Examination of Witnesses (Questions 80
- 91)
THURSDAY 25 MARCH 2004
PROFESSOR MIKE
RICHARDS, PROFESSOR
STUART TANNER,
MRS JANE
SCOTT AND
MS SUE
HAWKETT
Q80 Mr Amess: The second issue, have
any of you, in your various fields of involvement in this area,
encountered any problems with access to palliative drugs?
Professor Richards: I think, in
terms of access to drugs, it depends. Sometimes there can be difficulties
with access out of hours for particular drugs. Is that what you
are referring to?
Q81 Mr Amess: Yes.
Professor Richards: Again, there
are lots of examples of good practice around the country where
arrangements have been made with PCTs to make sure that pharmacies
are open. I think a lot of this is down to planning in advance
and making sure that we do have the services, including the pharmacy
services, in place. One which perhaps we have not touched on very
much is the new GP contract, and the opportunities, in a way,
that gives for Primary Care Trusts to reshape out of hours services
completely, reshape the medical services but also then to integrate
them with nursing services, with social care services and indeed
with pharmacy services, to make sure that across a whole patch
they have got better out of hours provision.
Professor Tanner: I think that
the majority of the cases we are talking about should have open
access to a hospital facility, and if there was a question of
drug availability out of hours it should be solved that way as
a last resort. I think there are issues relating to the expertise
in prescribing analgesia for children, and of course this is where
we welcome the appointment of as yet a relatively small number
of specialists in the area but growing, and the activities of
the British Society of Paediatric Palliative Care, which has some
50 nurse members now. There is a lot of activity and development
there, but I think it has been a problem in the past.
Q82 Mr Amess: Thank you. The final
issue I wonder if you would like to comment on is, I have been
advised that, at present, in South Essex, patients and families
may wait between two and 12 hours for an on-call GP to arrive.
Do any of you have any observations about out of hours GP support
and service provision? I know that you have been to our area and
had meetings. It has been a big issue in Thurrock, I gather.
Professor Richards: The first
thing I would say is that out of hours services are of huge importance
in the delivery of palliative care. If people are going to stay
at home, having good out of hours services is clearly an important
component of that, otherwise they may have to go into an accident
and emergency department when otherwise they could have been cared
for. That is important. I think the new contract, which is going
to be coming in and where PCTs will be assuming responsibility
for out of hours services between April and December of this year,
does provide that opportunity to get this a whole lot better than
it has been in the past. No doubt it will be a different mix of
provision of care between doctors and nurses, but that may be
no bad thing in itself, and there is a lot of work going on amongst
the primary care team within the Department of Health to make
sure that comes about.
Q83 Mr Amess: You would agree with
me that the examples certainly I have been given of the wait at
the moment can be very distressing for the relatives?
Professor Richards: I do not know
the details of the cases, but if there are those delays certainly
that would be distressing to relatives, and we should certainly
make sure that there are better services, but I think we have
the opportunity to do that.
Professor Tanner: For many the
first port of call would be NHS Direct and we are working with
them to try to improve the situation that a child with a known
medical condition is not known to NHS Direct, as it were. It would
be better if there were knowledge of that child so that agreed
protocols could be put into place more swiftly.
Q84 Mr Burstow: I want to come back
on this point about out of hours services and what you have just
said, because how real is this opportunity to re-engineer, redesign
the services in the sorts of timescales we are talking about?
You have mentioned that by December PCTs will assume responsibility
for this. Obviously, work is being done on this already, but certainly
things that I hear would suggest that we are likely to have, in
many parts of the country, the traditional GP-led models continuing,
because there is not enough time to put in place all the necessary
reskilling, upskilling, and so on, to design the new organisations.
How confident are you that really we will see the opportunities
you are outlining being realised in practice?
Professor Richards: I cannot say
I am an expert in this area. I do know that a lot of planning
has been going on at the Department of Health involving GPs in
this process, and it is the PCTs assuming responsibility for commissioning
the care, not necessarily for delivering it, and looking at different
models of having quite large-scale organisations, covering quite
a wide population, providing out of hours care. They have done
a lot of work looking at what the frequency of night calls is
to GP services and seeing how that can best be provided. I think
they are giving the models of best practice to PCTs. Of course,
it will take time to move to those new models and I do not suppose
it will all be sorted out between now and December, no, but I
think that the opportunity is there and over time that can be
developed.
Q85 Mr Burstow: It has been put to
me that in some parts of the country the likely outcome by December
is that contracts will be let with many of the organisations which
already provide out of hours services for relatively long periods
of time into the future, so they are locked into an existing model
rather than having the opportunity to engineer a new model. Is
that something the Department is alive to and is it working with
PCTs to try to avoid it?
Professor Richards: I am sure
the Department may be alive to it. I have to say, it is not the
area that I am an expert on, but we can seek to find out more
for you on that.
Mr Burstow: If you could, that would
be very helpful.
Q86 John Austin: Can I go back briefly
to the Treasury's cross-cutting review, and it may not be the
area of responsibility of anyone who is here. My understanding
is that 2006 is the deadline by which the Department will have
to pick up all of the costs of services provided in the public
service by the voluntary sector. In order to calculate those costs
it will have to set up a system of national tariffs, and a number
of the people who have given written evidence to us have expressed
some concerns about how that will pan out. Would it be sensible
if we could write to you or the Department with the specific questions
and queries they have got as to how that will pan out and what
work is being done on national tariffs?
Professor Richards: By all means,
write to us. Obviously, some of this is in the hands of the Treasury
initially but the Home Office are doing more work on the cross-cutting
review as well. I think I have told you the direction of travel
we are taking in relation to hospices in particular, which is,
as soon as we can do the work to make sure we have got a tariff
which could be agreed with our partners in the voluntary sector
which is a reasonable tariff then I think we can move quite quickly
from there to a transition from the sort of block grant contract,
which is present in a lot of places now, over to a commissioning
model based on that tariff.
Q87 Chairman: Can I ask each of you
for a very quick, final thought, and it is very unfair to ask
this question but I will ask it anyway? Imagine you are free of
all the constraints that you have got at the present time and
the roles that you have and you are starting from scratch in planning
palliative care provision in this country. What would you do,
what would be your ideal model?
Professor Richards: In terms of
the model for non-cancer patients, I do not think we are at the
point yet of knowing what that best service model is. I think
we have got the right way of getting to knowing about it, through
the initiatives I described earlier. I do think that absolutely
vital to any model will be more specialist palliative care staff
and better-trained generalist staff.
Q88 Chairman: Actually I am thinking
of the structures of provision, because you talked about the way
in which, in certain areas, health and social care were meeting
together on the whole issue. What about that sort of issue, if
you were to look afresh at how we structure our health and social
care system?
Professor Richards: I think the
opportunities are there through pooled budgets. I would like to
see more of that being done and again more proper planning done
at a local level between health and social services to get this
right. I think that is doable but I am not saying I think it has
been done yet.
Ms Hawkett: I think the thing
that really we are all striving towards and would love is that
integration between social services, the Health Service and the
voluntary sector, because I think that is an important element
in the delivery of palliative care.
Q89 Chairman: If you were starting
from scratch, would you have a split between health and social
care? In terms of palliative care, to me, if there is any area
which does not make any sense it is this area, where you have
debates about means-testing, on one side, and free care, on the
other. It is pretty unfair to press you on this, because obviously
I appreciate your position in the Department, but is it not somewhat
unhelpful to have that split?
Ms Hawkett: I do not think it
is always very helpful at all, and I would much prefer to see
a system which was totally integrated. I would like to say also
that, in that integration and planning, that I would like to see
a stronger voice for the user.
Professor Tanner: I would endorse
the recommendations in the September last year publication from
ACT, the Association for Children with Terminal Illness and their
families. And the Royal College of Paediatrics and Child Health
I think they describe it very well. The recommended model of care
is a locally-based, multidisciplinary team, with ready access
to a children's hospice and to specialist paediatric palliative
care advice for families and professionals, when needed. Most
of the day-to-day care should be in the community, with the specialist
community teams working in co-operation with primary care, social
services and education.
Q90 Chairman: I am just checking
whether we have that as a submission, that document to which you
have referred?
Professor Tanner: I do not know.
We can make it available to you. It is the second edition.
Q91 Chairman: Thank you very much.
Mrs Scott: I think, building on
that and what Sue was saying, we really do need to listen to the
voice, and in our particular case we need to listen to the voice
of the child and the young person. I think we have got better
at listening to the voice of the mother and the father but not
necessarily the child and the young person. For example, quite
often, particularly for teenage cancer units, they are such great
places to be, the young people like to stay there because they
get to see the football stars, pop stars and everyone. Really,
I think, if actually we are listening to what they want, often
they want to maintain as normal a life as possible and to be young
people first and foremost.
Chairman: On behalf of the Committee,
can I thank you for a very helpful session. We are most grateful
to all of you for your participation. Thank you very much.
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