Friday 6 February 2009


My normally calm and affable disposition has been perturbed. Why? Because of this (which I chance upon here).

Oh my giddy aunt, where do I begin?

I agree that elderly abuse is common, undetected and poorly addressed. We have a "new" law for this, now. The Mental Capacity Act 2005, section 44 (2), criminalises both ill treatment and willful neglect of incapacitated folk which can result in imprisonment for up to 5 years and a fine. We don't need new laws, we need CSCI and statutory organisations (in health and social care) having strength to highlight this then for it to be addressed.

I can't think of a month, through the last year, where I've not been involved in elderly abuse proceedings. It's commonly seen and flagged up in my corner. Police have a nigh on impossible task of generating evidence "beyond all reasonable doubt" when elderly incapacitated folk are involved. They're honest about this. Last time I was at a High Court for a protection case, the CPS barrister met with me and asked how sure I was about the patient's account, given he had advanced dementia. I explained that the detail could contain erroneous elements but that his account of what grossly trainspired was internally consistent, repeatedly stated with the same content, coherent, fitted with informant and corroborating history/evidence, fitted with the contusions/abrasions and injuries sustained so I saw the minor nuances of flux in his account as inconsequential and that I was 95% sure the account was valid. 95% still left 5% doubt, she said. Not good enough. She met with the judge and it never even went to trial.

Laws alone won't help. We have the laws. We need surveillance, intervention and sanctions if we're to effect change.

Picking on the issue of antipsychotics and running parallels to prescribing this in dementia care as being a criminal act, what?!

Frankly, this just really, really pissed me off. Antipsychotics shouldn't be used first line in dementia care. Or second line. But they can have a place. Babies and bathwater. We don't want to say that there's no patient with dementia who could ever benefit from an antipsychotic. Some experience psychosis. Some benefit from an antipsychotic. Antipsychotic are not placebo. They're proper drugs, with real risks and real side effects. These are serious (eg a 2% increase of a year of having a stroke). Of course, if you're psychotic and tormented and won't live a year, a 98% chance of not having a stroke but getting relief may p'raps have some appeal . . .

Every patient in care homes in my corner gets reviewed. By me. They're not my patients. Most of the time I've not started the medication. But I still believe antipsychotics are such risky drugs and dementia care needs such support that it's worth my time visiting each and every care home in my patch, going through each and every MARS sheet for every resident and ensuring there's rational prescribing for all of them. I see this as good clinical practice. My GPs see this as a useful service, meaning care home patients receive appropriate Consultant Psychiatrist input into their drug regimens without having to refer every care home resident to me. Most of the time I am stopping antipsychotics. Very rarely, I start them. Sometimes I fiddle with the dose. I try and ensure that there's appropriate patient centred care - every patient gets due consideration of the risks, benefits and appropriateness of medication for them, with their history, at that stage in their illness. I would suggest that this is one element of decent clinical care. I do not think that what I am doing is wayward, let alone criminal.

Oft times GPs are called out of hours or at weekends and the "on call" GP has to take a view on how to support a care home with an "unmanageable" patient they don't know, in a care home they don't know, managed by staff they don't know. The GP has no idea on what training the staff have and on what they should be able to manage. GPs try and be helpful. GPs hear care home staff say their resident is battering other folk and "needs medication" so often feel obliged to prescribe. It makes sense for me and my team to then review care.

I have no hospital in-patients at present. This is largely because EMI Nursing Homes accept my patients knowing that nursing staff and I support them, a lot, with frequent visits and use of Continuing Care for 1:1 care so they can adequately staff their units and that use of medication is easily and appropriately reviewed. Use of antipsychotics is a small but important part of care for some patients some of the time. I'm much in favour of acetylcholinesterase inhibitors, I use benzodiazepines, but sometimes, just sometimes, an antipsychotic is appropriate.

What's being proposed?
Patients without dementia can have antipsychotics.
Patients in their own houses can have antipsychotics.
Patients with dementia can not have antipsychotics.
Patients in care homes can not have antipsychotics.
Erm . . . isn't this blatantly flagrant prejudice?

Politicians offering either "guidance" to clinicians or criminalising clinical care is so so missing the point.

The newspaper goes on to say that the issue is of poor detection by Social Services and poor resourcing (with a predicted £6billion funding gap). Well then, there we are. Use the MCA 2005 if we need legal redress but let's crack on and look at malign care in care homes/institutions, CSCI's role (and teeth), CPS guidance on when to go to trial, training and support for care home staff. Then, critically, look at the lack of resourcing which has generated this system. I'll say it again. We don't need more laws. We need surveillance, intervention and sanctions if we're to effect change.


That's not my name! said...

Posting back cos I put the original post up about the story. Actually, I just put the story up as is.

You know the bottom line is whatever laws are in place...I can't see them making a flying fart's difference.

How may bodies are there out there to monitor 'care' already? Like I wrote on my blog are we to have a massive police force? (no..because as a nation we can't afford one) and practically speaking how they would monitor 24/7 that the law is being implemented is beyond my capacity to comprehend...all i can envisage is more bureaucracy and it doesn't seem to work too well the bureaucracy there is already.

The story, for me, was more about reflecting on what is going on. The decline in care (not just in services...which - from what you write - is patchy). As in you seem to be on the ball and caring towards those individuals you come into contact with and have professional responsibility towards.

I don't understand why services can be so patchy...with all this monitoring that is going on.

And I am sure there are people that think I am a professional moaner. Nothing would please me more than good service provision. It would make my lot (and my Dad's life) more bareable.

However, the fact that the entire Non Exec Management Committee have resigned from Beds and Luton Trust is another saga in the long running battle to get local services somewhere better than they are. Actually, to me their resignations are more a statement of 'no confidence'.

I won't go on. This is your patch but something is fundamentally wrong somewhere. And I wish my father was under the care of someone like you.

Pem said...

Interesting discussion of the study here:

The Girl said...

That is just ridiculous. How the hell can somebody refer to beating and torturing elderly patients and prescribing them drugs for symptom relief in the same article? Paracetamol has horrific effects when used the wrong way, too, perhaps we should ban that.

Unknown said...

No, you misunderstand. All this politicking is achieving exactly what is intended: to be seen to be taking action, as opposed to sitting down, having a think and coming up with a solution that will actually do some good. The politician's syllogism from Yes Prime Minister:

"We have to do something,
This is something,
Ergo, We must do this".

It's essential that some macho action verbs be included as well, like "tough" or "hard" or "decisive".

The fact that it creates more paperwork that actually does SFA to improve the real situation doesn't matter.

Having spent a fair bit of time working in large organisations, if the management at the top goes in for this crap, you get it at every level.