End of Life Care

Baroness Walmsley Excerpts

Tuesday 14th March 2017 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, as the King’s Fund report Understanding NHS Financial Pressures commented yesterday, terminally ill patients have very little political voice. Therefore, I am delighted that the noble Baroness, Lady Finlay, has spoken up for them this evening. Indeed, I am very grateful that I live in Wales and will probably die there.

Over the last five years, we have seen several reviews of palliative and end-of-life care with multiple recommendations. Therefore, I hope that, at the end of this debate, the Minister will be able to provide us with an update on progress towards meeting those recommendations. For example, the Government’s response to the review of choice made two commitments that are particularly relevant to the topic we are debating today—namely, to,

“engage with clinical commissioning groups and Health and Wellbeing boards on improving end of life care provision through local strategic planning and commissioning”;

and,

“to provide commissioners with data, tools and palliative care currencies to help identify palliative care needs in local areas and the best ways to commission services to meet those needs”.

I hate jargon, so I looked up what “palliative care currencies” means. I found that it refers to payment models for palliative care. As the Minister will know, the majority of community palliative care providers in England, which are largely in the voluntary sector, are currently commissioned by block contract, and a lot of hospices in particular have been working within the same cash envelope for many years. Indeed, yesterday’s report from the King’s Fund commented that one of the factors that make some services particularly vulnerable is that block contracts have not been adjusted to match rising demand, and that demand is continuing to rise.

In 2010, Marie Curie’s review of funding recommended that the NHS move to a per-patient funding model, defined by phase of illness, so that providers would be paid more for patients with more complex care needs. One of the major difficulties encountered was the fact that most voluntary sector providers have a mixture of NHS and charitable funding, so it was difficult to identify which aspects of care were NHS-funded and which were charitably funded. Therefore, moving every provider to per-patient funding has its problems. Can the Minister now confirm that NHS England will provide a number of different palliative care currencies so that commissioners can choose which method is right for their locality? If that is the case, how will value for money be audited and by whom?

We have heard that palliative care in this country can be the best in the world. However, successive national care for the dying audits have found wide variations in the quality of care in different hospitals. I welcome the fact that end-of-life care is now a key area for assessment in the Care Quality Commission’s inspections of hospitals, but can the Minister update us on the plans in place for those that perform badly to learn from the best?

However, poor patient and family experiences are often due to poor commissioning, planning and co-ordination, as well as insufficient provision for family support, rather than poor delivery. Clinical commissioners have a vital role in co-ordination because it is increasingly rare that individuals’ needs will be met by one service alone and they often need to be moved from one location to another as their needs change. Co-ordination is particularly crucial when terminally ill patients wish to die at home. Last year I spoke in your Lordships’ House about a particularly distressing case that I know of where that all went wrong. Obviously it makes sense to get services right in the community rather than have the patient admitted to hospital when the family can no longer cope.

Despite the numbers needing these services, according to Marie Curie, just over half of health and well-being boards in England made no mention of palliative care in their strategies, only a third had comprehensive plans, and 30% of STPs made no mention of end-of-life care at all. Given that NHS England says that it requires local leaders and professionals to ensure that a strategy for end-of-life care is in place, this is pretty disgraceful, and, having made that statement, it does not audit what is in place, so there is no accountability. Therefore, I ask the Minister how CCGs and health and well-being boards are being held to account for this state of affairs.

Finally, I want to raise clinical training. A professor of palliative care who is a friend of mine told me recently that some medical graduates have no more than one day of training in end-of-life care. In other places, such as Royal Liverpool University Hospital, students spend three weeks in local hospices, which equips them much better. Although we need palliative care specialists, we also need generalists with enough knowledge of pain management and other issues linked to end-of-life care, including how to help the bereaved. I understand that Health Education England’s end-of-life care core skills education and training framework—what a mouthful—is soon to be published. Can the Minister say how soon it will be implemented?