimum standards published last year for care homes sets the target of a minimum of 50 per cent. of members of care staff trained to NVQ2 level or equivalent, to be achieved by 2005. Can the Minister give us a categorical assurance that there will be no relaxation of that target, and that enforcement action will follow swiftly if it is not met? There can be no sliding on that standard.

My third area of concern is the legal protection of older people in care. The law continues to deny legal rights to people who are judged by others to lack the mental capacity to make decisions for themselves; they are not only denied proper legal status as autonomous individuals, but many areas of law simply ignore their existence. For example, under the Mental Health Act 1983, it is assumed that people who make no attempt to discharge themselves from hospital have consented to informal detention as patients. Who has authority? How is capacity defined? How can people with mental impairments, such as dementia, be enabled to participate in decisions affecting their lives?

The current "all or nothing" approach whereby authority is passed to those claiming power of attorney, or professionals giving health care and legal advice, will no longer do. Common law recognises that third parties must act in someone's best interests, but incapacitated people's best interests are about more than managing money or rationing services to meet their care needs. We must ensure that they have a decent quality of life, that they can express their needs and emotions, and that they are treated with respect as autonomous individuals.

The Government have shied away from reform in this area, despite promises of legislation year after year. The rights to life, privacy and family life under the Human Rights Act must be given real form; the legislation that has been lying around for too long in the Lord Chancellor's Department needs to be brought forward. In particular, it is time to introduce a new statutory offence to cover abuse of vulnerable adults. Why is there no such offence on the statute books?

My final area of concern is the inappropriate use of medication in care homes. Last December I published a report entitled "Keep taking the medicine?", which examined the evidence for over-medication and inappropriate medication of older people in care homes. The report drew on parliamentary answers and on an extensive review of both domestic and international research evidence. It concluded that antipsychotic medication was being used inappropriately to "chemically manage" some residents in care homes. The report called for action and set out seven recommendations, including more frequent reviews of medication in care homes, better documentation of prescribing, tougher requirements for the proportion of trained staff, and a change in the law governing informed consent.

Since its publication, the report has sparked considerable interest, and has resulted in a wide range of care professionals contacting me to express support for its findings and recommendations. When it was published I sent a copy to the Secretary of State for Health, and I look forward to receiving a letter setting out the Government's response.

The over-medication of elderly people is a form of abuse that can result in death, and denies them their dignity. The consequences of over-medication have been studied extensively and have been well reported. Despite that evidence, poor practice has persisted in the United Kingdom, and the prescription of antipsychotic medicine has continued to rise. Over the past 20 years concern has grown about the inappropriate use of antipsychotic medication in the care of the elderly, and drugs that were developed for one purpose have been switched to other purposes.

Although antipsychotic medication has beneficial effects in some cases, a succession of studies both in this country and abroad have demonstrated that the level of prescription greatly exceeds the number of elderly people exhibiting conditions that are treatable by such drugs. Research suggests that about 10 per cent. of residents in care homes have psychotic symptoms such as hallucinations and paranoid ideas, but about 30 per cent. of residents in care homes are regularly prescribed antipsychotic medication. If that pattern were repeated in England alone, more than 35,000 residents in nursing homes, and possibly as many as 53,500 elderly people in residential homes, would be kept in a state of sedation for no medical reason.

Elderly people with dementia are particularly at risk, and having to manage challenging behaviour without trained staff is no excuse for relying on chemical solutions. International evidence suggests that annual reviews of prescription for elderly people, as proposed in the national service framework, would be inadequate, and that harm can be done to people in far less than a year. Successive studies have consistently called for change. The chemical management of elderly people is an unacceptable scandal, because it denies them their dignity and their quality of life.

I hope that the Minister can tell us more about what the Government are going to do, not least about increasing the frequency of medication reviews. Will she undertake an awareness campaign targeted at care staff and GPs to ensure that over-medication is recognised and stamped out?

Elder abuse casts a sinister shadow over the care system and beyond. Elder abuse is more of a taboo than child abuse, and our attitude to it seems to be years behind our achievements in tackling child abuse. The national service framework for elderly people and the national minimum standards published last year are steps in the right direction, but more steps need to be taken. Without extra resources and law reform, elder abuse will remain hidden, and its victims will be dead and buried.

11.17 am

Paul Flynn (Newport, West)

I congratulate the hon. Member for Sutton and Cheam (Mr. Burstow) on obtaining today's debate, and on his energetic, creative and intelligent campaigning; the House owes him a debt of gratitude.

The first thing that strikes one about this morning's debate is that it has attracted only one Back Bencher, although Front Benchers are present. The previous debate, which was about gambling, attracted at least 20 times as many Back Benchers, which illustrates the point of raising this issue. The ninth commandment of the Back Bencher's 10 commandments says, "Neglect the rich, the obsessed and the articulate, and seek out the silent voices." There are no voices quieter than those of people who are in residential homes for the elderly. Many of them have no relatives, or only relatives who are indifferent to their welfare. They are often broken and defensive and feel themselves to be weak, and their voices are rarely heard. The empty green leather Benches that surround us this morning are eloquent testimony to that.

As the hon. Gentleman rightly said, this campaign is enormously important. Sadly, it is not a new campaign, and although I wish him well in his plea, we have to look at the failures of the past decade. A number of early-day motions have been tabled in this Session of Parliament, the first of which was early-day motion 66, headed "Elder Abuse". There was also an early-day motion in 2000, and others in 1999, 1998, 1997, 1996, 1995 and 1994. I shall read out one of them to illustrate the fact that the position has hardly changed.

Early-day motion 1565, dated 1998, said: That this House is shocked by the evidence from the Alzheimers Disease Society and Age Concern on the dangers of the over-medication of the elderly; is alarmed by reports that up to one in five admissions to hospital of the elderly are caused by the misuse of medicines and by investigations in England and Scotland that found 54 per cent. and 88 per cent."— the 54 per cent. was in Manchester and the 88 per cent. was in Glasgow— of prescriptions of powerful neuroleptic drugs to elderly residents in homes were not needed, so were "wrongly prescribed". The early-day motion calls for an improvement in care services, and calls on the Government to replicate the reviews nationally"— that is, the reviews in Manchester.

There have been other parliamentary efforts, too. The Residential Care Homes and Nursing Homes (Medical Records) Bill 2000 sought to change the situation, and Adjournment debates in 1996, 1998 and 2000 made the same points—and those are not the whole story, but all the results of the activity of one MP. Others, too, have been pursuing the matter.

Whenever the issue is raised in Parliament, whenever I mention it in a question or in debate, hon. Members from both sides come up to me and say that what I have described also happened to their elderly mother-in-law, or to their father, or someone else in their family. The stories are very similar. The old people concerned went into homes, reluctantly, because they were physically frail but very alive and sharp mentally, but within a short time, they were turned into zombies. People in that condition are easy to manage. Many of us conclude that prescriptions of neuroleptic drugs are given not because of medical conditions but because it is much easier to run a home full of passive supine people who will take orders easily, than a home full of argumentative elderly people. The results for the elderly people are catastrophic.

Several studies have been carried out. One in Glasgow, which I have already mentioned, said that 88 per cent. of drugs were wrongly prescribed. As has been pointed out, that largely involves antipsychotic drugs, which are meant for people who are deeply psychotic. They are being used for an entirely different purpose—as a chemical cosh to induce lethargy in elderly people. Every study carried out by any independent body here, elsewhere in Europe or in the United States has found evidence of vast overuse of such drugs. Reactions from Governments of all colours have been discouraging and inappropriate.

The study carried out by Professor Alistair Burns, Sarah Kathryn Lloyd Craig and Lee Furniss in Manchester is probably the most celebrated. On my way to the debate this morning, I passed the Financial Secretary to the Treasury, who gave Professor Burns an award for that study when he was a Health Minister. It was a greatly encouraging study, and one assumed that the world would change after it. Professor Burns took into homes an independent group of doctors and pharmacists, who were not attached to the homes in any way, but, coming from outside, looked critically at the prescriptions being given out. Many of them were historic—people were getting prescriptions for illnesses that they had had 40 years earlier. Some of those were wholly inappropriate and clashed with other prescriptions.

The result of the study was to alter prescriptions, and greatly to reduce the number of prescriptions issued and medicines taken. The elderly people started to take milder medicines, often in lower doses. As a result, not only were their lives improved, but they made connections with members of staff and other residents. They were healthier and lived longer. Perhaps best of all—in the view of some people—there was a financial saving as well. That would have been irrelevant, because the aim was not to make financial savings, but every investigation has shown that savings result.

A similar exercise was carried out on a smaller scale in Ceredigion. The investigators did not find a significant amount of over-prescription, but they found that repeating prescriptions of appropriate medicines reduced the total amount of medication and resulted in a financial saving. Professor Alistair Burns and the others who took part demonstrated that large numbers of elderly people do not have to suffer from misery and confusion at the end of their days. We all applaud that priceless achievement.

Sadly, as suggested by the report referred to by the hon. Member for Sutton and Cheam, little progress has been made. The reasons are Government timidity and a reluctance to take on the medical establishment and challenge the opinions of doctors. A simple way to find out whether there is abuse would be to publish the percentages of residents in homes who are on dangerous drugs such as Largactil and the other neuroleptics. It would come out clearly that in some homes 100 per cent. of the residents are on neuroleptic drugs and in other homes none are. A health worker who was horrified by the drugs' effects set up his own home and decided not to allow them in. As a result, his home is successful, happy and profitable. Even that simple exercise, which would tell us where abuses are taking place, has not been undertaken.

Age Concern, Action on Elder Abuse and the Alzheimer's Disease Society have published details of heartbreaking cases. In some homes, all the residents are routinely given a pill at 6 o'clock at night. They are then put to bed and miss life, television and everything else that happens. When they wake up and wander around at 2 and 3 o'clock in the morning, they are given another pill. That is elder abuse on a large scale. There is a report in the papers this morning about the abuse of illegal drugs, but the greatest abuse of drugs takes place in this age group. We do not measure the numbers who have suffered from over-prescribing since 1993 to 1994, when the issue arose in this country, but they would be not in the hundreds or in the thousands but in the hundreds of thousands.

Is there a way out? There is in America, which, to its credit, went through this process a long time ago. Similar debates took place in the parliaments of countries such as Canada and America in previous decades. They concluded that it was necessary to institute a truly independent system of inspections, with powers attached.

The owners of care homes tell us that it is not they but the doctors who issue prescriptions, make decisions and have the power; one is quoted in the report referred to by the hon. Member for Sutton and Cheam. Of course that is right. However, there is often strong evidence of collusion; the two work together. The situation is similar to that of doctors in hospitals and prisons. There is a community of interest, and the parties close ranks.

A parallel situation exists in prisons, in which there is a routine knee-jerk reaction to women prisoners who mutilate themselves—a common action by young women who have been abused, perhaps by the care system, their family or their partner. In her book "Invisible Women", Angela Devlin described the almost universal reaction of prison officials. The doctors prescribe antipsychotic drugs, which turn the young women into what are called, in the cruel language of the prison, "muppets". Young women are given drugs that were meant for the deeply psychotic.

I am afraid that the cosy relationship between the doctors and the nursing homes is allowing the problem to continue. Often in such cases, those who are prescribed the drugs do not have an examination, or reexamination, by doctors; they are given them on the say-so of staff in homes. I join the hon. Gentleman in saying that many homes are run in an exemplary manner; the staff are dedicated, and they do jobs that most of us would be reluctant to do, and would, I suspect, be bad at doing. The tasks that they must perform are often heartbreaking, and the financial rewards are very small. They are an army of dedicated people, and I would not criticise such workers in homes for the elderly.

We look to the Government to react strongly. I have a copy of a letter that I sent to Ministers in the past, which contains terms similar to those used by the hon. Gentleman. Pleas have been made again and again, but progress is small, if there is any at all. We want to ensure that all homes are inspected. In America, prescriptions are checked monthly, then rechecked and improvements are made. If that does not happen here, the misery of a large number of unprotected and defenceless people will continue.

Mr. Deputy Speaker (Frank Cook)

I seek to help hon. Members. In these 90-minute debates it is the common convention to start the winding-up speeches of the two Opposition spokespeople and the Minister 30 minutes before the end, but we are well ahead of that stage at present. In similar situations in the past—on two occasions, in my experience—a Member who spoke early has taken an inordinate length of time, which is not fair on other Members, nor on the replying Minister. I therefore earnestly appeal to hon. Members not to extend their contributions unduly, so that the time available is equitably shared.

11.32 am

Sandra Gidley (Romsey)

Thank you, Mr. Deputy Speaker—but you have obviously never heard me speak before, because I do not tend to speak at length.

I thank my hon. Friend the Member for Sutton and Cheam (Mr. Burstow) for securing the debate. This is an important subject, and I echo the thoughts of the hon. Member for Newport, West (Paul Flynn) that it is disappointing that so few hon. Members are in the Chamber. It has been a big disappointment for me on coming to Westminster to find that debates on health topics are frequently among the less well attended, and combining the subjects of health and the elderly seems to create a double problem.

I shall begin with some anecdotal evidence. I have taken a close interest in nursing homes since I was a mayor. One of the delights, or otherwise, of being a mayor is visiting all the nursing homes and care homes at Christmas, and it struck me powerfully that one could judge a home as one walked in. In some, residents are happy and lively and chat to each other—one can have an enjoyable visit, perhaps meeting old suffragettes, and all sorts. In others, residents sit in chairs and no effort is made to encourage people to communicate with one another. Often that is a result of the leadership of the owners. It is a subtle rather than a deliberate form of neglect. I found it upsetting to enter those homes, and I wondered who spoke to the residents all day.

The chemical cosh has been a problem for some years. Nearly 20 years ago—I was a pharmacist at the time—doctors were bulk prescribing for nursing homes. Prescriptions for packets of 500 tranquillisers at a time were common. Thankfully, that has changed and things have got a bit better over the years. GPs now have to take more care and pay more attention to their prescribing. They often officially endorsed whatever was going on in the nursing home—that has been hinted at already. They took the word of the nursing home owner at face value. Questions arose in my mind about that when one home that I regularly dispensed medication for changed hands. The prescriptions for antipsychotics dropped dramatically. As a pharmacy manager, I had a problem because they were left on my shelf, so I quizzed the new owners, who said that the drugs were not necessary. Since they had got over the hurdle of withdrawing them, they felt that the residents were healthier, happier and livelier—and they did not have a problem with that, because they thought that older people should be lively. Their view was certainly not that of the majority.

The research by my hon. Friend the Member for Sutton and Cheam has highlighted a 70 per cent. increase in the use of atypical antipsychotics among the over-60s in 1999–2000. We must be careful when we refer to percentages; it might be easier to use numbers, so I shall say that that means about 150,000 prescription items. There was a corresponding drop in prescribing traditional antipsychotics with more side effects, but only a drop of 2.9 per cent. There has been a big increase in the prescribing of chemical coshes.

Part of the problem—here it would be useful if the Minister could tell us what information has been given to GPs—is that when introducing such drugs one cannot treat older people in the same way as the rest of the population. Many older people are already taking various types of medication that may interact with each other, which is called polypharmacy. Because of failing kidneys or liver, they are less able to get rid of drugs when they are administered, so it is important that they begin with a low dose. If such good practice is not followed, the risk of side effects is considerable, including mental impairment, uncontrolled and involuntary movements, tremor, problems with blood pressure, sweating, incontinence, and dizziness. Those are all normal side effects of the drugs, but older people are less likely to be able to cope with them.

The side effects are very unpleasant, and could also exacerbate existing problems to a small degree. It is vital that we train staff, and GPs, in understanding the problems of older people, particularly dementia. Not enough work has been done to understand that problem and find ways to deal with people without resorting to chemical methods or some form of abuse. The poor wages in the sector have already been highlighted. Often there may be a very willing nursing home owner, but because of frequent changes of staff—working in a home is not a popular job—it is difficult to get that message across to the staff consistently.

GPs have many demands on their time, and probably do not have the time or the money to devote to this issue. Standard 9 of the national minimum standards is designed to protect people from inappropriate medication, through clear policies and procedure for dealing with medicines. However, many concerns have been raised about the fact that that the question of who will monitor that standard has not been adequately addressed. The Minister may respond to those concerns today.

Any form of restraint is a problem. I have highlighted the problems of incontinence and other side effects, and if people experience those, it can create a vicious circle. People simply sit there, not reacting to their surroundings, and the problem continues. Who will police the carers? I echo the concerns that have been expressed about the provision of adequate resources to protect people.

There is a case from close to home that, unfortunately, illustrates the point that I am trying to make. There is a nursing home whose owner has high standards, the home is kept very nicely and the residents are generally happy. However, the owner admits that he has problems from time to time, one being that he cannot be there every hour of the day. He arrived one morning to find a patient very distressed, which was unusual, because the lady in question was usually bubbly and happy. Something had obviously gone wrong. In talking to her and to the staff, who were keeping fairly quiet, he discovered that she had been taken to the toilet early in the night and forgotten, so she had been left there for hours getting cold, frightened and distressed.

The owners took that seriously, and promptly sacked the nurse in question. The nurse appealed and took them to an industrial tribunal, but they were on safe ground. I found it particularly appalling that the nurse was then able to enrol with an agency and earn a living filling in at nursing homes throughout the area. The story has a relatively happy ending, because the nurse eventually appeared before the United Kingdom Central Council for Nursing, Midwifery and Health Visiting, which removed her from the register. However, for 18 months she had been able to subject other old people to neglect or abuse.

Sometimes the abuse is unthinking rather than deliberate, which is why we need to get the message across about positive ways of looking after our elderly people. A Counsel and Care publication, putting it very well, says: An act of omission rather than a deliberate act of tying a knot or turning a key can restrain residents, and staff may not be consciously aware that they are doing it. The phrase "consciously aware" is the key. The problem is connected with education. The publication continues: Staff might think that, "He has had a good day today, he has been sitting quietly in his room." In fact, the resident might not have been given his walking stick, or he might still have his breakfast tray fastened across his lap. He might desperately want to get up to go to the toilet, go for a walk, or simply relieve the pressure on his lower back, but he can't. So he sits, having a quiet day. There is a cultural perception with older people, as there is with children, that if they are quiet it must be good. That is not necessarily the case.

I would also like to echo the comments of the hon. Member for Newport, West about how residents feel that they cannot stand up for themselves, while their relatives, who perhaps do not visit as often as they should, do not want to make a fuss either. There is often an advocacy problem. Has that ever been considered or dealt with?

To sum up, I will list certain ideas or suggestions. First, does the Minister agree that it would be helpful to have an annual review of prescribing for elderly people? If that could not be done for all elderly people, perhaps a way of monitoring prescribing in care homes could be devised. If over-prescribing is a growing trend, that is a problem, particularly with an increasingly elderly population.

Mr. Burstow

A comprehensive annual review would undoubtedly be a useful tool. As the hon. Member for Newport, West and I have said, medication reviews need to be much more frequent to prevent the damage and harm that can be done in a very short time. If the concentrations are wrong, the effects can quickly become devastating.

Sandra Gidley

I agree with my hon. Friend, but much of that comes back to the fact that GPs do not necessarily have the time or the inclination to deal with what may seem a small part of their work load. We certainly have to address the problem from an educational viewpoint. Here I should put in a plug for my fellow professionals, the pharmacists, who are in an ideal position to monitor medication. Some already do so, and are paid for visiting homes, but not all homes are keen to take up that offer. Perhaps we should move in that direction.

Who can give real advice about antipsychotic drugs? One could accept guidance from the National Institute for Clinical Excellence if nothing else was available, but the trouble is that NICE considers only one drug at a time. It does not consider other drugs that could be prescribed for the same symptoms, and its prescribing recommendations can mean that other medications suffer. We need some helpful guidelines on when it is appropriate to prescribe particular types of antipsychotic.

The problem has been highlighted for a number of years, but the impression that I gained from listening to the hon. Member for Newport, West was that little has been done and that the problem is ignored—probably for the same reasons as there are so few of us here today. Have the Government any plans to study the abuse of the elderly, as suggested by my hon. Friend the Member for Sutton and Cheam? Will increased resources be made available to the National Care Standards Commission?

The other problem, at least in my locality, is that the local authority rate paid to nursing homes is low, and most relatives are forced to top up the nursing home fees. The problem about a low rate being paid is that inadequate attention is sometimes paid to providing the best possible service. However, some homes manage it, and we need to find a way of spreading that best practice. Increasing the grant from local authorities might help. We would then be assured that nursing homes would not have to resort to the measures that have been highlighted so eloquently today.

11.46 am

Mr. Simon Burns (West Chelmsford)

I add my congratulations to the hon. Member for Sutton and Cheam (Mr. Burstow) for giving us the opportunity to debate this important issue. As he said, it is a taboo subject to many people.

All too often, when considering abuse one thinks of child abuse. That emphasis can be seen in many social services budgets, because a significant proportion of their money each year is spent on the protection of children and their interests. I do not criticise that, but society concentrates on the problems of children and the horrendous problems of child abuse, with which we are far too familiar, to the exclusion of elder abuse. That is partly because many people do not realise that such a problem exists. It is either swept under the carpet or, because we are dealing with adults, people are unable to reconcile themselves to the fact that it occurs. As previous speakers have made clear, that fallacy needs to be addressed.

Sadly, far more elder abuse takes place than one realises, although as hon. Members have said, part of the problem is a general lack of understanding. There is also a lack of information, which, together with the fact that people do not understand the problem, means that one cannot realistically quantify the level of abuse that exists. There are various types of abuse. The obvious forms of abuse are physical, but far more insidious is psychological abuse. The latter is particularly cruel to the vulnerable and the weak, but it is also particularly difficult to prove and to combat.

There are also financial abuses. The Court of Protection can of course help, but all too often it does not play as sound and vigorous a role as one would hope in protecting the interests of those who can no longer look after their own financial and other affairs. Finally, there are the issues of sexual abuse—however distasteful that may be—and neglect, which, like psychological abuse, can be difficult to pinpoint and combat.

One difficultly is that abuse can happen anywhere—in the homes of the individual or of a carer, in residential or nursing homes, and even in hospitals. None of us should make the mistake of grossly generalising and tarring everyone with the same brush. The vast majority of privately owned and local authority owned residential and nursing homes, and the vast majority of medical staff in national health service and private hospitals, do a first-class job of looking after the elderly and other members of society. It would be unfortunate if carers and professionals in nursing were tarred with the same brush as the few who cause the elderly so much misery and suffering.

The scant evidence available suggests that, ironically, most abuse is carried out by individuals who are well known to the person who is being abused. We have a duty to ensure that elderly members of society have the right to a standard of living that is as high as possible—the standard that we would seek for ourselves. We also have a duty to ensure that they enjoy the dignity to which they are entitled.

The sad fact of life is, however, that changes that have occurred in society over the past 20 to 40 years are placing, a strain on the elderly. I have in mind greater mobility—younger family members sometimes need to leave the traditional home to search for work in other parts of the country—and the breakdown of the concept of family that existed 40 years ago. Family members often do not live close to each other, as they would have done 40 years ago. There is, therefore, no family support system, although the problem does not affect the elderly alone. Young families with children often do not have the stabilising influence of grandparents who can provide support. All too often, family members move away from the area in which they were born and brought up, and grandparents and elderly parents become isolated because there is no family support system. There is, therefore, an increasing reliance on agencies and on other forms of accommodation for the elderly, which can give rise to a greater propensity for abuse.

One comes to realise, from acquaintance with organisations such as Action on Elder Abuse, that there is great ignorance on this subject, and that abuse is carried out for a variety of reasons.

There are elderly people who are fortunate enough to be still living in their own homes, possibly with a carer or a domiciliary care package to help them to remain in those familiar surroundings, but abuse can arise from poor long-term relationships in the home, or a carer's inability to provide the required level of care. Sometimes the carer has mental or physical problems. There is a considerable and increasing burden on carers. The statistics, which reveal a worrying prospect for the future, show that people who care for elderly people are becoming older. Many of them are pensioners themselves. That causes a problem, not just because of the strains, frustrations and difficulties of caring for someone, but because the carers will have their own problems and hardships.

In other settings, such as residential or nursing homes, abuse is thought to be more often a symptom of staffing problems. Some staff may be poorly trained or supervised, or have little support from management in carrying out their duties. They may also work in isolation, which puts strains and pressures on them.

It is necessary to consider how to move forward. That does not involve the Government alone, although of course they have a role, which I am sure the Minister will fully accept. There are no differences of opinion among hon. Members about the problem, and I suspect that there will be little difference between our views about what we need to achieve. However, we should also pay tribute to the organisations that work with the elderly, providing support and back-up and playing a key role in enhancing elderly people's quality of life, as well as trying to minimise opportunities for abuse.

More needs to be done. Many hon. Members have talked about raising care standards, which is critical. As the hon. Member for Sutton and Cheam said, we are not talking about the size of rooms, or whether there is a lift. We are concerned about raising standards among people who look after elderly people in residential or nursing homes and people who provide domiciliary care for those able to remain in their homes. Of course the National Care Standards Commission has an important role to play. Similarly, more care and help is needed for carers, to reduce their feelings of isolation and frustration.

Ironically, it was only this morning that I was talking to someone who told me about the frustration felt by carers when, with all the other work that they do, they need to talk to someone from the authorities, such as a doctor or representative of the social services department. All too often they are told that the person in authority is not prepared to discuss the problem with them, but will speak only to the individual concerned. That is ludicrous in many cases, particularly if the elderly person is suffering from dementia or Alzheimer's disease. Such people cannot rationalise the problem that must be discussed with the agency, and there should be a more sympathetic and realistic approach.

Mr. Burstow

The hon. Gentleman is making an important point. Many have experienced the practical difficulty that the system does not allow for another person to take decisions on health and welfare matters when someone has lost the mental capacity to make decisions on their own behalf. Would he agree that there is a need to examine and change the law in that regard?

Mr. Burns

I would agree that the matter must be reconsidered carefully, because the situation is unsatisfactory, but I hesitate to give a knee-jerk reaction in favour of new legislation, even after the hon. Gentleman's valid intervention, without seeing more evidence about the extent of the problem and hearing further suggestions about sensible improvements. It is dangerous to call automatically for legislation as a solution. If one has enough evidence to justify changes in the law, they should be considered, but I would not want to give a blanket call for a change in the law at this stage. I agree that something must be done to provide more co-operation and assistance for carers in that respect, as it is deeply frustrating for them to have to cope with the bureaucracy on top of everything else.

All the hon. Members who have spoken have talked about the use of medication. I do not think anyone would disagree that it is deeply distasteful and morally wrong to fill elderly people up with pills and keep them sedated and quiet simply to give those who look after them an easy life. It is not right to take the easy option of pill-popping for a quiet life. More must be done to solve that problem, and we must discover sensible ways of stopping that from happening.

More protection must be given to those vulnerable people, especially those who are senile or approaching senility and who do not have complete control over their lives. One hears stories of unscrupulous staff who, while in a position of responsibility looking after those people, plunder their assets.

I know of a case of an elderly lady, living in a residential home, who owned an original Lowry and kept it in her room. When she died, the picture had disappeared by the time her stepdaughter arrived at the home a few hours later. The nurse who had been looking after the lady was a locum who, as was established after a complaint to the police, had taken the picture upon her death. When the police tracked the nurse down, she said, "The picture is mine. The old lady said I could have it when she died." When the old lady had entered the nursing home, however, she was in no fit mental state to give anything to anyone. I have serious doubts that the picture was ever promised to the nurse—indeed, it could not have been, because the lady was not of sound mind. Yet in the light of that interview the police decided not to pursue the matter any further. Only when the stepdaughter decided to take out a private prosecution, because the picture had turned up for sale at an auction house in Sussex, did the nurse back off and return the picture. However, there was no prosecution and the family involved in the situation—which dragged on for about 18 months—felt let down by the police because it seemed clear that the lady concerned was in no fit mental state at any stage, from the moment she entered the residential home, to make a rational decision about giving her possessions to anyone.

I wonder how frequently elderly people are abused in that way by a small minority of unscrupulous people who prey on them in the hope that they will never be prosecuted, or even found out, because of the state of their victims? More attention should be given to the matter. The picture was sold at Christie's in London about two years later and reached the record price for the sale of a Lowry. This was an object worth not a few hundred pounds, but—from memory—almost six figures.

We have been fortunate in the success of the hon. Member for Sutton and Cheam in securing this debate. The issue is too often swept under the carpet; people either refuse to accept that there is a problem, or, because it is in many ways such a horrendous problem, they do not want to confront it. More must be done to eradicate this obscenity from our society.

Mr. Deputy Speaker (Mr. Nicholas Winterton)

Before I call the Minister to reply, may I indicate that as this is a critical debate—indeed, I am sorry that I was not in the Chair for the beginning of it—I hope that she will use the maximum time permitted for her reply if she needs it.

12.7 pm

The Parliamentary Under-Secretary of State for Health (Ms Hazel Blears)

I begin by concurring with your comments, Mr. Deputy Speaker. This is an extremely important debate. I am delighted that the hon. Member for Sutton and Cheam (Mr. Burstow) has secured it and given us an opportunity to hear from other hon. Members. I am sorry that there are not more of our Back-Bench colleagues present, although the quality of the contributions has not been any the lower for that. I know that my hon. Friend the Member for Newport, West (Paul Flynn) has a long and proud record of having raised such issues, particularly in relation to medication, on which he is probably far more of an expert than I shall ever be. He has made a great contribution to the on-going debate and it is important for us to pursue it.

I am grateful to the hon. Member for Sutton and Cheam for having given me notice of the areas of concern that he wanted to highlight. I hope to cover them in some detail, and, perhaps, to offer him reassurance. The first is the overarching legal framework in which the issue of elder abuse can be addressed. Secondly, he mentioned training, qualifications and the standard of staff providing care for elderly people—a crucial issue. As he said, quality of care is not about the width of doorways, passenger lifts, and room dimensions—although those things are important; physical standards and the environment in which people are cared for are matters of great concern. The time taken to talk, to listen and to interact with elderly people is key to their sense of well-being, so I particularly want to talk about training.

The third issue is resources. We must look at the adequacy of the National Care Standards Commission, what its budget will be, whether it will be able to monitor not just physical standards but the quality of care given in residential settings, what the numbers of employees will be and how they will draw on the work of other professionals, not simply the commission, to ensure that the picture is fully rounded.

The final subject raised was the important issue of medication, which prompts several questions, such as how often medication should be reviewed, and what systems are being put in place to prevent inappropriate prescribing and over-prescribing of medication for elderly people, particularly, but not exclusively, in residential care settings. Many elderly people are now supported to live in their own homes by intensive domiciliary care packages, which will be regulated for the first time. We should not think that the care of elderly people is only about residential care. I hope that in the future, it will increasingly be about maintaining people's independence in their own homes, which is how most elderly people want to be cared for.

I hope to cover a great deal of ground in my response. The hon. Member for Romsey (Sandra Gidley) said that on her visits to care homes, she had seen dramatic variations in standards of care. I am sure that all hon. Members will have visited care homes, either to see family or friends or to see constituents, and many of us would echo the hon. Lady's comment that to lay people, standards of care seem to vary dramatically from one care setting to another. This is an issue involving leadership, and the ethos set for their staff by people who run care homes. That brings me back not only to training, but to the stability of the care home sector. Stability is important so that people can plan for the future and provide not just a business but a residential care establishment of high quality. Therefore, some issues go beyond care standards and relate to the stability of the whole sector. If we want a substantial well founded residential care sector that can meet the necessary standards, we must think ahead to where we will be in five or 10 years' time and consider the sort of care that can be provided.

The Government share hon. Members' concern about elder abuse. We are trying to ensure that there is a comprehensive framework to minimise the prospect of such incidents occurring. However, I want to put it on record at the outset that cases of deliberate elder abuse are very few, and I am thankful for that. Our real concern should be directed towards abuse that results from poor quality and inadequate care. Cases of deliberate neglect and abuse are in a tiny minority.

Sandra Gidley

Would the Minister not describe the over-prescribing of neuroleptics as deliberate?

Ms Blears

If a deliberate decision were taken that was not in the best interests of a patient who was receiving medication from their GP, that would be a matter of concern not only to the Government but to the authorities who regulate health care professionals. We are talking about the extent of prescribing and the effects of over-prescribing. A deliberate clinical decision to harm a patient would be abuse, but we are not talking about that. There are issues surrounding the over-prescribing of antipsychotic drugs, but I am certainly unaware of any widespread, deliberate clinical decisions to harm patients, so it would be wrong to consider the issue in those narrow and restricted terms.

I want to put on record my appreciation of the immense dedication of thousands of members of staff who work in sometimes intense, pressured situations, caring for elderly people in residential care settings. Many of them do a first-class job caring for people, so we should ensure that our debate remains in that context. One of the worst things that we can do is to drive down the morale of people who are working extremely hard, often on very low pay, at the sharp end of care in our communities.

I also want to thank the charities and other organisations that advocate for older people and try to push relevant issues up the agenda. Action on Elder Abuse has campaigned tirelessly to ensure that the issues are in the public domain. Local authorities such as Lewisham, Cornwall, Sheffield and Surrey have developed adult protection procedures through their social services departments to co-ordinate the response of relevant agencies to abuse. That mirrors the child protection multi-agency machinery that we are developing.

Such matters are not the responsibility of one agency. There are several statutory and voluntary organisations that must work together to ensure that incidents are minimised and that when they do occur, there is a proper, considered response.

Paul Flynn

My hon. Friend is rightly focusing on the positive aspects of the care of the elderly, which should be stressed. Perhaps we have neglected one area during the debate: the wonderful work done to expand the lives of elderly people through new technology. The infirm and those who are seriously handicapped can be liberated to roam across the vast prairies of the world wide web. That has greatly expanded the life experience of elderly people. We should commend organisations such as Hairnet, and the local authorities that have encouraged the development of fuller and richer lives for elderly people in residential homes and elsewhere.

Ms Blears

My hon. Friend is right. I read a report about that from a community organisation in my constituency, where some elderly ladies in their late 80s have obtained their first new technology qualification. They are surfing the web with real enjoyment. That means that increasingly well armed and knowledgeable constituents will raise serious issues at our surgeries. New technology can allow interaction with the outside community even for people with physical infirmities.

The Government take the regulatory framework seriously. We began with the White Paper in 1998, and subsequently passed the Care Standards Act 2000, which put the aspirations of the White Paper into law. New regulatory frameworks are being introduced for residential care and nursing homes and agencies. Moreover, for the first time we will regulate domiciliary care agencies. The framework will be overseen by the National Care Standards Commission. Those are significant steps, and I am glad that the hon. Member for Sutton and Cheam welcomed the introduction of the commission, and the national service framework for older people. Those are recent significant steps in ensuring that we have a more coherent regulatory framework for the care of the elderly.

I would like to draw the attention of hon. Members to the creation of the protection of vulnerable adults list. In health and social care for vulnerable adults, the list will introduce a ban on workers who have harmed such individuals. The list will be similar to those in other public services: if it is proven that someone has harmed a vulnerable adult, they will not be re-employed. That is a significant step in providing real protection for older people.

The gateway to the system will be through the already established Criminal Records Bureau. A person included in the list must not be offered employment in a care worker position. If an employer has a reasonable belief that a care worker has abused a vulnerable adult, that worker must be referred to the Secretary of State for provisional inclusion on the protection of vulnerable adults list, even if the person is an ex-employee or retired. If the Secretary of State decides to include the person's name provisionally, inquiries will be undertaken to decide whether that inclusion should be permanent. Individuals may appeal to the tribunal if they have been put on the list. That is a significant step to ensure that we have a proper record. As in the case raised by the hon. Member for Romsey, if someone has harmed an older person, that individual should not be re-employed in the same service and allowed to continue such behaviour.

We also have the General Social Care Council, which will regulate the work force. Qualified social workers will be the first group to be registered, but we expect residential care home managers to be in the next group. In order to be registered with the GSCC, a person will have to demonstrate that they are of good character, physically and mentally fit to carry out the work for which they seek registration, and competent to do so, having attained a proper level of training.

Mr. Burstow

Can the Minister tell us when she expects front-line care workers to be registered with the GSCC? Given that she has said that a small minority of staff go through due process and are reported for direct abuse, does she agree that although the list is a welcome addition, there is still a need for research that will give us a better picture of the entire iceberg, and not just its tip?

Ms Blears

I will come later to research—an important matter, which the hon. Gentleman has already raised. I cannot give him a specific date on which front-line workers will be registered, because the process is on-going. We are starting with social workers and moving on to residential care home managers. We want to ensure that the whole of the work force who are in contact with elderly people are properly regulated and trained. Those are new measures, which are part of the new regulatory framework. Let us see how it settles down and beds in, and how we can begin to roll out a more extensive programme.

It is easy to call for overnight action on issues that have been outstanding for decades. Action is beginning to be taken, and we have to ensure that we set challenging targets that are also realistic. There are people out there who care for many elderly people. If our targets are not realistic and do not inspire confidence that they can be achieved, we will be in danger of setting our sights too high and setting people up to fail, which is the last thing we want. The most sensible way forward is the twin-track approach of setting new challenging targets and seeing how we can meet them.

In terms of training, we have set up a new fund specifically to ensure that we train people on induction standards when they first come into the sector. We should try to have a properly qualified social care work force, wherever people are working. Again, the record on that issue is poor. The National Training Organisation for Social Care published its training strategy—the first national strategy—in July 2000. That strategy includes details of the training and qualifications that care staff should have, starting with induction training for new staff.

In 2001–02, £2 million was set aside for induction training. Those standards cover essential elements such as understanding the principles of care and understanding the experiences and the particular needs of the service user group. The standards look at training from the point of view of the people who are being cared for, rather than from the point of view of the profession. That is a significant change that places patients and service users at the centre of the services that we are trying to set up. It will ensure that training is relevant to the needs of the people who are being cared for.

The National Care Standards Commission's national minimum standards include standards for training and qualifications for both care staff and managers. Those standards start with the induction training that new staff should undertake within six weeks of commencing their employment. They will move through foundation training to a competence-based qualification. In that way care staff will be more confident about their work, and I hope that they will take a more mature attitude to it.

There are about 1 million people in the social care work force, but only 20 per cent. of them have a relevant qualification. As I have said, we have to be realistic because we cannot expect to get everybody qualified overnight. We must ensure that services are still provided while staff are undertaking qualifications. We also have to know that there is sufficient capacity on the supply side with staff coming through. We must address the relatively low pay, and the fact that that kind of work has been undervalued.

Mr. Burstow

The Minister is right that there is a question about capacity. Can she assure us that when we get to 2005 and half of all care staff have to be trained to NVQ2 level, capacity will not become a reason for allowing the standard not to be applied in full from that date?

Ms Blears

We have set a target for 50 per cent. of care staff in residential care homes for older people to hold an NVQ2, and we aim to meet that target. There should be no excuses for having unqualified staff in a very important service. One way of raising the value of work in the sector, and thereby attracting more people to work in it, is to ensure that there is access to proper qualifications. We want to make faster progress if we can; that is why we have set that target.

The hon. Gentleman mentioned staff struggling with numeracy and literacy. There are some 10,000 people in the national health service as a whole who have such problems. We have a huge problem with access to basic skills in this country, so training in that area must also be considered.

We have care standards, the protection of vulnerable adults list, the qualifications required by the GSCC, the No Secrets guidance and the National Care Standards Commission. Let us see how that regulatory framework beds in and works. The overarching criminal law also provides for action to be taken when there are unfortunate incidents. We believe that that regulatory framework is an appropriate way forward.

Several hon. Members have mentioned overmedication and the over-prescription and inappropriate use of antipsychotic drugs for older people. The hon. Member for Sutton and Cheam has set out some of the research on that in his report, and I understand that he is awaiting a reply from the Minister of State, Department of Health, my hon. Friend the Member for Redditch (Jacqui Smith), which I am sure he will receive shortly.

We agree that excessive and inappropriate use of antipsychotics is a form of abuse. Because of our concern, we have tried to examine the available data on the change in prescribing rates of typical and atypical antipsychotics. The picture is complex and there is not one single explanation for the changes. The data that we have are captured from the Prescription Pricing Authority are about changes during the past year. The hon. Member for Romsey quoted the figures that show that prescribing of atypical antipsychotic drugs has increased. There is a reduction in the prescription of typical antipsychotic drugs, but that does not account for the whole difference in prescribing.

We are currently considering research on antipsychotic drugs in different care settings and the recommendation to ask the National Institute for Clinical Excellence to produce guidance on the use of such drugs for older people. That is an important field of research. It is difficult to drill down into what the data from the Prescription Pricing Authority really mean in residential care settings and in the community for older and younger people.

It is possible that the prescription of atypical antipsychotic drugs has increased because care for older people is catching up with trends in care for younger people, where there is an increasing use of modern drugs that have fewer side effects and are more beneficial. However, I do not think that that is the full explanation. The request for research is important.

On restraint, and the report from Counsel and Care, I reassure hon. Members that the care standards require that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self-harm, inhumane or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. I believe that that standard is sufficiently wide to cover inappropriate restraint. That is important, and enforcing the standard will therefore be the key.

We have been asked how many inspectors the commission will have. I understand that the ratio of inspectors to homes will be approximately the same as at present—one inspector to 27 establishments—but because there will be a single and consistent regulatory regime, the arrangement is likely to be more efficient. At present, there are several different regimes, and people operate to different standards, which means that we do not make the best use of available resources. Increasingly, new technology will be used, which will give us an opportunity to do that.

I understand that inspectors will have access to 66 full-time equivalent pharmacist inspectors, who will help with the whole medicines management programme. Pharmacists play a key role in ensuring that medicines are managed properly and that there is regular review. We are beginning annual reviews for people over 75, and the prescriptions of people taking four or more medicines will be reviewed every six months. Let us see how the reviews work, because they represent significant steps forward in ensuring that medicines are managed properly.