Examination of Witnesses (Questions 360
- 379)
WEDNESDAY 26 MAY 2004
MISS MELANIE
JOHNSON MP AND
DR STEPHEN
LADYMAN MP
Q360 Chairman: To be fair, we will
get back to you with more information.
Dr Ladyman: I agree with you,
on the face of it. That would be ridiculous. We have just said
to strategic health authorities that we do not expect there to
be a time limit on palliative care. We have asked them to make
sure that nobody is setting time limits on palliative care. They
have assured us that nobody is.
Chairman: It would appear to be happening
and we will provide you with more information.
Q361 Mr Burstow: To go back to the
piece of work the Minister was telling us about just now, the
piece of work evaluating the criteria and so on, has that work
been completed and, if so, is that work that can be made available
to the Committee?
Dr Ladyman: It has not been completed
yet, no.
Q362 Mr Burstow: It has not been
submitted to ministers?
Dr Ladyman: I only asked my officials
to start doing it fairly recently, so it has not even been submitted
to me yet.
Q363 Mr Burstow: The Health Service
Ombudsman published a report well over a year ago which made a
whole series of recommendations, some of which your colleague
has already referred to in terms of the processes SHAs have been
going through. Since that report, there has been a whole series
of further referrals to the Health Service Ombudsman, some of
which appear not just to deal with the criteria that were drafted
pre-Coughlin, but also criteria that have been published post-Coughlin.
Some of those appear to have had findings in favour of the appellant,
not the health service. Surely that would imply that there are
still serious problems with the criteria that are being used by
the NHS?
Dr Ladyman: You may be talking
about a judgment in the Cambridge area. That was misinterpreted
in the media.
Q364 Mr Burstow: That is not the
one I am referring to. I am referring to those where, more specifically,
it is dealing with continuing care in care home type settings.
Dr Ladyman: I am not aware that
the Ombudsman has made any judgments about any of those issues
that affect the legal position or the strategy. Of course, there
have been findings that people did not apply the criteria that
were in place appropriately. I am not aware that there has been
any finding that suggests that any of the new criteria do not
meet the needs of the law.
Q365 Mr Burstow: Do you not think
some people outside of this Committee will find it very strange
that a minister will come to this Committee today and say that
he has just commissioned work on this issue of continuing care
criteria, years after the courts made some very clear rulings,
a year and a half after the Ombudsman made a very damning report?
Is it not the case that the government has been very slow to act?
Dr Ladyman: First of all, it is
not years. Secondly, we set time scales for the strategic health
authorities to review their criteria and come up with criteria
that met acceptable guidance. Then we have given them another
deadline by which we expected them to have made progress in reviewing
the local cases as to the outstanding cases. Of course, it has
always been intended that we would analyse that process. I am
very concerned about the way the process is working and I am determined
to make sure that it is working right. For one thing, we have
made a commitment that everybody who has had financial loss as
a result of poor judgments in this area will be compensated. It
falls to me to make sure that those decisions are taken as expeditiously
as possible and everybody gets the money they are entitled to
as expeditiously as possible. This is ongoing work and I have
no doubt that, as soon as we have the work available, we will
put it in the public domain and you and your parliamentary questions
that you ask me on a regular basis will force me to do that, even
if I was in any way reluctant to do it.
Q366 Mr Burns: It would be nice if
we got less holding answers from you.
Dr Ladyman: Unfortunately, I can
only give holding answers when we do not have the completed work
yet. As soon as we have the completed work, the answers will be
made available.
Q367 Mr Burns: It is extraordinary,
on that narrow point, to get a holding answer when you ask for
hospital waiting list figures on a Wednesday that were published
by the government the previous Friday.
Dr Ladyman: You and I have an
ongoing conversation about the timing of these questions. Unfortunately,
data is often available to local acute trusts and primary care
trusts.
Q368 Mr Burns: And the NHS Executive.
Dr Ladyman: It belongs to them
and they give it to us at the centre and are shifting the balance
of power for publication on a particular date. Although they may
wish to publicise it before that date, we are not allowed to.
Q369 Mr Burns: You have missed the
point. You, as the Department, published the figures on the Friday
and the next following Wednesday you give me a holding answer
on that information.
Miss Johnson: If they have been
published, why have you been asking the question?
Dr Ladyman: I think that was something
that happened about six months ago and you got a written apology.
Q370 Mr Burns: Can we get back to
palliative care? You rightly said that you wanted everything to
be done expeditiously and quickly. No one would disagree with
you but there is a degree of concern, particularly arising out
of the Health Service Ombudsman's inquiry, where it was determined
and she said—you backed it up—that SHAs throughout
the country should review all the cases from 1996 as quickly as
possible. You set a deadline of 31 March this year. It is now
late May. That deadline has been missed. It would seem, certainly
from some of the figures that I have been given by some strategic
health authorities, that the pace of carrying out these reviews
and assessments is going remarkably slowly, which is contrary
to what you want, what the Health Service Ombudsman wants and
what is in the interests of natural justice. What are you doing
to try and expedite this matter? What have you been doing in the
run up to the 31 March deadline and when do you expect these assessments
to be completed?
Dr Ladyman: First of all, we have
been very careful to remind SHAs of the deadline and of their
duty to get these things reviewed as quickly as possible. I was
as disappointed as you that some SHAs were not able to complete
by the deadline, so we have gone back to them to ask why.
Q371 Mr Burns: Is it not all of them?
Dr Ladyman: Let me just finish.
The messages that I am getting at the moment, which I am pushing
back on and trying to explore with them, are that what happened
was the publicity around this whole issue has meant that new cases
appeared. A lot of new cases appeared a lot more quickly than
they were expecting them to appear and new cases are still appearing
now, right up to the deadline. Were it not for the fact that these
new cases had appeared and added to the workload, they are claiming
that they would have completed by the deadline. The overlap of
the deadline is a result of new cases they were not aware of coming
out of the woodwork. I am having that explored as urgently as
possible to find out whether that is a legitimate excuse for why
it is delayed. Like you—I will be honest with you—I
am embarrassed by the fact that we have not been able to publish
this because I was given assurances that we would be able to publish
the analysis of the judgments on time. I am surprised and disappointed
that we have not been able to do it. I am determined we will do
it as quickly as possible.
Q372 Mr Burns: When do you think
as quickly as possible is realistically?
Dr Ladyman: I really do not want
to be pinned down to a date now but I am quite happy to do my
best to work out a date for you in the near future and to write
to the Committee and let you know.
Q373 Mr Burstow: When you write to
the Committee, could you set out for the Committee the precise
nature of the work that has been commissioned, which pieces of
work have been completed and which pieces of work are still outstanding
on this whole issue of continuing care?
Dr Ladyman: I will try to be as
helpful as possible.
Q374 Dr Taylor: We have touched on
delayed discharges briefly but I want to go back to those. I am
delighted to hear that integrated equipment stores are working
and are getting equipment out within four hours, which is absolutely
brilliant. Delayed discharge in palliative care is absolutely
crucial because these are the people who do not perhaps have many
days left. To avoid them is crucial. When we did our inquiry into
delayed discharges, you may remember some of us did not really
like the idea of the financial penalties. Because there are financial
penalties for delayed discharge from acute care but not from this
sort of centre, is there any suggestion that people in palliative
care in the more chronic settings are being penalised because
more efforts are going to get the acute care people out, because
of the fines they will face if they do not?
Miss Johnson: The legislation
still puts all health and social care partners under a statutory
duty to provide appropriate care. Obviously, nothing has changed
about that basic duty. The intention has always been to extend
reimbursement to all the patients following consideration of the
benefits for each patient group. We have engaged with Help the
Hospices to get an idea of the impact on hospices of delayed discharges
and how many patients are affected. Help the Hospices is currently
working with the Hospice Social Worker Association to identify
five or six hospices to undertake a data collection service --
that, I understand, commenced in March—so that we can get
a better picture. Obviously, when we have that picture, we will
reflect upon it but certainly the intention is not to have this
effect. We are not clear whether this effect is being had or how
extensively it is being had but we are collecting information
to assess.
Q375 Dr Taylor: We have certainly
had examples where there have been tremendous delays in setting
up the necessary meetings, to say nothing of the equipment. Do
I gather it is the government's intention to consider bringing
in fines for delayed discharges in other sections, other than
the acute care sections?
Miss Johnson: I think we are more
focused on making sure that discharges happen from all sectors
equally effectively, effectively for the patient in terms of being
able to be discharged to wherever they need to go as quickly as
they can be and obviously in terms of the use of hospital resources
as well. I mentioned earlier on that the whole delayed discharges
work has led to the equivalent of eight extra district general
hospitals as a result of more rapidly reducing delayed discharges.
That is a phenomenal outcome and it is to the patient's advantage
too to be in that position because they are going more rapidly
to the setting which they really should be in.
Dr Ladyman: It is not entirely
our choice because I think I am right in saying that to extend
delayed discharge, as Melanie says, it has been such an outstanding
success, we are bound to be looking to where we can extend it
to, but we have to have parliamentary permission to do it. It
would be a matter for debate and, I think I am right in saying,
negative resolution but we certainly have to come back to the
House for permission to extend it to other areas.
Q376 Dr Taylor: You might get umpteen
extra hospices if you instituted it in the hospice world.
Miss Johnson: Equivalent, yes
indeed. There are all these potential gains to be had out of the
much better working. At the end of the day, it is not just about
the better use of resources. At the end of the day, it is about
the feelings of the patient and how much better that is. We need
to make sure that we maximise it.
Q377 Dr Naysmith: I know you have
covered the position a little about lack of consultants in this
area and you have also dealt a little with communication and the
need for better communication. In your memorandum to us you said
that many health care professionals who care for the dying have
received little or no postgraduate training in palliative care
and some, especially more senior staff, may not have received
any training before registration at all. In the course of the
inquiry, other witnesses have also highlighted this issue and
Professor Richards told us that training in palliative care needs
to be part of GPs' continuing professional development. Do you
agree with that and do you think it is sufficient or should such
training be mandatory and become a clearer requisite for revalidation?
Miss Johnson: We obviously do
not set the curriculum for either undergraduate or postgraduate
training.
Q378 Dr Naysmith: Do you think it
is something you might want to press for so you can make your
views known?
Miss Johnson: We certainly would
hope to see that there is training available for GPs and certainly
post-doctoral or post-graduation training available. In terms
of what is possible to fit in for doctors in training as undergraduates,
clearly again the same issues exist as for many other areas. It
is a question of how many skills can you usefully fit in. How
many of the skills that are missing are things that are more generally
applicable and so would be of a wide benefit across a whole range
of different engagements, as it were, between doctor and patient?
How many of them are very specific to a particular area and therefore
how much you can expect people to undertake in a given programme
of training over a period of years? There are questions there
that it would be best to engage with the royal colleges. The regulation
of postgraduate training for general practice is going to be soon
with something called the Postgraduate Medical Education and Training
Board, which I understand runs under the acronym of PMETB, which
is a lot easier to say than that mouthful. We think that it is
difficult for GPs to develop specialisms in all areas, but we
think GP registrars could cover the range of services that they
ought to provide as fully fledged GPs. We are aware that GPs do
see palliative care as important but in reality it is quite a
small part of their workload. Even if we look at palliative care
in its widest sense, it will not be more than a few patients each
year that each general practitioner will have, who will fall into
this category. I think further discussion with those who are responsible
for training would be helpful. We have allocated £6 million
between 2001 and 2004 as part of the cancer plan to improve the
training of district nurses which I mentioned earlier on and that
has been extremely well received and very enthusiastically taken
up. I think one of the issues is to look more widely than doctors
and to look at the whole range of skills and professionals, and
to recognise that some of those professionals will possibly spend
a much greater proportion of their time and therefore it will
be much easier, both to enthuse them and to find the time in their
training to put in a stronger mix of skills that are relevant
to palliative care.
Q379 Dr Naysmith: I take the point
you are making about palliative care and GPs perhaps not seeing
many patients in a year. On the other hand, I also take the point
you are making that lots of other professionals are involved as
well. If you are going to move more people in the community to
die at home, we need to have more people having these skills in
the community and not just taking on half a dozen patients a year.
Miss Johnson: I am not sure, because
I do not have the figures, what impact that would have on the
number of patients because obviously a lot of these patients exist
in the community for some time before they are maybe hospitalised
in the run up or around the time of their deaths. I am not sure
that it would affect the numbers hugely. I understand the point
you are making but I think there is still an issue and we entirely
accept there is an issue. I think it is worthy of further discussion.
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