Mental Welfare Commission's Draft good practice guidance in the use of covert medication

Alzheimer Scotland's response submitted on 28 July 2006

Introduction
Alzheimer Scotland is the leading specialist dementia charity in Scotland and works to improve the lives of everyone affected by dementia. Our members include carers, relatives, people with dementia, professionals, groups and organisations. We run services in over sixty sites, and provide the freephone 24 hour Dementia Helpline, publications and an extensive website. We aim to be the national and local voice of and for people with dementia and their carers in Scotland and work to improve public policies for their benefit.

There are currently 64,000 people with dementia in Scotland, almost 2000 of whom are under the age of 65. The number of people with dementia is predicted to rise in line with the ageing population.

Alzheimer Scotland welcomes the opportunity to comment on the draft good practice guidance. Our comments primarily relate to dementia, as this is our area of expertise.

General comments
Overall, we found the guidance to be helpful and believe that it is a vital step to reducing the inappropriate administration of covert medication.
Alzheimer Scotland has created a policy on drug treatment in dementia in which there are some policy proposals relevant to this issue. The Mental Welfare Commission have been sent a copy, and the document can also be viewed online
Drug Treatment Policy

Once the guidance is finalised it will need to be distributed widely to service providers and frontline staff to ensure that it is followed.

Comments on draft good practice guidance

Presentational issues
Although we recognise that this is a draft and not in its final form, it would be helpful for the finished document to have a clear hierarchy of headings and perhaps numbering of sections, for ease of use. In addition, there are a number of typographical errors throughout the document that should be corrected.

Page 2 (where p1 is the cover page)
A reference is needed for the following sentence: “research suggests that over 70% of care homes have used covert medication at some time”.
It would be helpful to have “The 2000 Act” and “The 2003 Act” as subheadings in “The Law and Covert Medication” section, so that it is clear which paragraphs refer to which Acts and which apply to both.

Page 3
The statement that giving medication by deception is potentially an assault is unclear and needs some explanation, such as “it is generally unlawful to administer medication without consent, and where consent is not possible it could still be regarded as an assault unless done appropriately”.

Page 4
The section on the 2003 Act should make it clear that its provisions apply only to treatment for mental disorder and not to treatment for physical conditions.

Page 5
In the decision of whether to give covert medication section (number 2 - capacity) it is timely to reiterate that if someone has the capacity to decide about medical treatment, then administering covert medication could be an assault.

Page 6
The second two sentences of the first paragraph, covering temporary incapacity, are confusing and need to be clarified. Do they imply that someone with temporary incapacity cannot be given medication covertly? If so, how does this relate to someone with dementia who has capacity under normal circumstances but develops e.g. a urinary tract infection, temporarily loses capacity to consent to taking medication and refuses to take medication for the UTI? Should they not be given the medication covertly? What would be the health implications of not doing so?

Alternatively, is what is meant that upon regaining capacity, the person cannot be given covert medication? The argument about temporary or permanent incapacity seems irrelevant – if someone at a specific time does not have capacity and needs to take a medication which is necessary, but refuses it, then they should be given the medication covertly with the proper safeguards in place and with regular reviews. It should be noted here that capacity can fluctuate, as in dementia.
In the first bullet point (“Benefit”), it should be stated after the sentence: “it may carry a degree of risk by changing the way medication is absorbed” that a pharmacist should be consulted.

Advance directives and living wills should be included in the third bullet point along with advance statements.
In the fourth bullet point, it should be noted that the Care Commission and MWC could be consulted in difficult cases.

Page 7
There needs to be clarification on whether “carers giving treatment at home” in the second bullet point refers to informal carers or home care staff. In many areas home care staff are being trained to administer medication as part of their role, therefore these workers and their supervisors need to be more aware of the issues surrounding covert medication. Additionally, if there was no community nurse / CPN involved in the case, would the GP be happy to complete a covert medication pathway and incapacity certificate? This is an issue as not all GPs are happy to complete an incapacity certificate at present, even when asked. If an AWIA section 47 certificate was not completed, then what position would the home care staff be in? There is an additional issue regarding advising and supporting family carers who may be giving covert medication.

The fourth bullet point appears to be avoiding the issue of the time scale of reviews. A suggestion would be that after “individual circumstances” a sentence such as, “but long term covert medication giving should be subject to at least a monthly formal review” should be inserted.

The last bullet point makes an extremely important point, therefore should either be made earlier or should be emphasised here.

Appendix 1
It would be useful to record the diagnosis, where there is one, of the person being considered for covert medication. In the last check-box, there should be some recommendation about when a review should occur.
In the review document (as in the initial pathway document), examples of people who should be consulted should be given e.g. pharmacist or welfare attorney. Check boxes for a section 47 certificate and MHA & TSA should also be given in the legal documentation box. Finally, there should be a recommendation of when a review should take place, such as 1 month.

General comments
At the consultation day there was some discussion about some central gathering of data to attempt to map the extent of the issue. This is not mentioned in this document – is this something that may happen? What will happen to the information recorded by this document? It would be a good opportunity to use the information to analyse the extent of the issue. In addition, will anyone monitor the pathway documents? Alzheimer Scotland is recommending in the policy on drug treatment in dementia referred to above that, “the practice of medication by covert means should be subject to a Part 5 certificate. Proper recording of the process and an introduction of the necessary regulations to ensure this is done are required” and “there should be a requirement under the Code of Practice to Part 5 of the 2000 Act that all certificates should be sent to the Mental Welfare Commission, who have the power to enquire about any issues arising from the care of an individual patient”.

It would be useful to include in the case study section an example where covert medication is given inappropriately by staff managing ‘difficult’ patients as a matter of convenience.

Summary
In summary, Alzheimer Scotland welcomes the development of this guidance and with clarification on a few points believes it will be an extremely useful document for practitioners and provides some protection for people who receive covert medication.
We hope this response is helpful and are happy to provide clarification on any of the points we have made.