Hospices and Palliative Care Services

Earl Howe Excerpts

Wednesday 15th December 2010 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, I begin by thanking my noble friend for tabling this Question for debate and introducing the subject so ably. I very much recognise the considerable knowledge that he brings to this subject, not least as a result of his past chairmanship of St John’s Hospice in London.

Thanks to the dedicated work of hospices, many people do die well: where they choose, with the people they love, and with all the medical, psychological and spiritual care they need. The Government are committed to supporting the work of hospices. We have confirmed the £40 million hospice capital grant for 2010-11, allocated under the end-of-life care strategy, supporting 123 projects in 116 hospices. More generally, we are determined that care should be compassionate and appropriate and that it should support personal choice. We will do that by putting patients, their families and carers at the heart of everything we do.

The end-of-life care strategy aims to improve care for all adults approaching the end of their lives, whatever their diagnosis and wherever they are, including enabling more people to be cared for and to die at home if they so wish. However, while many people receive excellent care, others do not. There are still variations in people’s experience by region, by age and, as my noble friend Lord Cavendish, pointed out, by disease, with greater emphasis given to people with certain conditions, particularly cancer. We can and must do better. We are taking forward a number of initiatives to improve end-of-life care services for everyone.

The issue of funding was introduced by many noble Lords, not least the noble Lord, Lord Faulkner of Worcester. I agree with much of what he said. End-of-life care needs a long-term system of sustainable funding. We committed, in the coalition agreement, to a per-patient funding model for palliative care. I listened with care to what the noble Baroness, Lady Finlay, said in that connection and I am grateful to her for the points that she made. My right honourable friend the Secretary of State for Health has asked Tom Hughes-Hallett, chief executive of Marie Curie Cancer Care, to chair an independent review of palliative care funding. I am sure that he will wish to take account of the experience and expertise of the noble Baroness in this area.

The review, covering services for both adults and children, is looking at options to make sure that the funding of hospices and other palliative care providers is fair. It will make recommendations for a funding system that will cover care provided by the NHS, a hospice or any appropriate provider, which encourages more community-based care so people can remain in their own homes, if they wish. It will be fair and transparent to all organisations involved in end-of-life care. The review is making good progress and I know that many in the hospice movement including, as my noble friend Lord Howard will be pleased to know, Help the Hospices, have provided evidence to inform its work.

The review’s interim report, published on 3 December, sets out a definition of dedicated palliative care and initial thoughts on a national funding system, stressing the importance of 24/7 community services. I look forward to receiving the final report and its detailed recommendations for funding in the summer. Of course, the funding review comes with a caveat that it has to be affordable within the constraints of the current financial climate.

Beyond sustainable funding, we need to consider how we will deliver end-of-life services. The NHS operating framework, published today, emphasises the importance of implementing the end of life care strategy and of developing round-the-clock, community-based services. The best services already know that good end-of-life care is not only more effective, but can be less expensive than poor care. A recent National Audit Office report found that in a typical PCT, around 40 per cent of the people who died in hospital had no medical need to be there. They could have been cared for at home or in their care home if the community-based support had been in place to support them and their family or carers.

We want services that enable people to have more control over the care they receive when they are dying. As one way of achieving this, our intention is for people to be able to add their end-of-life care plans to their own summary care record. We need to develop the services that allow people to die in a place and in a manner of their choosing. I recognise that this is not easy. Nor can it be done overnight. There is a great deal of work to do. In 2013 therefore, we shall review our progress and see how close we are to giving people the control that they clearly wish for.

We need more imagination, more radicalism, more courage in commissioning. We need to shift the landscape of end-of-life care in favour of the service user. The best commissioners are already challenging old conventions, finding new ways of designing services, and new ways of bringing hospices and other community organisations together to meet patients’ needs. Soon, new GP consortia will commission services. GP-led commissioning has clear advantages over the current model for end-of-life care. GPs have a better understanding of patient needs and better connections within the local community. They know what is available locally to support patients at the end of their lives. I firmly believe GP consortia will be advocates of hospices, not their enemy. But hospices themselves should be proactive. They should talk with their local GPs. They should also talk with their local authorities, which will play an increasingly important role in co-ordinating care, as we move toward joint-commissioning and planning through health and well-being boards.

My noble friend Lord Bridgeman dwelt with some emphasis on funding. The Department of Health is providing £286 million of additional funding to support implementation of the end-of-life care strategy over the two years 2009-11. A huge amount of money is being spent on end-of-life and palliative care. We know that it is often not used as it should be. That is why the palliative care funding review is looking at how we can better deploy the resources that we currently provide.

My noble friend Lord Bridgeman and others were right to highlight the particular issues surrounding palliative care for children. The Coalition: Our Programme for Government, states that the Government will provide,

“£10 million a year beyond 2011 from within the budget of the Department of Health to support children’s hospices in their vital work”.

As I have already mentioned, the children’s palliative care services are being specifically considered by the palliative care funding review.

My noble friend Lord Bridgeman also asked me about 24/7 community services. The end-of-life care strategy encourages commissioners and providers to develop 24/7 community-based services for medical, nursing and personal care which people need to enable this to happen. The funding review has already highlighted the importance of treating 24/7 community services as a priority.

The noble Lord, Lord Faulkner, asked about future funding. I have already referred to our intention to introduce a per-patient funding system. More generally, the strategy makes clear the responsibilities of the NHS to ensure adequate support for hospices, including through stronger commissioning and adhering to the principles of the compact code of good practice. That should mean more funding stability, including longer-term contracts, for hospices. My noble friend Lord Howard referred, quite rightly, to the cost-effectiveness of palliative care. The new health and well-being boards will follow on from the current commissioning arrangements that are already directed at end-of-life care because improving quality and improving productivity are, effectively, the same things.

The noble Lord, Lord Patel, asked me about commissioning in the future and the noble Baroness, Lady Thornton, questioned the Government’s commitment in this area. The NHS commissioning board will determine how best to deliver high-quality services, including end-of-life care, by working with GP commissioning consortia and making use of the various tools and levers it will have available. The board will commission NICE to develop quality standards to define the quality of care necessary to deliver the desired outcomes and use those standards to produce a commissioning outcomes framework. That framework will then be used to hold GP consortia to account. NICE has already begun the process to develop an end-of-life quality standard and we look forward to seeing the fruits of that work.

My noble friend Lord Bridgeman asked about the extent to which choice will be embedded in the system. We recognise how important it is to give people choice over the care that they get when they are dying and the place in which they receive that care but, as I have mentioned, we also recognise that it is not an easy task and cannot be done overnight. We need to do a lot of work and, as I have mentioned, we will be reviewing progress in 2013 so as to be sure of what we are capable of committing ourselves to on the issue of choice.

My noble friends Lord Patten and Lord Cavendish and the right reverend Prelate stressed the importance of spiritual care. The end-of-life strategy recognised that each person has spiritual, religious or emotional needs and that spiritual care is an important, integral part of the care given to people at the end of their life and to their carers and families. The department has produced a set of quality markers for end-of-life care and in the strategy’s second annual report, published in August, we said that we would consult on the effectiveness of the quality markers and revise them. Those will include spiritual care and consultation will begin in the new year.

My noble friend Lord Bridgeman referred to the importance of training and education. The department has taken forward a number of initiatives to develop the workforce, including: the development of core competences and principles; publishing an e-learning package on end-of-life care, which is free to access for health and social care staff, and supporting communication skills so there is a lot going on in this area.

To conclude, my noble friend Lord Cavendish referred to hospices as places where patients receive the best kind of care and I would not wish to disagree with him. Having said that, surveys consistently show that up to 75 per cent of people would prefer to die at home but at present only about 20 per cent do so, with a further 17 per cent dying in a care home. It is about choice; however, I take note of the powerful points that he made. Lest any noble Lord should think otherwise, the Government remain committed to delivering good- quality end-of-life and palliative care services and we believe that the action we are taking will improve the quality and range of options available to those in England at the end of their lives, including the many who receive such excellent care from hospices.