Hospices and Palliative Care Services

Viscount Bridgeman Excerpts

Wednesday 15th December 2010 Lords Chamber

Asked by

[Viscount Bridgeman]

To ask Her Majesty’s Government what plans they have for the future of hospices and palliative care services.

[Viscount Bridgeman]

My Lords, I hope that we shall have an hour of singing from the same hymn sheet. I am very grateful for the opportunity to introduce this debate on this most important of subjects. It comes at an important time for the hospice movement in the United Kingdom, for the interim report of the independent funding review has just been released. On 11 November, the noble Baroness, Lady Finlay of Llandaff, led with great distinction a debate on palliative care for cancer sufferers, and this debate, I suggest, is entirely complementary to that one.

I declare an interest as the former chairman of St John’s Hospice in central London. This is one of a number of hospices which cater for the three main killer diseases: cancer, HIV/AIDS and motor neurone.

No debate on palliative care or end-of-life treatment is complete without the mention of Dame Cicely Saunders, who is widely accepted as having founded the hospice movement in the United Kingdom. It is a worthy tribute to her memory that a recent report by the Economist Intelligence Unit puts the United Kingdom first, ahead of 39 other countries, in the provision of end-of-life care, and this was attributed in part to the “well-established hospice movement”.

In the short time available to me, I wish to speak briefly on funding. In the past, there has been a certain complacency on the part of every Government towards the funding of hospices. The unadorned truth is that any Government are well aware that any shortfall will in the end be made up by way of appeals and fund-raising and that, to put it bluntly, it will be all right on the night. On the whole, Governments of all hues have got away with it, although I pay tribute to the previous Administration, who made available £40 million to improve the environment of palliative care. In the case of the hospice with which I was associated, its share was gratefully put to good use in improving out-patient facilities, and the confirmation of this grant by the present Government is to be welcomed.

Up to now, there has been no national tariff for hospices contracted to the NHS. The disadvantages of this are obvious, as it makes it difficult to produce long-term strategic budgets, and inevitably it means that the funding as between different hospices is going to differ significantly. Additional funds invested through the end-of-life care strategy have not been invested in a consistent way. In many cases, hospices are forced to carry an overhead for negotiating staff with the many PCTs to which they are contracted, and they are ill-equipped to afford this. Some of the less well-resourced establishments inevitably lose out. I would mention that a joint report by Healthcare at Home and Dr Foster estimates that delivering end-of-life services in the home could save the NHS £160 million a year.

I am very pleased that the NHS tariff group is reporting on behalf of palliative care. Now we have a real opportunity in the review of commissioning to move towards 100 per cent funding across the board. However, does that mean that fund-raising from the third and voluntary sectors will no longer be required? Most certainly it does not. It will simply mean that that part of a hospice’s expenditure which is clearly clinical will be looked after within the commissioning structure, leaving those involved in fund-raising to concentrate on amenities such as day centres, bereavement counselling and the training of volunteers and carers, which are not part of the NHS’s responsibility.

Before leaving the subject of funding, I wish to mention the particular case of children’s hospices, where currently the contribution to operating costs tends to be at the lower end of the scale, although I am aware that these hospices are likely to receive a greater element of mainstream primary care than their adult counterparts and they also receive Section 64 additional funding. The number of children with life-terminating illnesses is, mercifully, relatively small. Nevertheless, there is a danger that for that very reason the special needs of children's hospices may be overlooked. I hope that that will be recognised in the current review.

As the population ages, so will the burden of care increase. There will be more long-term conditions and, with those conditions, there will inevitably be symptom-control elements, and it is those that palliative care must address. It is fair to say that all the national strategies for older people and those with dementia recognise the role for palliations, and I hope that the department will ensure that that is reflected in the commissioning structures which, I hope, will be the product of the fundamental review.

I turn to community support. Speaking in the debate initiated by the noble Baroness, Lady Finlay, on 11 November, I referred to the totem of the hospice movement being hospital avoidance—and for hospital, you might read, hospital and hospice avoidance. The apparent paradox of all debates on hospices is that we are talking about ways to avoid using the institution itself and moving the emphasis of patient treatment away from acute into community and primary care settings, which, apart from freeing up beds for unavoidable acute cases, has the incalculable benefit of letting patients choose their place of care, and possibly where they will die. In that debate, several noble Lords referred to that. It is important that the primary care trusts—or, as they will now be, GP funding consortia—should record as early as practicable patients’ preferred place of death. My noble friend was very helpful on that point at col. 322 of the Official Report of that debate. However, I should welcome his confirmation that that will become a statutory obligation.

I mention as an example of admirable community support the single point of access project in Westminster. The project delivers a single telephone number for patients to use to access all palliative care services in the borough. It has been made possible only by numerous teams giving up their systems and working together with the out-of-hours GP co-operative to run the system. With the impending amalgamation of services between Westminster, Kensington and Chelsea, and Hammersmith and Fulham, it is to be hoped that that service will be available in all those three boroughs with the minimum of bureaucracy and optimal cost savings, and that that will form a useful pattern for other authorities.

An important component of that scheme is out-of-hours work. That is of concern to all branches of primary care, but it is particularly vital with palliative care, for one simple reason: pain does not keep office hours. I know that the matter of 24-hour cover is already being addressed across the country. Currently, it is piecemeal, with services varying from telephone advice only to personal visits. The palliative care funding review, in its interim report, recommends that the Government use the forthcoming NHS operating and outcome frameworks to ensure that a structured 24-hour service is put in place.

Finally, I say a word about education. This is of course a subject in itself and time does not permit more than a passing reference to it. Palliative care is now included in GP training, but that specialised training needs to extend right across the palliative care community, from qualified doctors to undergraduates and carers—both hospice-trained and from outside. Training is too big a subject to be left to the charitable sector. I hope that the Minister will confirm that it is to be given high formal priority in the commissioning structure.

We in the United Kingdom can take pride in the leadership that we have given to the hospice movement worldwide, achieved through the dedication and commitment of staff, consultants and volunteers. They deserve our gratitude. I end by thanking those noble Lords who have chosen to take part in the debate. I look forward to their contributions and to the reply from my noble friend.