Access to Palliative Care Bill [HL]

Lord Davies of Stamford Excerpts

Friday 23rd October 2015 Lords Chamber

[Lord Davies of Stamford (Lab)]

My Lords, the Bill is an excellent initiative, and I congratulate the noble Baroness, Lady Finlay, on bringing it forward. I cannot imagine that anyone would object to the substantive provisions of the Bill. Some people might think that it is too prescriptive, that it overrides local initiative and clinical commissioning groups and forces everyone into the same Procrustean bed, but there will always be a trade-off between having some local autonomy in the health service and having a national health service and avoiding a postcode lottery. If we have to err—and one does always have to err in human affairs—we should err more on the side of having a national service, because that is both what the public expect and what the consensus in this country has believed that we have, ever since the 1946 Act and the 1944 White Paper.

One of the great problems of the NHS is the complete lack of external accountability. It is a platonic system in which the experts—or supposed experts; mostly they are no doubt genuine experts—provide for the public as a whole, the hoi polloi, what they think the public need. There is no accountability and no way in which to second-guess that. In the private sector you can of course shop around and go elsewhere, but in the public sector—in the NHS—that does not work. The experiment with GP commissioning, allowing GPs supposedly to commission secondary healthcare all over the country, never worked. We do not even have the indirect democratic accountability that we now have with the police service, with elected police commissioners setting out what should be the strategy and priorities in their own area. In those circumstances, Parliament has a very important role, and an initiative like today’s Bill is a very good idea, because we are at least accountable to the public in Parliament and it is important to make sure that we set down the sort of standards and norms that the public are entitled to believe will be applied in the health service.

There is one thing that I believe should be in the Bill—and if the Bill goes forward to its next stage, as I profoundly hope that it does, I might venture an amendment of my own along these lines—which is that in this matter of palliative care, above all, the patient must be sovereign. There must be an absolute obligation or condition, so long as the patient is conscious, to explain fully the facts of the patient’s diagnosis and prognosis and the implications of any change in treatment or proposed change in treatment, and implications of any change in venue. For example, being downgraded from an intensive care bed to a general ward or acute bed will reduce considerably the chances of a successful resuscitation, if it is to be attempted. If a patient leaves a general hospital—I totally agree with the argument put forward in favour of often doing this and in favour of a hospice in the last moments of a patient’s life—the patient will be in a facility that probably does not have certain means of life support such as dialysis or ventilation. Indeed, I once asked staff in a hospice whether it had drips for providing intravenous hydration and nutrition to their patients. They looked at me rather strangely and said that they had them but they rarely used them. The implications were fairly obvious.

If I am ever in a hospice, I shall be absolutely terrified every time I receive an injection. I shall wonder whether it is the last one and it is the moment when I am going into palliative sedation, as it is euphemistically called—I tend to call it a palliative coma—from which I shall never awake. I want to be in charge and I want to know what is going on, and so long as I have breath in my body and a mind that is working I want to be able to conduct a dialogue with my clinicians. Above all, I want to be able to choose. If a patient wishes to choose to have the full apparatus of medical science apply to maximising his or her longevity, the patient should be entitled to that. If he or she wants to choose palliative sedation along the lines of the Liverpool or some other pathway, he or she should be entitled to that. If he or she wants to choose the exact moment, timing and method of his or her death, with all the legal safeguards set out in the late and much lamented Bill of my noble and learned friend Lord Falconer, in my view he or she should have that—and that is a matter that remains open, to which Parliament must return. I hope that it will, in the next Parliament.

--- Later in debate ---

[Lord Prior of Brampton]

My noble friend makes a good point. There is tension in the health service between local autonomy, local accountability and the National Health Service. There has always been this tension. We believe that in driving up standards it is best to have the local autonomy. However we must also have transparency so that we know who is falling behind and who is forging ahead. As to transparency at a clinical level, I was talking to a former president of the Royal College of General Practitioners recently—she comes from a different political background from myself—and she said that within the DNA of all doctors is a huge sense of competition: they want to deliver better care than the next-door doctor. That is true of surgeons probably more than anyone, but also true of GPs, physicians and hospitals, and increasingly it will be true of CCGs as well. My response to my noble friend is that we are embedding a much higher degree of transparency into the system and it is through that transparency that we will drive improvement by highlighting the best and the worst.

[Lord Davies of Stamford]

On the matter of transparency, does the Minister agree with my point that it is important that the commission should be transparent vis-à-vis the patient and that there should be a policy of full disclosure to the patient of the diagnosis, prognosis and any implications involved or deriving from changes in treatment or changes of venue from, for example, hospital to hospice or otherwise?

[Lord Prior of Brampton]

I accept and agree with that. One should not underestimate that even sophisticated, well-informed people put huge trust in their clinicians. How many of us, confronted with a difficult diagnosis, say, “What would you do?”. That is the question that most people put to their doctors. Of course individual choice is extremely important, but the role of the clinicians and the trust that we as patients put into them should not be underestimated.

In conclusion, let me reiterate how much we support the underlying intent of the Bill but that we do not believe that legislation is the right way to address the problems that the noble Baroness has outlined.