Resolution: Access to controlled drugs in care homes

This resolution was passed by voting members at Congress 2024.

Care homes without nursing cannot store controlled drugs unless they are prescribed for individual residents as per the Misuse of Drugs Act 1971. This means there are challenges with access to controlled drugs in residential homes which can impact negatively on the ability of staff to provide the best care possible at the end of life.  It is important to acknowledge the challenge is due to the legal position of storage of controlled drugs in these homes.

Care homes with nursing are permitted to hold stocks of controlled drugs in schedules 3, 4 and 5 without a Home Office license (CQC, 2023).

Stock of controlled drugs in schedule 2 can be held in care homes with nursing where the home is wholly or mainly maintained (50% or more) by a public authority, out of public funds, by charity, or voluntary subscriptions (Home Office, 2014). Otherwise care homes with nursing  must apply for a UK Home Office Controlled Drugs license (Jones, 2023). However, this is a prolonged process with associated costs and in itself is prohibitive. Awareness and uptake levels of the license are unknown but likely to be low.

This is a system problem as opposed to any criticism of staff providing clinical care. The consequence of the current situation is a delay in alleviation of symptoms posing a risk of unnecessary suffering by the resident and distress to families and staff. 

There are approximately 441,000 people in about 16,700 care homes in the UK (Berg, 2024).  Approximately 70% are residential (without nursing) and 30% are care homes with nursing (Berg, 2024). While UK-wide statistics on deaths in care homes are problematic because of definitional differences between the nations, it is estimated that between 17% and 21% of all deaths registered in the UK in 2022 were registered in care homes (ONS 2023). Accessing prescribed medication for end of life is complex and lengthy, especially out of hours, causing unnecessary suffering and risk of inappropriate admissions.

There is a growing body of evidence regarding this issue (Finucane et al 2014, Bowers et al 2020,2022 & 2023). A change in the law would have a significant impact on thousands of people dying in care homes (with and without nursing), who are a vulnerable group. It would also support bereavement care and staff wellbeing. It would comply with all the policies and guidelines in the four countries to support comfort and preserve dignity.

We have a duty of care as nurses to those in care homes to facilitate equitable access to high quality care – the current legal system restricts our ability to provide that for some at the most vulnerable time of their lives and we only have one chance to get it right – please support this resolution.

The reading list for this debate is available here.

Further reading and references

Aitken C, Boyd, M, Nielsen L and Collier A (2020) Medication use in aged care residents in the last year of life: A scoping review, Palliative Medicine, 34 (7) pp. 832-850. https://doi.org/10.1177/0269216320911596. 

Berg V, Care home stats: number of settings, population and workforce. Available at: https://www.carehome.co.uk/advice/care-home-stats-number-of-settings-population-workforce 

Bowers B et al. (2020) GPs' decisions about prescribing end-of-life anticipatory medications: a qualitative study, British Journal of General Practice, 70 699 pp. 731-739.

Bowers B (2022) Simultaneously reassuring and unsettling: a longitudinal qualitative study of community anticipatory medication prescribing for older patients, Age Ageing, 5, 51 (12) doi: https://10.1093/ageing/afac293

Bowers B, Howard P, Pollock K (2023) Is end-of-life anticipatory prescribing always enough?, BMJ, 381 p1106 doi: https://doi.org/10.1136/bmj.p1106

Carter AJE et al. (2022) Providing palliative care at home aligns with the professional identity of paramedics: a qualitative study of paramedics and palliative health care providers, Canadian Journal of Emergency Medicine, 24, pp751-759.

CQC (2023) Controlled drugs in care homes. Available at: https://www.cqc.org.uk/guidance-providers/adult-social-care/controlled-drugs-care-homes
Francis S A, Yardley S, Franklin B D, Ogden M, Kajamaa A and Mattick K (2023) Modelling of intended and ideal medication processes for palliative care symptom control: an international scoping review. Available at: https://discovery.ucl.ac.uk/id/eprint/10190054/ 

Gordon A L, Franklin M, Bradshaw L, Logan P, Elliott R and Gladman J R F (2014) Health status of UK care home residents: A cohort study, Age and Ageing, 43, pp. 97–103. https://doi.org/10.1093/ageing/aft077

Home Office (2014) Domestic Controlled Drug Licensing in Healthcare Settings. Available at: https://assets.publishing.service.gov.uk/media/5a8196de40f0b62305b8fc47/Domestic_Controlled_Drug_Licensing_in_Healthcare_settings__FINAL__2014-11-18.pdf

Jones E (2023) Controlled drug stock licensing is working against high-quality palliative care for care home patients. Available at: https://pharmaceutical-journal.com/article/opinion/controlled-drug-stock-licensing-is-working-against-high-quality-palliative-care-for-care-home-patients

Finnucane A et al. (2014) Anticipatory prescribing at the end of life in Lothian care homes, British Journal of Community Nursing, 19 (11). doi: 10.12968/bjcn.2014.19.11.544.
Mannix K (2017) With the End in Mind, London: Harper Collins.

Majumder M, Bowers B et al (2022) End of life care in UK care homes – controlled drugs: systematic review and narrative synthesis BMJ Supportive and Palliative Care 12 pp. 253-261.
Marie Curie (2022) The Daffodil Standards for GP Practices. Available at: https://www.mariecurie.org.uk/professionals/working-in-partnership/daffodil-standards/general-practitioners

Marie Curie (2022) The Daffodil Standards for Pharmacies. Available at: https://www.mariecurie.org.uk/professionals/working-in-partnership/daffodil-standards/pharmacies

Mason B et al. (2020) Unscheduled and out-of-hours care for people in their last year of life: a retrospective cohort analysis of national datasets, BMJ Open, 10 (11). doi:10.1136/bmjopen-2020-041888

Morgan L, Barclay S, Pollock K, Massou E and Bowers B (2023) The financial costs of anticipatory prescribing: A retrospective observational study of prescribed, administered and wasted medications, using community clinical records Palliative Medicine, 37(10), pp. 1554-1561. doi:10.1177/02692163231198372

ONS (2023), Deaths in care homes, UK 2015-2021. Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/socialcare/articles/deathsincarehomesuk2015to2021final2022provisional/2023-03-15

Public Health Scotland (2023) Care Home Census for Adults in Scotland. Available at: https://publichealthscotland.scot/publications/care-home-census-for-adults-in-scotland/care-home-census-for-adults-in-scotland-statistics-for-2013-to-2023/

Royal Pharmaceutical Society (no date) Care Home Policies. Available at: https://www.rpharms.com/recognition/all-our-campaigns/policy-a-z/care-homes-policies 
Savic J and Atherton IM (2022) Have increased deaths at home during the pandemic returned to pre-pandemic levels? An analysis of publicly available Scottish death registration, Journal of Public Health, 45 (4), pp. 664-667

Scottish Government (2022) My Health, My Care, My Home - Healthcare Framework for Adults Living in Care Homes. Available at: https://www.gov.scot/publications/health-care-home-healthcare-framework-adults-living-care-homes/ 

Tapsfield J (2019) Many people in Scotland now benefit from anticipatory care before they die: an after death analysis and interviews with general practitioners, BMJ Supportive & Palliative Care, 9 (4). doi:10.1136/bmjspcare-2015-001014

Tegi D and Woodthorpe K (2024) Anticipatory Prescribing of Injectable Controlled Drugs (ICDs) in Care Homes: a qualitative observational study of Staff Role, Uncertain Dying and Hospital Transfer at the End-of-Life, BMJ Geriatrics, 24. doi: https://doi.org/10.1186/s12877-024-04801-z

Wilson E et al. (2015) Administering anticipatory medications in end-of-life care: a qualitative study of nursing practice in the community and in nursing homes, Palliative Medicine, 29 (1), pp.60-70. doi: 10.1177/0269216314543042.

Williamson LE, Leniz J, Chukwusa E, et al. (2023) A population-based retrospective cohort study of end-of-life emergency department visits by people with dementia: Multilevel modelling of individual- and service-level factors using linked data, Age and Ageing, 52(3), 1-11. doi: https://doi.org/ 10.1093/ageing/afac332

Xie Z et al. (2023) Screening instruments for early identification of unmet palliative care needs: a systematic review and meta-analysis, BMJ Supportive & Palliative Care doi: 10.1136/spcare-2023-00446

Yardley S, Francis SA, Franklin BD, Ogden M, Kajamaa A and Mattick K (2022) Getting palliative medications right across the contexts of homes, hospitals and hospices: protocol to synthesise scoping review and ethnographic methods in an activity theory analysis, BMJ Open, 12(3). doi: 10.1136/bmjopen-2022-061754

Yardley S (2023) Exposing and Understanding the Hidden Work of Getting Prescription Medications Right at Home, in Hospital and Hospice: An Activity Theory Analysis to Improve Patient Safety and Carer Confidence. Poster presented at the 19th World Congress of the European Association of Palliative Care, 15-17 June, Rotterdam.