Access to Palliative Care Bill [HL]

Debate between Baroness Barran and Baroness Hollins

2nd reading (Hansard): House of Lords
Friday 14th June 2019 Lords Chamber

[Baroness Barran (Con)]

My Lords, I start by expressing my great respect for the noble Baroness, Lady Finlay, and her long-standing contribution to palliative and end-of-life care, not just in the UK but worldwide. As noble Lords have all said, every one of us in your Lordships’ House has had experience of death, whether, tragically, in our role as parents, as children, as friends or as family members, so this debate touches every one of us personally in a particular way. I also recognise the invaluable and tireless work of all the end-of-life care charities, staff and volunteers around the country.

While we know that the vast majority of services are delivering excellent end-of-life care to patients, we also know that more needs to be done to meet our ambition to reduce variation in care at the end of life and to ensure that everyone can access care of the highest quality with the greatest possible choice. Of course, I include children in that, as the noble Baroness, Lady O’Loan, articulated so clearly. I therefore understand the intention of the Bill, which is to improve end-of-life care and tackle the variations in provision, whether those be regional variations or variations touching more vulnerable groups, such as those with learning difficulties, as the noble Baroness, Lady Hollins, explained.

As we have heard, the Bill seeks to introduce a range of measures relating to the provision of palliative and end-of-life care services and to create a duty on all clinical commissioning groups to publish a palliative care strategy including these service elements. I fear that I am going to disappoint my noble friend Lord Bridgeman and the noble Lord, Lord Browne of Ladyton, when I say that the Government believe that decisions regarding the configuration of services and the approach to meeting need in a local population are for clinicians, commissioners and providers—of course, taken in consultation with patients as far as is practicable. I will try to explain later in my speech what measures we are introducing which mean that these inequalities—in the words of the noble Lord, Lord Browne of Ladyton—do not persist.

No other area of clinical care is mandated in this way in primary legislation. We believe that such an approach would set an unhelpful precedent and suggest that each condition, service or treatment pathway should also be enshrined and stipulated in legislation, along with the need for a corresponding local plan. We are concerned that this could unhelpfully and unnecessarily complicate local planning and interfere with best practice decision-making.

Clinical commissioning groups are bound by a duty to commission health services based on the assessed needs of their local populations, and palliative care is covered by this general stipulation. However, I accept that—as many noble Lords including my noble friend Lord Sheikh pointed out—there are significant variations in the provision of palliative care across clinical commissioning groups in England, including in access to 24/7 specialists in hospital and the percentage of people dying in their own homes. The noble Baroness, Lady Jolly, echoed by the noble Baroness, Lady Thornton, raised points about how we oversee the commissioning by CCGs of end-of-life services and the inspection regime. On support, NHS England works with local area teams to support CCGs and sustainability and transformation partnership areas to develop and improve their end-of-life services. On inspection, the CQC inspects end-of-life care providers on the quality of their services, including on the choice indicators in place at death, and where there are three or more emergency admissions to hospital in the final three months of life. The status of the GP palliative care register also helps to assess performance. However, in recognising that the intention behind the Bill is to ensure that everyone can access high-quality end-of-life care, I will set out some of the key progress that has been made over the last few years and what steps will be taken as we continue to drive up the quality of services.

As noble Lords know, choice at the end of life is the centrepiece of the Government’s drive to improve end-of-life care. Where there is real choice, and where it is personalised and matched by healthcare services that respond in an effective and timely way that places patients, families and carers at the centre of decision-making, the NHS gets it right. In Our Commitment to You for End of Life Care, published in July 2016, we set out what everyone should expect from their care at the end of life, and the actions being taken to make high quality and personalisation a reality for all and to reduce the variation in end-of-life care. NHS England is responsible for delivering the commitment, in partnership with system partners and other key stakeholders, through its end-of-life care programme board. This has led to improvements in hospital care, where the CQC had found gaps, and to innovation in community-based care. The noble Lord, Lord Low of Dalston, and the noble Baronesses, Lady Brinton and Lady Hamwee, all mentioned training. That has now been introduced to the curriculum for doctors and nurses. We obviously acknowledge that there is more to do.

Looking to the future, on 9 January 2019 NHS England published its long-term plan for the NHS. This set out key actions to drive improvement in end-of-life care and to support choice over the coming years, including a focus on culture change, which the right reverend Prelate the Bishop of Coventry so wisely observed. As part of this, we are accelerating the rollout of personal health budgets to up to 200,000 people, including those with palliative and end-of-life care needs benefiting from a PHB, by 2023-24. We are rolling out further training to help staff identify and provide personalised care planning for everyone identified as being in their last year of life, improving care, reducing emergency admissions and supporting more people to die in the place that they have chosen.

We are putting in £4.5 billion of new investment to fund expanded community multidisciplinary teams, providing rapid and targeted support to those identified as having the greatest risks and needs, including those at the end of their lives. We are upgrading NHS support to all care home residents and making end-of-life care one of two new quality improvement areas for the revised GP quality and outcomes framework. We are match-funding CCGs which commit to increase their investment in local children’s palliative and end-of-life care services—raised rightly raised by the noble Baroness, Lady Brinton —by up to £7 million a year by 2023-24. However, we recognise that we need to do more, particularly because home and hospice are the preferred places of care and death for many people, yet 47% of all deaths currently occur in hospital. The £4.5 billion that NHS England is investing in primary and community care will go some way to addressing this.

Furthermore, earlier identification of patients approaching the end of life is crucial. It means effective care planning can take place, and people can express their views on the interventions that they may or may not wish to receive. I note the concern of my noble friend Lord Balfe about the Dying to Work campaign and undertake to highlight this to my honourable friend the Minister in the other place. However, all employees with progressive or debilitating diseases are protected against any discriminatory conduct by the Equality Act. The noble Baroness, Lady Meacher, asked me to write to the department about how many hospital admissions could be avoided if palliative care is provided. I am happy to undertake to do that. I would be equally delighted to meet the noble Baroness, Lady Jolly, to discuss her amendment, which touches on such an important and sensitive area.

In conclusion, I again thank the noble Baroness, Lady Finlay, for raising the issue of end-of-life care through this Bill and giving the Government a chance to set out our plans to achieve continued improvements. If she has any continuing concerns, I will of course write to the Minister in my department suggesting that they have a meeting, so she can explore them more. In general, I hope that my response has reassured noble Lords that the Government are taking action and are absolutely committed to improving end-of-life care through the choice commitments and the initiatives in the long term—

[Baroness Hollins]

The Minister asserted that no other condition is mandated and that this would set a precedent. Surely midwifery services are mandated? Birth and death are just either ends of life. I do not quite understand.

[Baroness Barran]

I will have to write to the noble Baroness to confirm. I questioned and triple-checked that point with the department, so I undertake to write and clarify it if there was a misunderstanding. I hope she will accept that. To recap, our view remains that legislation is not required on this issue.