Access to Palliative Care Bill [HL]

Lord Elton Excerpts

Friday 23rd October 2015 Lords Chamber

[Lord Elton (Con)]

My Lords, I begin, as we all do, with thanking the noble Baroness and congratulating her on getting this slot. I also thank her for the enormous dedication, expertise and persistence with which she has pursued this task—this calling—of easing the way out of this world for so many hundreds of people. I should say that I come to this debate as a learner, not as a teacher. I am far from certain that I have grasped all the issues—I have certainly not grasped the final solution—but I would like to make a couple of observations and one suggestion.

My noble friend Lord Crisp was advocating greater openness in discussion about death. I reflect that, to initiate that, you need a largish community with a high average age containing a number of medical professionals and a scattering of clergy. Indeed, here we are, doing what he asked.

My interest and motivation, apart from that which all of our age share, comes from having contrasted the experience of a close friend of mine, whose death at home I observed, wonderfully supported by the local palliative care team, and a report from another friend of an appalling end of life where the person was for several days in such pain that, whenever the person was conscious, the bed was vibrating. That is an inequality which is absolutely insufferable in a civilised society.

Two images float into my mind that suggest how compassion enters into this. The first is the telephone answered after midnight for the noble Baroness, Lady Byford, when her husband was dying. The other was the bowl of porridge mentioned by the noble Lord, Lord Howard of Lympne, brought to a man coming from a hospital into a hospice and, I fear, on the way out.

The number and diversity of people involved in evolving a proper, coherent service seems to me one of the biggest difficulties, and there is the question of establishing communications between them, one with another. We are talking about professionals, who have the royal colleges, and clinicians, who have endless conferences around the world, all of them highly productive, but we are also talking about non-professionals, non-clinicians —care workers, paramedics, sometimes policemen or prison officers, all of whom have been mentioned. There is no forum for them.

It would be wrong to try to attempt that in legislation, but an early focus of attention after the Bill either goes on to the statute book or does not ought to be how to remedy that. How good are communications between different clinical commissioning groups? Should there not be a central, national forum for them—perhaps there is, I do not know, I am a novice—in which each group or cluster of groups could exchange notes on their practice? From the evidence that we have been sent and the stories we have been hearing, practice differs violently between one area and another.

There should be an established, respected and, I think, independent but supervised forum that could begin to generate a corpus of accepted best practice that could be shared around the country—indeed, across the nations; we have three nations represented here, and how much other groups seem to be able to learn from the Welsh groups. This is the beginning of that process. How it gets carried down to the next level of the variety of people involved is for another debate, and certainly for someone more learned in these things than I am, but I hope that we can get the fertilising cross-flow of experience between groups to begin.

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[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, first, I join with everybody else in thanking the noble Baroness, Lady Finlay, for raising this issue and bringing the Bill before us. She has a long history of passion, commitment and experience in this area, and we all recognise that. There seems to be violent agreement from all sides of the House on the substance of her Bill, and so I congratulate her on the support that she has garnered, which of course goes way beyond noble Lords in this House.

Before I address the Bill directly, I want to draw out three themes that have emerged out of the debate today. The first is that, despite the report from the ombudsman and some very upsetting individual stories, the UK does pretty well in this area. My noble friend Lord Howard referred to the report in the Economist. For the second time—the first being five years ago—out of all 80 countries surveyed, the UK came top, and that includes all the richer nations. We come significantly higher than most other European countries. In part, that is because the hospice movement in the UK has been extraordinarily successful. My noble friend Lord Howard referred to the CQC report. It is quite extraordinary that 90% of all hospices inspected have been “good” or “outstanding”.

However, in praising the hospice movement and the care that it delivers at home, let us reflect for a minute on how difficult it is to provide good-quality palliative care in a very busy acute hospital. It is true that they probably do not do it as well as it is provided in hospices, but, given the circumstances, they often do a remarkable job. My noble friend referred to the bowl of porridge that was provided in a hospice. I refer him to the Wrightington Hospital, where a lady coming near to the end of her life said that her one last wish was to see her horse. They brought the horse to the hospital and wheeled her down to see it. We do see these extraordinary acts of kindness and compassion in NHS hospitals as well. That is the first point that I would like to make: the UK does this pretty well.

Secondly, the most important point to come out of today’s debate is the patchiness of how we do it. Variation, I am afraid, is a problem that runs right through the NHS. The noble Lord, Lord Davies, went right back to 1946. Whether it is in end-of-life care, orthopaedics, stroke care or cancer care, there has been this level of variation since the inception of the NHS in 1946. The way that this Government have decided to try to confront this level of variation is through transparency.

It is a fact that, outside healthcare, the only way to drive out variation is through a market—we all know that. If you have choice and competition, they will drive out variation. It is much more difficult in an area such as healthcare, where there is such imperfect information and such imperfect choice. Our approach is to try to confront this issue of variation through transparency. It is not just through CQC reports but through having a much more open culture within the NHS. I say to the noble Lord, Lord Warner, that choice is also a key factor in that, where it is possible.

The third key theme to emerge from this debate is the importance of out-of-hospital care. Where we can deliver good-quality, safe care outside hospital, it tends also to be at lower cost. If it is at lower cost, we have more resources to spend elsewhere in the system. I say in response to my noble friend Lord Howard that I know that Hospice UK is in discussions with NHS England about whether it can help us deliver more care outside hospital. Other noble Lords referred to the huge importance of district and community nurses. Delivering out-of-hospital care to people who are at the end of their lives requires considerable expertise; you need district and community nurses on hand to administer pain relief and the like. In the case of my own mother, who died very recently in an NHS hospital, it was essential to have people there all the time who could adjust the level of pain relief, oxygen and the like.

Those were the three general points that I wished to make. I am afraid, however, that the Government cannot support the Bill and I will set out the reasons why. The most important reason is not that we disagree at all with the underlying intention of the Bill—we are in full agreement with it—but that we do not feel that primary legislation is the right way of tackling the issues raised because it could lead to unintended consequences. Most importantly, we feel that it attempts to deal with issues that, in the main, are best tackled by clinicians, ideally together with patients, carers and loved ones, based on a combination of the patient’s individual condition, preferences and the clinician’s professional expertise.

There is no other part of the healthcare system, be it cancer, stroke, maternity—the beginning of life as well as the end of life—where we have the mandated system that is proposed in the Bill. I will withdraw the following analogy if it is not fair. When the Liverpool care pathway was introduced—I was a huge supporter of it—there many parts of the country and many hospitals where it was implemented sensitively and where it contributed greatly at the end of many people’s lives. Yet, because in some parts of the system it became a tick-box solution where people were ticking the box and missing the point, I sometimes feel that a top-down, central directive, be it through legislation or from another source, can interfere with best-practice decision-making. That is the primary reason why we oppose the Bill.

However, there is a second reason—it is probably less strong, but it is strong nevertheless. It is that we feel that the Bill goes against the whole concept and principle of local autonomy that was established in primary legislation through the Health and Social Care Act 2012. I accept that clinical commissioning groups are still in their infancy—they have only been there for just over two years—but they are bound by a duty to commission health services based on the assessed needs of their local population, and palliative care is included in that stipulation. There is also concern that legislation on this issue as set out in the proposed Bill could stifle local innovation by NHS bodies, including commissioners, as they seek to improve the quality of care and provision.

As well as the responsibilities given to the local commissioning bodies, the 2012 Act also enshrines specific responsibilities for health education and training on Health Education England. This Bill would supersede those provisions, thus undermining the role and responsibilities of Health Education England, which works in partnership with local training and education boards to commission and deliver appropriate training and education.

I could go on and talk about what the Government are doing in this area, but that is the fundamental point and I should probably leave it there. We have huge sympathy for the underlying intent of the Bill.

[Lord Elton]

My noble friend has put local autonomy at the centre of his argument. If local autonomy results in unacceptable variations between localities, will the Government be on the look-out for this? It has only been running recently, as my noble friend says, but will he keep it at the forefront of his watch? If it increases or does not diminish, then something will have to be done about local inequalities.

[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.