Response to General Medical Council review of Good practice in prescribing medicines and devices

Consultation body

General Medical Council (GMC)

Response date

May 2011

Focus of consultation

Good practice in prescribing medicines and devices

Alzheimer Scotland is very aware of the complexities of prescribing and administering medication for people with dementia, especially when the medical condition is complex and the person is unable to give informed consent. We are aware that sometimes people with dementia are disadvantaged by discriminatory practices and do not always receive appropriate and timely treatment (e.g. timely prescribing of anti-dementia drugs). We are also aware that patient safety can also be compromised by medicines being mixed or given in a form which increases risks. We therefore welcome the GMC's review of Good practice in prescribing medicines and devices and the opportunity to comment. We have limited our responses to those questions which are of specific relevance to people with dementia and their carers.

Q3. Keeping up to date and prescribing safely – (paragraph 11)

Yes.

Q5. Prescribing to meet patients identified needs

Alzheimer Scotland agree that prescribing should only be to meet the patient's identified need and never for the convenience of others. The example provided by the guidance serves to highlight a key problem.

There is inappropriate prescribing of psychoactive drug treatments in response to behaviours such as restlessness and aggression that nursing and care home staff find challenging. Whilst attention has been largely focused on this problem in care homes, it is essential that prescribing practice in hospitals and individuals own homes is also appropriate.

Whilst the use of psychoactive treatments can be appropriate for people with dementia it should be emphasised that in Scotland, prescribing should be in line with the National Dementia Strategy and good practice guidance . The recent case of Mrs V published in the Mental Welfare Commission's report 'Starved of Care' (26 May 2011) highlights the need for very careful assessment and prescribing, including method of administration of medication. Mrs V (aged over 80yrs) received an average of two injections of sedative medication per day and four administrations of sedation rectally per day over a 16 day period, receiving not food and fluids administered by infusion.

Q6.

Yes

Q8.

Yes, also acknowledging that patients who lack capacity may have a proxy decision-maker with medical decision-making powers as an attorney or guardian and that they should be treated as partners in care and have the same right to information as the patient; in addition, the primary carer (family member, partner, friend) has a right, under the principles of the Adults with Incapacity (Scotland) Act 2000, to be informed and consulted.

Q9. Consent to prescribe section

It is essential that the underlying cause of a patient's condition is investigated; people with dementia should be treated equitably to those without the condition, it should not be assumed that all symptoms relate to the illness.
The assessment of capacity to consent is central to supporting the human right of individuals to be as fully supported to make decisions about their own care and treatment as possible, however many medical practitioners inform us that they do not have the competency always to do this, highlighting a need for training. We are especially concerned about the lack of compliance with Part 5 of the Adults with Incapacity (Scotland) Act 2000 and welcome the recognition given to these legal and ethical issues in the Scottish Government's National Dementia Strategy. It would be helpful to add a footnote referencing the Adults with Incapacity (Scotland) Act 2000.

There are certain clearly defined circumstances covered by legal provisions (such as the Mental Health Act and Adults with Incapacity Act) in which necessary medicine may require to be given without the patients consent.

The giving of covert medication should only happen after a careful assessment, documentation, monitoring and review. Good practice guidelines should be referenced e.g. The Mental Welfare Commission for Scotland, 'Covert Medication –
Good Practice Guideline.'

The symptoms of dementia are not well understood or managed. Inappropriate prescribing of psychoactive treatments means the underlying cause is not being met; this may result in the person with dementia continuing to endure pain and discomfort.

There appears to be inequitable access to analgesia for people with dementia. The expression of pain in someone with dementia may be confused with inappropriate behaviour and be treated with anxiety medication rather than analgesia. The frequency and severity of physical and psychological problems in dementia is very similar to other advanced diseases such as cancer. An assessment of pain is still possible even in severe dementia; this is important as different pains must be treated differently.

Q10.

The patients consent status should be recorded (in relation to a specific treatment or medical treatment plan).

Q11.

Sharing information should be between relevant members of multi-disciplinary teams, and may be required between agencies in certain circumstances.

Q13.

Information should be shared on the patient's consent status and any potential difficulties in administration.

Q16. & Q17. Repeat prescribing and reviewing medicine section

People with dementia should be treated equitably to those without the condition in relation to repeat prescribing and medicine review. People with dementia may be on complex medication regimes; regular review is important to ensure they only continue to be prescribed medication that is of benefit and can be tolerated by the individual.

Q14. For Scotland, NHS Healthcare Improvement Scotland. Medicine related adverse incidents should be require Critical Incident Review. This is necessary to ensure individuals competencies of individuals responsible are reviewed and to ensure any systemic failures are addressed e.g. in the systems for audit and supervision.

Q16. 'As required' and repeat prescribing is problematic and frequently leads to adverse incidents for people with dementia, especially those living in care homes. The guidance needs to be strengthened in this regard. Paragraph 48 is important here

Q17. Reinforce points made in paragraph 48.

Q18. Balance between patients' autonomy and safety

The majority of people with dementia live in their own home with the support of family and friends. This section should include guidance on the sharing of information on prescribed medication with informal carers, as they are essential to ensuring compliance with instructions on dosage and frequency.

Q21. Yes

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