Examination of Witnesses (Questions 60
- 79)
THURSDAY 25 MARCH 2004
PROFESSOR MIKE
RICHARDS, PROFESSOR
STUART TANNER,
MRS JANE
SCOTT AND
MS SUE
HAWKETT
Q60 Mr Burstow: Particularly in this
area, where we are talking about end of life, is it appropriate
to have too great a focus on simply providing intensive home care
of a personal nature at the expense of providing domestic help?
Professor Richards: We need to
meet patients' needs, and if their need is for domestic help I
believe that should be met. If that is what is going to enable
them to spend their last weeks or days at home then that is what
we should be finding a way of providing. As I have said, we have
already made this a priority area, but I do not think we have
got the right solutions. I think we will identify exactly what
needs to be done through these various pilot programmes.
Q61 Mr Burstow: The other thing I
want to come on to, Chair, if I may, which relates to that, is
what appears to be a continuing confusion about the applicability
of continuing care funding arrangements for people who are being
provided with services, not just in terms of nursing home settings
but also residential care and, for that matter, in their own homes.
Are you satisfied that the current arrangements for providing
and assessing entitlement to continuing care funding from the
NHS are understood by all practitioners responsible for such assessments?
Professor Richards: It is very
difficult for me to know whether it is working in every single
part of the country. What I can tell you is that all strategic
health authorities have reviewed this area, and specifically to
do with the eligibility for NHS funding, and have made very clear
that should be based on need, not on an anticipated time to death,
because, frankly, anticipating the time to death is very unreliable.
Q62 Mr Burstow: Would it be appropriate,
therefore, in those assessment methodologies which are being drawn
up by the 28 strategic health authorities, for a person to be
able to travel from one locality to another in England and find
that they would be eligible in one locality but not in another
for continuing care?
Professor Richards: I have no
evidence that is the case. I cannot say more than that because
I have no evidence whatsoever.
Q63 Mr Burstow: Is that because you
have not had the occasion to look at and examine that?
Professor Richards: Personally
I have not had the occasion to look at and examine that, so I
cannot answer that.
Q64 Jim Dowd: We have received a
number of submissions from people mentioning recent developments
in Canada, principally looking at it more from the point of view
of the carer, in those very supportive roles in the terminal stages.
I wonder if the Department has looked at that at all and do you
have any similar plans for making any assessment of the value
of it?
Professor Richards: I have not
looked at it in detail. I may say that I am going to Canada in
June and I am trying to make arrangements to meet development
people in Canada when I go there. I am not yet in a position to
report back in detail, but I am aware of what they are doing and
I think there are lessons probably that we can learn in both directions.
Q65 Jim Dowd: Is your strategy taking
into account the needs of carers and supporters for those terminally
ill as well, in the way that the Canadian model is intended to
perform? What are you doing in that area to look at the needs
of carers?
Professor Richards: As I said
a little while ago, in relation to the NICE guidance on Supportive
and Palliative Care for cancer patients, we have a specific chapter
in that on families and carers and identifying their needs during
the care process for the patient and then meeting those needs.
As we implement that NICE guidance, we will find to what extent
we are not meeting the needs of carers, and I suspect that at
the moment we are not meeting them.
Q66 Mr Burns: Can I read to you a
statement which was in a written memorandum submitted to us by
Dr Keri Thomas, where she said: "Most end of life care will
always be provided by generalists—GPs and District Nurses
in the Community, ward staff in hospitals and Care Home Staff.
We can improve care through improving access to education and
training and the use of guidance and frameworks, backed by specialist
and social support." Do you agree with those views and do
you think that, in order to achieve some national equity, there
should be national planning and management of extended training
programmes, for example, the extension of distance learning programmes
for the Palliative Care Diploma?
Professor Richards: I agree with
it wholeheartedly and it is very much along the lines of what
I have been saying in terms of our End of Life Care initiative.
She has written it down there as a paragraph but it is almost
exactly what we are planning to do in this initiative. I agree
completely on that. As I have said earlier, we are rolling that
out across the whole country.
Q67 John Austin: Some of the hospice
providers have suggested to us that the regulatory burden is somewhat
heavy. I wonder if you have any comments on that? I understand
that, although the National Care Standards Commission currently
has responsibility for care homes, when the new arrangements come
in stand-alone hospices will come under the new CHAI and CSCI
will have responsibility for adult and outreach services generally.
There appears to be a possible fragmentation of regulation. I
wonder if you have any views on whether there should be a single,
seamless arrangement?
Professor Richards: Actually,
I hope it is going to work the other way round, because, at the
moment, voluntary hospices have been regulated by the National
Care Standards Commission, whereas NHS services have been regulated
through the old CHI, (the Commission for Health Improvement),
if you like .What we are trying to do, by developing the national
guidance to which I have been referring, is have guidance on what
the service models should look like, whether they are provided
by the voluntary sector or by the NHS itself. Those service models
are based on best available evidence combined with consensus.
From there we will develop the standards and then we will develop
an inspection process to see whether services are meeting those
standards. We have been working very closely with the new CHAI
on this, and that will bring together those two bits of work.
We are also aware that the new CHAI is working very closely with
the CSCI on social care and they have a Memorandum of Understanding.
Having said all that, the new CHAI does not actually get up and
running until April 1, so we have been doing a lot of preparatory
work with them to try to make sure that the regulatory processes
are brought together. Indeed, even with the National Care Standards
Commission, the standards they used for inspecting hospices were
based on the first draft of the NICE guidance, so I do not think
it is going to be too difficult a process to bring all those things
in line.
Q68 John Austin: Can I come on to
staffing issues, because I think it is quite clear that the Department's
evidence acknowledges the serious shortfall in specialist and
qualified staff, although your memorandum does show considerable
progress in redressing that. Nevertheless, in the evidence that
we have had, staffing issues are among the most difficult, and
in my own area, in particular, there has been comment about the
lack of responsive overnight specialist care and support available.
Are you able to identify the particular problems which are faced
in inner-city and similarly deprived areas, and what are the implications
for those areas and what is the Department doing to address that?
Professor Richards: First of all,
if we think about the consultant staff, the specialists in palliative
medicine, I think we all acknowledge that we have too few consultants
in palliative medicine, and, what is more, yet again, they are
not evenly distributed across the country. There are some particular
parts of the country, there is an area, effectively, to the west
of Birmingham and an area up near Hull and the Yorkshire coast,
where there are very few staff, and probably there are other areas
as well.
Q69 Dr Naysmith: Could I ask, while
you are mentioning consultants, what do you think the figures
are, because we have had some discussion about what are the correct
figures, and so on?
Professor Richards: May I say,
that I would advise you to take the figures from the Association
for Palliative Medicine because I think they have the most reliable
figures. I will explain why. In the past not all consultants working
in hospices have had an NHS contract, a contract with an NHS Trust,
therefore they have not been reported to the Department of Health
in their workforce surveys. I am hopeful now that we are getting
all the consultants to have at least honorary NHS contracts, and
therefore that we are counting them in our workforce surveys.
Q70 Dr Naysmith: In a number of areas,
it always strikes me that the best way to get the figures is to
take what the colleges say is the absolute maximum and then what
people are saying is what they have got and what they need and
somewhere in the middle is the correct minimum. Are you disputing
that?
Professor Richards: No, I am not.
I am saying that, in terms of making sure we know what we have
got currently, I would advise you to take the figures from the
professional group itself, which is the Association for Palliative
Medicine.
Q71 Dr Naysmith: What is the shortfall
now?
Professor Richards: I have to
say, I have not brought those figures with me but I am sure that
I can get hold of them fairly quickly.
Q72 Dr Naysmith: Is it going to be
better in five years' time than it is now?
Professor Richards: Yes, on that
I can be sure. Because the number of trainees in palliative medicine
has gone up, I am confident that the numbers of staff across the
country will go up. Having said that, there are some caveats on
that as well. A lot of the trainees are women and a lot of them
have already expressed a wish to work part-time when they become
consultants, and so we should not immediately think that head
count converts into whole-time equivalents. I am confident that
over the next few years the numbers will increase quite substantially,
but also I am confident that we need more.
Q73 John Austin: Even if those targets
are met, and, as I say, you acknowledge in your memorandum, you
show a considerable move towards the additional targets, but you
mentioned specific areas yourself where there is a vacuum. I am
conscious particularly of the more inner-city areas which have
difficulty in recruitment and retention. Are there any specific
measures which are being taken to ensure that there is a more
equitable distribution of resources?
Professor Richards: I am not immediately
aware of the fact that it is inner-city areas which have that
problem. I am sure there may be some inner-city areas, but I think,
for example, London, by comparison with other parts of the country,
is moderately well staffed in terms of doctors. I think we need
to think differently about whether it is doctors or the nursing
workforce. I think, in the nursing workforce, particularly for
specialist palliative care, again, it is very difficult, from
our perspective at the Department of Health, to know what the
age profile of the nursing workforce is, because a lot of them
are working in the voluntary sector and therefore we do not have
records of them. Having said that, we will be working through
the National Partnership Group and with all the other voluntary
sector colleagues that are part of that Partnership Group to do
a survey of the hospice workforce so that we get a better picture
of that, because I think we need that for planning purposes.
Q74 Dr Naysmith: You were mentioning
specialist nurses just now. Do you think the recently negotiated
Agenda for Change will make a difference here?
Professor Richards: Our nursing
adviser will take the question on Agenda for Change.
Ms Hawkett: Agenda for Change
actually have quite a huge impact on the nursing workforce pay
modernisation, looking at the jobs and skills and competences.
One thing that we are very conscious of though is the impact that
Agenda for Change will have on the voluntary sector. Primarily
this is modernisation for the NHS, but nevertheless three-quarters
of our specialist palliative care services are provided by the
voluntary sector and the majority of the workforce are nurses.
The National Partnership Group for Palliative Care have set up
a sub-group to look at this quite seriously and assess what the
impact will be for hospices.
Q75 Dr Naysmith: What do you think
it might be? Why are you looking at it, what is it you are worried
about?
Ms Hawkett: They are competing
for the same pool of staff, and so if the NHS have moved to a
different pay system and the way in which they are designing their
jobs then, of course, this will have an impact on how hospices
can recruit staff. I have to say though that the sub-group have
already started their work, and on that group there are a number
of hospices who have looked at this already and are ahead of the
NHS in many ways, and they have looked at their staff profiles,
looked at the grading and actually have done quite a lot of work
ahead of the implementation of Agenda for Change. They
see it very positively as not just a matter of salaries but an
opportunity to redesign. One of the outputs from the sub-group
will be the development of a toolkit for the voluntary sector,
working with strategic health authorities, the workforce confederation
together with the voluntary sector to look at how they can support
this change and one another.
Q76 Dr Naysmith: You say you have
got a group looking at the possible effect of this on the voluntary
sector. I am not asking you to say when it will be published but
when do you think they will have completed that work?
Ms Hawkett: A member of the sub-group
is also from Help the Hospices, who themselves are looking at
this issue quite seriously so will be working together, and we
hope to be able to report back to the National Partnership Group
by the summer.
Q77 John Austin: We have referred
to the National Partnership Group and about an hour and a half
ago Professor Richards was talking about the £50 million
and that it is now coming through and being deployed. Of course,
palliative care is a complex pattern of provision involving the
NHS, the voluntary sector, organisations like Macmillan and Marie
Curie and the hospice movement, and there are different streams
of funding, and particularly there is the additional funding which
has come through the New Opportunities Fund. We have had evidence
actually from some organisations and hospices that they are not
seeing much of that money and it is being creamed off by the PCTs
and not being used in specialist palliative care. I wonder, first
of all, if you would like to comment on that, and, generally,
what you think the impact of the Treasury's cross-cutting review
of funding in the voluntary sector will have on palliative care
services?
Professor Richards: If I start
with the question about the £50 million. First of all, we
developed a set of criteria based on the draft NICE guidance for
what that money could be spent on. Then we invited networks, which
included both the voluntary sector and the NHS, to develop their
action plans in line with those criteria. We then had a group
from the National Partnership Group, with equal representation
from the voluntary sector, the NHS and Department of Health, to
assess the action plans and to make sure, first of all, that the
actions recommended genuinely were related to specialist palliative
care. Secondly, to make sure that there was a fair contribution
going into the voluntary sector and into the NHS, and that would
vary from place to place, but we had the right group, I believe,
to assess those plans and make sure that there was a fair distribution.
Having said that, we are now monitoring how that money has been
spent, what we have got for that money, as a population, if you
like, in terms of doctors and nurses, extra palliative care beds,
etc., so we are watching that money very closely indeed. In terms
of the cross-cutting review, we are looking now towards a different
mechanism for funding the hospices, and, again, working through
the National Partnership Group to establish the right way of doing
this. We have two sub-groups that are relevant to this, one looking
at the rights and responsibilities of different partners with
the voluntary sector and the NHS, and one which is looking specifically
at the costs of providing hospice care. A lot of work again is
being done by partners within the voluntary sector on this. I
think the way forward will be to develop a tariff for the costs
of providing an inpatient stay within a hospice, for example,
and the sooner we can reach an interim tariff the sooner we can
change the commissioning model in that direction. Clearly, it
will then be for local negotiation about the level and volume
of service which is provided locally. Again, I would hope that
would be in line with proper needs-based assessment. Of course,
hospices will be able to provide services above and beyond those
agreed levels, should they choose to do so with their voluntary
funding. That is the direction of travel as we see it.
Q78 John Austin: I think it has been
said earlier, hospices do not only provide residential care, they
act as a resource and a support, and I think, as Mrs Scott was
saying in terms of children's hospices, very often they do not
provide residential places at all but are there as a resource
and support. Of the New Opportunities funding, I note that £48
million of it was specifically for home-based care teams and bereavement
teams dealing with children. You mentioned a group of organisations
who are represented on the working group, or committee, or whatever.
Is the children's hospice movement involved in those?
Professor Richards: At present,
the National Partnership Group on Palliative Care is related to
adults. That may be something which needs to change over time,
or it may not, it depends, I think, how the children's NSF develops
and what is most appropriate for their services.
Mr Bradley: Can I just link back to my
earlier request, when you happily agreed to look at the North
West as an example, to see again how the funding flow from NOF
and other things has fitted in to that co-ordination of the services
for the region? That would be very helpful as well.
Chairman: Seriously, if it is possible
for you to give us an indication in our own areas, mine is the
North East.
Q79 Mr Amess: There are three points
I want to put to our witnesses which are not on our script. Obviously,
all hospices are very grateful for any money which they receive
but, at the same time, they value and cherish their independence.
Recently I was talking at some length to the Duchess of Norfolk
and she advised me that it is a frequent practice for hospices
to set their yearly budget without formal notification from Primary
Care Trusts of the extent of the annual grant, including any uplifting
fund. Would our four witnesses agree with her that the financial
management of the hospices would be assisted if such notification
was received prior to the commencement of the new financial year
and/or the funding was paid directly to the hospice?
Professor Richards: I think this
relates back to the earlier discussion about commissioning, where
if we can have proper planning of services according to need,
working out where those services need to be provided and then
PCTs, often PCTs working together, not just one PCT but PCTs working
together across a network, working out what they need to purchase,
if you like, from the hospices, yes, I think we can improve that.
I think we are improving that by having developed these networks.
I acknowledge that in the past that has not always worked very
well, and certainly I would hope through the development of networks
that would be better.
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