Funding issues
116. The months leading to an individual's death
pose the highest cost burden of all on the NHS. One estimate suggests
that 90% of all health expenditure occurs in the last months of
life, and that almost a quarter of hospital bed days are used
by patients in their last years of life.[130]
117. The Department cited an estimate produced by
the National Council for Hospice and Specialist Palliative Care
Services that total expenditure on adult palliative care in 1999
was around £300 million per annum of which £170 million
was provided by the voluntary sector. No figure for expenditure
on children's palliative care has been provided to us. Janet Vickers,
a nurse consultant in palliative care described this as a major
problem:
Children's palliative care … is not a high
profile specialty with distinct separate funding, it has, in the
majority of cases, been excluded from accessing recent Government
funding for palliative care which was specifically designated
for adult palliative care.[131]
118. ACT asserted that children's hospices received,
on average, just over 5% of their funding from statutory sources.[132]
119. The NHS Cancer Plan, which is a key policy framework
document for palliative care, acknowledged that the voluntary
sector had for too long shouldered the burden of funding palliative
care.[133] It pledged
to increase funding for specialist palliative care by £50
million per annum by 2004. In July 2002, Ministers reaffirmed
their commitment to ensure that the full sum was devoted to specialist
palliative care and the National Cancer Director was charged with
developing a mechanism to achieve this. He set up the joint NHS/Voluntary
Sector/Department of Health National Partnership Group for Palliative
Care. In order to speed up progress an extra £10 million
was devoted to specialist palliative care in 2002-3. This was
allocated to PCTs "with clear instructions that it had to
be spent on specialist palliative care".[134]
120. The National Partnership Group's recommendations
included:
- Investment in specialist palliative
care should be in line with local strategic plans and NICE guidance
on supportive and palliative care.
- Inequalities in access to specialist palliative
care services needed to be addressed.
- Local decision-making and accountability were
essential.
- Voluntary sector organisations should be fully
involved in planning services.
- The NHS should make a "realistic contribution"
to services provided by hospices etc. but should not be the sole
provider. Equally, voluntary sector bodies, while having the freedom
to offer innovative services, should provide value for money.
- The voluntary sector should have more secure
funding flows but should be able to offer clear projections of
its future contribution.
- Local planning and funding should include, "over
time", non-cancer specialist palliative care services.
121. Primary Care Trusts are required to work together
through cancer networks[135]
(32 at present, set to rise to 34) to identify local spending
and development priorities. The networks are also currently engaged
in the process of correlating need for services against service
availability. The £50 million is intended to:
— Fund
an additional 66 whole-time equivalent palliative care consultants;
— Fund an additional 162 whole-time equivalent
Cancer Nurse Specialists;
— Produce an extra 92 specialist palliative
care in-patient beds;
— Give additional funding support to the
voluntary sector, including hospices, Marie Curie and equivalent
local services;
— Increase the availability of out-of-hours
provision, support hospital and community services; and
— Contribute to meeting the specialist
palliative care recommendations in the draft NICE guidance.[136]
122. In addition to this funding, the New Opportunities
Fund's Community Fund has issued 119 grants totalling £29
million to hospices and related programmes; £22 million towards
facilitating care at home; and £48 million to children's
hospices, home-based care teams and bereavement teams dealing
with children.[137]
This includes £25 million to children's hospices to enable
them to sustain or develop their provision. New Opportunities
funding is for a fixed period and does not provide for ongoing
funding of services. A particular challenge to recipients of such
funds is to sustain the gains made by projects once their funding
from the New Opportunities Fund is complete, and to develop continuation
funding.
123. Some submissions complained that PCTs were creaming
off part of the additional money awarded to palliative care and
were not devoting it to specialist services. For example, St Michael's
Hospice in Harrogate noted that the Craven, Harrogate, and Rural
District PCT had received £188,000 from the £50 million
allocation but that only £39,000 of this had come through
to the hospice.[138]
Similarly, Greenwich and Bexley Cottage Hospital noted that they
received none of the same funding, all of which was appropriated
by Greenwich PCT.[139]
A further problem, which was noted by Cotswold Care Hospice, was
the last-minute nature of much statutory funding, consequential
on the need for local NHS approval and the complexity of the relevant
application forms.[140]
124. A number of submissions commented on the possible
impact of the Treasury's cross-cutting review which has set a
deadline of 2006 by when statutory agencies will be obliged to
meet the full costs incurred by the voluntary sector in providing
public services. National tariffs will be drawn up to allow costs
to be calculated.
125. Precisely how the Treasury funding will work
remains unclear. Officials told us that agreed tariffs for services
provided would need to be drawn up which would allow the Government
to fund core services. Christine Shaw for Help the Hospices queried
whether there needed first to be an interim tariff established.[141]
Peter Tebbit for the National Council for Hospice and Specialist
Palliative Care Services suggested that the NHS would have to
swallow the bitter pill of paying for services which at the moment
they were receiving with a heavy subsidy from the voluntary sector.
In his view this would yield a bill of an extra £100 million
per year. He felt that this was not unreasonable, given that,
according to his estimate, the Government had received between
£1-2 billion worth of services at no cost over the last 10-15
years. Tom Hughes-Hallett for Marie Curie offered the analogy
of cream and milk: if the Government paid for the 'milk' that
the core services constituted, the charity would have more resources
to devote to the cream, "new ways of delivering care and
help".[142] Peter
Tebbit agreed that an end to the need to concentrate day to day
on how to raise funds would "release an enormous amount of
creative and innovative energy".[143]
126. What is not clear is the extent to which the
Treasury's obligations would be open-ended. For example, if there
is a substantial short-fall of hospice provision in one area at
the moment, would the Treasury be obliged to step in and fund
in full a string of new hospices opening up? Even in areas with
relatively generous provision, if the beds can be filled and care
provided, should the Treasury still offer funding? To what extent
will funding be related to the quality of provision?
127. How hospice services are to be funded in the
future is an important matter that is still being considered by
the National Partnership Group and the Department of Health. Peter
Tebbit told us that it was likely there would be "a funding
mechanism for governing NHS funding flows that is common to both
NHS and voluntary providers. If we put both the voluntary and
the NHS managed services on the same level playing field, I think
we will get a nationally agreed range of prices for the supply
of care services". [144]
128. We welcome
the additional resources that the Government has directed to the
development of specialist palliative care services throughout
the country. The allocation of the additional £50 million
has been facilitated by the establishment of the National Partnership
Group for Palliative Care, bringing together the voluntary sector,
the NHS and the Department.
129. We note the
momentum achieved in Canada by an end of life/palliative care
coalition. We recommend that the Department assesses the membership
of the National Partnership Group and extends it to include representation
from all relevant areas, including education; carers; charities
dealing with illnesses other than cancer; those suffering inequity
on the grounds of age; as well as black and minority ethnic groups.
130. It is now
widely accepted that the NHS has relied heavily on the goodwill
and charitable funding of the hospice movement. We welcome the
Government's statement that it is committed to increasing the
contribution made by the NHS to hospice costs. Witnesses repeatedly
emphasised the need to ensure that when hospices provided services
for NHS patients, they should receive an appropriate payment.
Important questions arise about the basis for calculating such
costs. We are aware of the perverse incentives which operate against
hospices admitting patients with non-cancer diagnoses. Patients
with conditions such as motor neurone disease, for example, may
have complex care needs of a long-term nature. When hospices are
paid on the basis of a care episode there will clearly be an incentive
to admit patients with a relatively short life expectancy.
131. We welcome
the transition that will take place to more sustainable funding
mechanisms for hospices, and the benefits this will have for the
voluntary sector by 2008. We are especially concerned that the
funding mechanism (whereby money will follow the patient) should
be sufficiently sophisticated to recognise the different requirements
of parts of the service and the distinction between longer and
shorter stays for different patients and diagnostic groups.
132. A fundamental
shift in funding from the voluntary to the state sector also offers,
in our view, a golden opportunity to address some of the issues
relating to equity. We believe that need should be carefully mapped
against resources, as is already happening, and that this process
should inform the distribution of central funding. If necessary,
tough decisions will need to be taken not to fund particular
projects if they are in areas which are relatively over-supplied.
Similarly, if particular centres are failing the needs of their
population in terms of ethnicity and age relative to other providers
serving populations with similar profiles, we believe commissioners
should consider withholding funding.
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