(7 years, 5 months ago)
Lords ChamberMy Lords, I am most grateful to my noble friend Lady Finlay for initiating this debate. I declare my interest as chair of Dignity in Dying, the sister organisation of Compassion in Dying, which is a slightly separate charity. Ensuring that people have genuine, meaningful choice at the end of life is central to improving care. Over the past decades, much of our NHS has shifted significantly from a somewhat paternalistic model of care, where the doctor is assumed to know best, to one where the patient’s wishes are paramount. This trend was strikingly evident in mental health care, where I worked for about 25 years. End-of-life care is lagging behind far too often.
Ben Gummer MP, Parliamentary Under-Secretary of State for Care Quality, in his foreword to the government response to the review of end-of-life care pointed out that,
“our care of dying people is … variable, haphazard and at times shockingly poor”.
The Government’s response also says:
“We know that too many people are not involved enough in decisions about their care … care is not sufficiently focused on the person’s individual needs and preferences”.
That seems profoundly true.
Dying people must be aware of their legal right to plan ahead for their own care and, crucially, their right to exercise their choice step by step along the way. Polling shows the enormous job that lies ahead to achieve those objectives. According to a YouGov poll in 2014, 82% of us have strong views about end-of-life care, yet only 4% of us have made an advance decision or appointed a lasting power of attorney. The Macmillan briefing points out that 73% of people with cancer would prefer to die at home, yet only one-third actually do so. Healthcare professionals and providers still too often impose their own views about what is best for their patients. My principles for end-of-life care come very much from the five years I spent chairing a clinical ethics committee. The principles of compassion and patient choice dominated then and, for me, they dominate today. A very important tool for patients and their end-of-life clinicians is, of course, the advance care planning process. One key message from this debate is surely the importance of commissioners funding the promotion and implementation of that process.
What are the benefits of advance care planning? Why does it really matter? Research shows that, when people are able to make informed decisions about their own treatment and care, those patients are far more satisfied. A 2015 YouGov poll revealed that when a patient’s wishes are not documented, 53% are likely to receive treatment they do not actually want—a complete waste of money. Academic research shows the potential of patient choice to produce significant financial savings to the NHS, a reduction in unplanned hospital admissions and the length of time spent in hospital in the last 12 months of life when, of course, most hospital care takes place. A real culture change towards patient choice, which involves planning ahead, is not only better for individuals but absolutely vital if the NHS is to cope with the financial pressures ahead. It is disappointing that only a minority of sustainability and transformation plans have laid out clear plans for addressing improvements at the end of life. Can the Minister assure the House that NHS England will insist that plans which fail to address end-of-life care—and preparation for advance care planning in particular—will be revised?
It is encouraging that the Government asked for advance decision-making to be central to the remit of the National Mental Capacity Forum. A recent study by the charity Compassion in Dying again emphasised the importance and benefits of making advance decisions. The report received widespread public support. Patients need information if they are to make informed decisions. Compassion in Dying recently commissioned qualitative research interviews with dying people. The results are worrying. One respondent—we will call her Sally—had ovarian cancer. She said:
“There are so many people out there who are certainly not getting the information they need from the professionals they’re dealing with, not about benefits, not about prognosis, not about symptoms, not about support, not about end of life care or the choices. Nothing. Nothing, unless you bring the subject up”.
The Government’s response to the choice review pledged that people would be able to have honest discussions about their needs and preferences. Clearly, this is often not happening. Commissioners need to ensure that doctors are trained to have difficult conversations with patients, and that doctors understand that patient choice is not a luxury add-on to good care but central to it.
(8 years, 7 months ago)
Lords ChamberMy Lords, one would expect the doctors concerned to make that presumption in the case of a very young child. But the noble Baroness makes a valid point and I am sure that NHS England will take it on board.
My Lords, does the Minister agree that this tragic case occurred in an environment of incredible pressure on GPs and others within the NHS, with a growing blame culture and huge numbers of patients—they have to see 60 to 70 in a day very often? We all have to accept that things will go wrong if we leave GPs, in particular, working under those sorts of personal pressures and so on. We know that 30% or so will leave the profession in the coming years. Will the Minister meet with me to discuss what he might do to alleviate some of those problems? That could be very helpful.
My Lords, unquestionably there are huge workload pressures on GPs. There is no doubt about that. I do not think they were a primary cause of this particular tragedy, but I will be happy to meet with the noble Baroness to discuss that.
(8 years, 11 months ago)
Lords Chamber
To ask Her Majesty’s Government what assessment they have made of NHS England’s management of clinical commissioning group allocations under the current funding formula.
My Lords, decisions on clinical commissioning group allocations are taken independently of government by NHS England, in order that such an important issue as funding is made objectively and free from perceived political considerations. The Government set some broad principles to which they must conform. NHS England’s decisions are informed by the recommendations of the independent Advisory Committee on Resource Allocation.
My Lords, I thank the Minister for that reply. As he will know, the Secretary of State is responsible for ensuring that NHS England allocates resources fairly across the NHS. Is the Minister aware that, at present, allocations to clinical commissioning groups are hugely variable in relation to the Treasury manual formula? For example, west London receives 31% more than the formula, while Hounslow receives 9% less than the formula, representing a discrepancy of some £110 million from one trust to another in relation to the formula? Despite some recent improvements, does the Minister share the concern expressed by the National Audit Office about the failure to end this unfairness—and, indeed, even the lack of any timescale within which to rectify this matter? Will he give an assurance to the House that within five years there will be a resolution?
The noble Baroness raises a very important issue. I think that she is raising issues not about the actual formula but about the speed at which NHS England reached the target levels of the formula. She points to the discrepancy of west London, which is 31% over the formula. I can tell her that NHS England is committed by 2017-18 to bringing all those under the formula by more than 5% up to that level. It will also be encouraged to address the issue of CCGs that are above the formula.
(9 years, 1 month ago)
Lords ChamberNICE has not been instructed to cease its work on safe staffing standards; on the contrary, it has been asked by NHS England to provide it with appropriate guidance.
My Lords, the noble Countess rightly raised the amount of time that nurses spend filling in forms and ticking boxes. Is the Minister aware that much of this work comes from the rather microregulatory requirements of the regulatory bodies, and indeed NHS London? There are some very precise measurements, and if those were monitored carefully government Ministers and NHS England would know well whether services were being managed properly. Would the Minister consider revisiting the degree of microregulation of our health services?
I am not entirely convinced by the argument about regulation when it comes to managing wards. My own observation is that when you have strong leadership from strong ward sisters, ward managers or charge nurses, many of the problems that we identify seem to disappear and there is very high staff morale, low absenteeism and little use of agency staffing. So much comes down to local leadership, and sometimes regulation is used as a scapegoat.
(9 years, 2 months ago)
Lords ChamberMy Lords, the Minister referred to a renaissance of general practice. Given that about 30% of GPs are expected to retire in the next five years and even the most popular training schemes cannot find anyone to come and train—I should not say “anyone”; however, Winchester has six people but places for 16—what sort of renaissance will it be? We actually need GPs, so perhaps the Minister can explain.
The noble Baroness is quite right. We do need GPs, and they will be at the heart of the renaissance in general practice. The Government are committed to recruiting an extra 5,000 GPs into general practice over the next five years—that figure is net of people retiring. We accept entirely the noble Baroness’s proposition that we must persuade more newly qualified junior doctors to opt for general practice rather than for working in hospitals.