Hospices and Palliative Care Services

Viscount Bridgeman Excerpts

Wednesday 15th December 2010 Lords Chamber

Asked by

[Viscount Bridgeman]

To ask Her Majesty’s Government what plans they have for the future of hospices and palliative care services.

[Viscount Bridgeman]

My Lords, I hope that we shall have an hour of singing from the same hymn sheet. I am very grateful for the opportunity to introduce this debate on this most important of subjects. It comes at an important time for the hospice movement in the United Kingdom, for the interim report of the independent funding review has just been released. On 11 November, the noble Baroness, Lady Finlay of Llandaff, led with great distinction a debate on palliative care for cancer sufferers, and this debate, I suggest, is entirely complementary to that one.

I declare an interest as the former chairman of St John’s Hospice in central London. This is one of a number of hospices which cater for the three main killer diseases: cancer, HIV/AIDS and motor neurone.

No debate on palliative care or end-of-life treatment is complete without the mention of Dame Cicely Saunders, who is widely accepted as having founded the hospice movement in the United Kingdom. It is a worthy tribute to her memory that a recent report by the Economist Intelligence Unit puts the United Kingdom first, ahead of 39 other countries, in the provision of end-of-life care, and this was attributed in part to the “well-established hospice movement”.

In the short time available to me, I wish to speak briefly on funding. In the past, there has been a certain complacency on the part of every Government towards the funding of hospices. The unadorned truth is that any Government are well aware that any shortfall will in the end be made up by way of appeals and fund-raising and that, to put it bluntly, it will be all right on the night. On the whole, Governments of all hues have got away with it, although I pay tribute to the previous Administration, who made available £40 million to improve the environment of palliative care. In the case of the hospice with which I was associated, its share was gratefully put to good use in improving out-patient facilities, and the confirmation of this grant by the present Government is to be welcomed.

Up to now, there has been no national tariff for hospices contracted to the NHS. The disadvantages of this are obvious, as it makes it difficult to produce long-term strategic budgets, and inevitably it means that the funding as between different hospices is going to differ significantly. Additional funds invested through the end-of-life care strategy have not been invested in a consistent way. In many cases, hospices are forced to carry an overhead for negotiating staff with the many PCTs to which they are contracted, and they are ill-equipped to afford this. Some of the less well-resourced establishments inevitably lose out. I would mention that a joint report by Healthcare at Home and Dr Foster estimates that delivering end-of-life services in the home could save the NHS £160 million a year.

I am very pleased that the NHS tariff group is reporting on behalf of palliative care. Now we have a real opportunity in the review of commissioning to move towards 100 per cent funding across the board. However, does that mean that fund-raising from the third and voluntary sectors will no longer be required? Most certainly it does not. It will simply mean that that part of a hospice’s expenditure which is clearly clinical will be looked after within the commissioning structure, leaving those involved in fund-raising to concentrate on amenities such as day centres, bereavement counselling and the training of volunteers and carers, which are not part of the NHS’s responsibility.

Before leaving the subject of funding, I wish to mention the particular case of children’s hospices, where currently the contribution to operating costs tends to be at the lower end of the scale, although I am aware that these hospices are likely to receive a greater element of mainstream primary care than their adult counterparts and they also receive Section 64 additional funding. The number of children with life-terminating illnesses is, mercifully, relatively small. Nevertheless, there is a danger that for that very reason the special needs of children's hospices may be overlooked. I hope that that will be recognised in the current review.

As the population ages, so will the burden of care increase. There will be more long-term conditions and, with those conditions, there will inevitably be symptom-control elements, and it is those that palliative care must address. It is fair to say that all the national strategies for older people and those with dementia recognise the role for palliations, and I hope that the department will ensure that that is reflected in the commissioning structures which, I hope, will be the product of the fundamental review.

I turn to community support. Speaking in the debate initiated by the noble Baroness, Lady Finlay, on 11 November, I referred to the totem of the hospice movement being hospital avoidance—and for hospital, you might read, hospital and hospice avoidance. The apparent paradox of all debates on hospices is that we are talking about ways to avoid using the institution itself and moving the emphasis of patient treatment away from acute into community and primary care settings, which, apart from freeing up beds for unavoidable acute cases, has the incalculable benefit of letting patients choose their place of care, and possibly where they will die. In that debate, several noble Lords referred to that. It is important that the primary care trusts—or, as they will now be, GP funding consortia—should record as early as practicable patients’ preferred place of death. My noble friend was very helpful on that point at col. 322 of the Official Report of that debate. However, I should welcome his confirmation that that will become a statutory obligation.

I mention as an example of admirable community support the single point of access project in Westminster. The project delivers a single telephone number for patients to use to access all palliative care services in the borough. It has been made possible only by numerous teams giving up their systems and working together with the out-of-hours GP co-operative to run the system. With the impending amalgamation of services between Westminster, Kensington and Chelsea, and Hammersmith and Fulham, it is to be hoped that that service will be available in all those three boroughs with the minimum of bureaucracy and optimal cost savings, and that that will form a useful pattern for other authorities.

An important component of that scheme is out-of-hours work. That is of concern to all branches of primary care, but it is particularly vital with palliative care, for one simple reason: pain does not keep office hours. I know that the matter of 24-hour cover is already being addressed across the country. Currently, it is piecemeal, with services varying from telephone advice only to personal visits. The palliative care funding review, in its interim report, recommends that the Government use the forthcoming NHS operating and outcome frameworks to ensure that a structured 24-hour service is put in place.

Finally, I say a word about education. This is of course a subject in itself and time does not permit more than a passing reference to it. Palliative care is now included in GP training, but that specialised training needs to extend right across the palliative care community, from qualified doctors to undergraduates and carers—both hospice-trained and from outside. Training is too big a subject to be left to the charitable sector. I hope that the Minister will confirm that it is to be given high formal priority in the commissioning structure.

We in the United Kingdom can take pride in the leadership that we have given to the hospice movement worldwide, achieved through the dedication and commitment of staff, consultants and volunteers. They deserve our gratitude. I end by thanking those noble Lords who have chosen to take part in the debate. I look forward to their contributions and to the reply from my noble friend.

Healthcare

Viscount Bridgeman Excerpts

Thursday 28th October 2010 Lords Chamber

[Viscount Bridgeman]

My Lords, I, too, thank my noble friend Lord Hunt for initiating this debate and I declare an interest as a former chairman of an independent hospital.

In the brief time available to me, I want to speak about overseas health professionals, particularly nurses practising in the United Kingdom. I hope that this matter will be covered in greater detail in a debate for which I have my name down and which is working its way up the list. As your Lordships will be aware, nurses coming from within the European Union have the right under the recognition of professional qualifications directive to practise in the United Kingdom subject only to producing evidence of technical competence obtained from their country of origin. The relevant directive specifically prohibits blanket language testing by the Nursing and Midwifery Council as a condition of registration.

The current immigration problems faced by this and previous Governments mean that, inevitably, recruitment of skilled personnel from outwith the European Union is severely restricted. Many hospitals feel the loss of top-quality Australian, New Zealand, South African and Canadian nurses. The supply of home-trained nurses barely meets demand, so inevitably many hospitals and healthcare institutes have to rely on the only other source of nurses—the European Union.

In some member states, particularly those in eastern Europe, there is a shortage of advanced clinical technology and it follows, therefore, a shortage of opportunities for their nurses to be trained in the use of advanced equipment. As for language testing, your Lordships will appreciate that there is a considerable difference between a working level of conversational English and the very much more technical language of, for example, the surgical theatre. There have, unfortunately, been cases of theatre nurses from the EU slipping through the language competency net. I know of one incident of a wrong instrument being handed to a surgeon in the course of an operation as a direct result of a language misunderstanding. I am in no doubt that this is not an isolated incident. I do not know whether the sad case related by the noble Baroness, Lady Masham, owed anything to a language misunderstanding but, on the safety issue, there is a disaster waiting to happen.

The directive is in the course of being revisited. The relevant department in Brussels has been engaged in a consultation exercise with the healthcare professions in the Union, which will, one hopes, determine how the language issue may be addressed. I am reassured that the UK’s Nursing and Midwifery Council was appointed to collate other members’ views. I have had a helpful meeting with the Minister on this matter and am grateful for his answers to my Written Questions, from which I note that the issue of language competence is currently being discussed with the European Commission, the GMC and other organisations. I suggest that for the commissioning body, which is in the early stages of gestation, there is a good alternative in the Nursing and Midwifery Council, which is up and running and perfectly placed to undertake this language supervision.

A resolution to this problem cannot come too soon. Patient safety must not be allowed to be prejudiced by the directive as it stands. I wish the Minister well in his efforts to address this urgent problem.

Queen's Speech

Viscount Bridgeman Excerpts

Thursday 3rd June 2010 Lords Chamber

[Viscount Bridgeman]

My Lords, I join every speaker in this debate in congratulating my noble friend Lord Howe on his appointment. It will be a great reassurance to this House to have the benefit of his experience, which he has built up with such distinction over the past 12 years when we sat on the opposite Bench. The noble Baroness, Lady Murphy, has referred to him seeing off successive Ministers of Health. I suggest that his approach has always been one of constructive engagement.

I shall speak briefly about the hospice movement, in which the United Kingdom has led the world and in which we can take great pride. I particularly honour the memory of Dame Cicely Saunders, the founder of the movement. I declare an interest as chairman until two years ago of the Hospital of St John and St Elizabeth in St John’s Wood, London. Unusually, within it is St John’s Hospice, which is part of the same charity on the same site. With those two institutions I maintain close links.

Hospices have suffered under successive Governments from what I might call an “it will be okay on the night” approach. In the case of hospices, that means that any shortfall in funding by government will be made good by the public conscience through charitable giving. Successive Governments have not been slow to realise that this virtually always works. Having said that, it would be churlish not to mention the contribution of the last Government in making available a substantial additional sum for hospices, of which St John’s share was £600,000, applied towards the refurbishment of its in-patient unit. But the reality is that the maximum normal contribution by central government to running costs is 50 per cent of the total, so in every case the shortfall of a minimum of 50 per cent of total running costs has to be made good by fundraising, which is a drain on hospices’ time with limited staffing resources, which could more productively be put to other uses. In the case of hospices, there is no national tariff and some hospices receive significantly less than 50 per cent. St John’s is fortunate in receiving government funding at the upper end, and its case is not untypical, in that it must have separate negotiations with each of seven primary care trusts to which it has contracted. This, too, is a considerable drain on limited personnel resources. The remarks of the noble Lord, Lord Patel, who is not in his place, on the contraction of primary care trusts, will read very well with many hospices.

All this is in marked contrast to those hospitals that are acute care providers where there are national tariffs for a variety of procedures. St John’s is leading the way in London on a north-central network comprising hospices and PCTs whose aim is to agree a local tariff. I hope that that will encourage the Government to roll this out on a national basis. A further encouragement to the Department of Health will, I hope, be the example of Wales, where a funding formula has been agreed across the Principality. I make a further plea to the Government to introduce rolling three-year contracts, which will enable hospices to plan strategically and deliver sustainable high-quality end-of-life care for all.

I turn to the last Government’s plans, which I welcomed, for a national end-of-life strategy that lays much emphasis on the need for patients to identify with their doctor or nurse the preferred place where they want to die. That depends on adequate resources being available. St John’s is fortunate in that three out of the seven PCTs to which it is contracted—namely, Westminster, Kensington and Chelsea, and South Brent—make available such resources. Unfortunately, patients in many other PCTs do not have the same opportunities for excellence in care, and for some of those people the stark and only choice is between a nursing home and dying on a general nursing ward.

The importance of being given the choice to die at home, with friends and family around, cannot be overstated and the difference between those PCTs that are able to support home carers and those who are not is, indeed, marked. Patients need real choices in care, in their place of care and in the way that they receive care. The vast majority of patients wish to live independently until they die, and this can be achieved by good, patient-sensitive, hospice-at-home services, supported in many instances by excellent organisations such as, dare I say it, St John’s and the Marie Curie nursing service. I emphasise the need for a level playing field and ask the Minister to eliminate what is, effectively, a postcode lottery as it applies to hospice at home.

I have received much help and advice from the noble Baroness, Lady Finlay of Llandaff, who cannot be here today as she has a medical engagement. She has asked me to raise with the Minister the matter of education in palliative care. Her concern, which I fully share, is that palliative care should be taught in all nursing schools at undergraduate level, as it now is in all medical schools in the United Kingdom. There are increasing pressures on the curricula in both medical and nursing schools, but if we do not teach the next generation how to care for those who are ill and nearing death, the standard of care will slip back as new graduates flounder. They risk picking up bad practice from those older practitioners who have never been taught proper pain control and other fundamentals of care. Do the Government plan to ensure that a comprehensive palliative care module should become a statutory part of all the proposed new nursing degree courses, since such education is the foundation of good care for patients?

I take this opportunity to welcome my noble friend Lord Hill, not only to his appointment to the Department for Education but for his masterly and, if I may say so, superbly delivered speech. May I also take this early opportunity to bend his ear? Hospices get no help from the universities for the considerable expense which they incur in training young doctors, in marked contrast to the general practitioners who get paid for having them. Therefore, this is indeed addressed to both my noble friends on the Front Bench: may this anomaly not continue to fall between two departmental stools?