APPENDIX 18
Memorandum by The Prince of Wales Hospice,
Pontefract (PC 22)
BACKGROUND
The Prince of Wales Hospice, Pontefract provides
specialist palliative care to a population in excess of 200,000.
It is broadly co-terminus with the Eastern Wakefield Primary Care
Trust and so serves the five towns of Castleford, Pontefract,
Normanton, Featherstone and Knottingley and the communities of
Ackworth, Kinsley, Hemsworth, South Kirkby, South Elmsall, Ryhill,
Havercroft, Fitzwilliam and Upton. However, in practice there
are no geographic boundaries and care is extended to patients
from outwith that area, in the main to those from in and around
the towns of Goole, Selby, Kippax and Sherburn.
Eastern Wakefield is an area of multiple social,
education, employment and health deprivation. For example:
— the workforce contains a higher proportion
of unskilled and partially skilled workers than both the region
and the country;
— 75% of the twelve wards are in the
20% most deprived in the country, with two being in the most deprived
5%;
— 75% of the twelve wards fall within
the top 20% most educationally deprived wards in the England,
as measured by the lack of qualifications;
— 83% of the twelve wards are within
the 20% of the most employment deprived wards in the country;
and
— life expectancy in Wakefield is a
year less than nationally for both genders and, overall, is five
to ten years behind the national trend in terms of life expectancy.
Significantly more people have health problems
and illness in eastern Wakefield compared to the region and nationally,
with all 12 wards in the 20% most deprived wards in England from
a health perspective. Half the wards are in the bottom 5% most
deprived wards. The most common causes of death are circulatory
diseases (35%) and cancer (30%), with the former predominating
in males and the latter in females: indeed, the current NHS Performance
Indicators (February 2002) illustrate that the Wakefield Metropolitan
District has the 19th highest cancer mortality rate in the country.
The third largest cause of death is respiratory disease, which
accounts for 10% of all deaths.
The Prince of Wales Hospice, Pontefract provides
specialist palliative care by way of a day care unit that accommodates
ten patients a day, five days a week; an incare ward that can
take up to nine patients at any one time; physiotherapy and complementary
therapies; pastoral care; social care; bereavement support; and
co-ordinated discharge. The Hospice also provides a part-time
Lymphoedema clinic for outpatients. Medical care is provided by
a consultant in palliative medicine and three doctors who either
have or are studying towards the diploma in palliative medicine.
The therapeutic team comprises specially trained and experienced
nurses, a physiotherapist, complementary therapists and a family
care team.
The Hospice works in collaborative partnership
with two other local providers of specialist palliative care,
one of which is based at the local hospital and the other in the
community.
RESPONSES TO
THE COMMITTEE'S
TERMS OF
REFERENCE
1. Issues of choice in the provision, location
and timeliness of palliative care services, including support
to people in their own homes.
Response: a weekly multi-disciplinary team
meeting of the three Eastern Wakefield local providers of specialist
palliative and others (eg district nurses) reviews and considers
the most appropriate care package for individual patients within
the resources available and how these are deployed. For the most
part, the Hospice provides specialist palliative care at the Hospice,
but is keen to extend the range of its provision to include providing
total care to patients at home should they wish to be treated
there. However, resource constraints (both financial and personnel)
currently prevent this. At this juncture all care is provided
in good time to meet patients' needs.
2. EQUITY IN
THE DISTRIBUTION
OF PROVISION,
BOTH GEOGRAPHICAL
AND BETWEEN
DIFFERENT AGE
GROUPS.
Response: an independent review of the provision
of palliative care in Wakefield in 2002 concluded that the area
as a whole warranted two independent hospices, one in western
Wakefield and the other in the east and that the current provision
of incare beds (16 and 9 respectively) was apposite for the socio-economic
and health profiles of both areas. The local primary care trusts
separately and subsequently took this view. Bed occupancy at The
Prince of Wales Hospice, Pontefract fluctuates throughout the
year, as it does at all hospices. However, average bed occupancy
of 86% would support the view that there is a need for the Hospice
locally.
The Hospice's referral and admission criteria
are wholly based on patient need, not diagnosis or age. On average,
95% of patients have malignant disease and 70% are over the age
of 70.
3. Communication between clinicians and
patients; the balance between people's wishes and those of carers,
families and friends; the extent to which service provision meets
the needs of different cultures and beliefs.
Response: the Hospice prides itself on good
communication between doctors and patients, believing that it
is essential to effective care and to trusting doctor-patient
relationships. The views and beliefs of patients are elicited
and respected. Patients are given the information they ask for,
or need, about their condition, treatment and prognosis in way
that they can best understand the information. That information
is shared with patients' relatives and/or carers as required,
once the patients' consent has been obtained.
The Hospice is also involved in training other
healthcare professionals in communication skills.
In providing the holistic approach that is the
kernel of specialist palliative care, the Hospice seeks to provide
care and support for both the patient and his/her family, carer(s)
and friends at often a time of great distress: that said, the
primary focus of care is the patient and his/her needs and wishes
always take priority, although the views of family members et
al are always elicited and considered either by Hospice staff
or at the multi-disciplinary meetings mentioned above.
The ethnic mix of eastern Wakefield differs
significantly from that of urban West Yorkshire in that less than
0.5% of the population is from an ethic minority. Therefore, mainstream
service provision reflects the needs of the majority of the population:
however, mechanisms are in place to ensure that the cultural,
spiritual and other needs of all patients and their families et
al are met on admission and throughout their care and support.
These mechanisms have worked seamlessly and well in practice.
4. SUPPORT SERVICES,
INCLUDING DOMICILIARY
SUPPORT AND
PERSONAL CARE
Response: whereas the Hospice always seeks
to provide such support and to contribute to the personal care
of patients, whether they are day care users at home or discharged
incare patients, in collaboration with other service providers,
the reality is that the resources at the Hospice's disposal necessarily
limit such support. It could be, therefore, that the best package
of care per se is not always provided if the specialist expertise
resides within the Hospice but cannot be utilised because of the
finite nature of its resources.
5. QUALITY OF
SERVICES AND
QUALITY ASSURANCE
Response: the Hospice was inspected by the
National Care Standards Commission (NCSC) in February 2003 but
has yet to receive a copy of the Commission's inspection report.
It has not been possible, therefore, to form a view as to whether
the NCSC provides a useful quality assurance vehicle that will
usefully contribute to raising the standards of care in the Hospice.
However, the Hospice is a member of Quality
by Peer Review in Specialist Palliative Care provided by the Yorkshire
Peer Review System and was last reviewed under this system in
January 2003, when it was determined that the quality of the services
provided rated highly when compared to those provided by other
hospices.
The Hospice retained Investors in People (IiP)
in 2003 in recognition of its efforts to become a learning organisation.
Clinical governance is provided through a committee
comprising all members of the therapeutic team and is chaired
by a Trustee. The Board receives and considers regular reports
on the work of this committee, and its first annual report will
be published in due course.
6. EXTENT TO
WHICH SERVICES
MEET THE
NEEDS OF
DIFFERENT AGE
GROUPS AND
DIFFERENT SERVICE
USERS
Response: the services provided by The Prince
of Wales Hospice, Pontefract fully meet the needs of all service
users who receive care at it, regardless of their age or illness.
This is ensured through the multi-disciplinary approach to care
used by the therapeutic team, regular diagnostic care plan reviews
and the adoption of an open, learning culture to issues as they
are presented. However, it is probably a moot point whether that
would be true of the services provided to the population of eastern
Wakefield as a whole, given the reliance on primary carers to
refer patients to the Hospice. A systematic approach to informing
primary carers of the services provided by the Hospice is now
underway with the objective of ensuring that referrals for specialist
palliative care are made when they best suit the needs of the
patients.
7. GOVERNANCE
OF CHARITABLE
PROVIDERS, STANDARDS
OF ORGANISATION,
LINKS TO
THE NHS AND
SPECIALIST SERVICES.
Response: The Prince of Wales Hospice, Pontefract
is a company limited by guarantee and a registered charity and
is registered with the NCSC as an independent hospital/hospice
for adults. In fulfilling its obligations as those entities and
by meeting its statutory obligations under, for example, health
and safety regulations and employment law, it could be argued
that the Hospice is not just adequately regulated but is overly
so. Certainly, the cost of meeting its various and several obligations
is onerous and diverts resources away from patient care.
Links between the Hospice and the NHS have been
fostered over the years and are now many-faceted, from formal
instruments such as the service level agreements between the Hospice
and the Eastern Wakefield Primary Care Trust and the Mid Yorkshire
Hospitals NHS Trust and the local palliative care strategic planning
group to informal working arrangements at all levels and between
all professional groups. By-and-large, these links are robust
yet sufficiently relaxed to facilitate optimum patient care. Similarly,
specialist services provided to the Hospice, either formally by
way a service level agreement or informally through, for example,
peer networks, are at a level and of a standard that are acceptable
to the Hospice. Specialist services purchased by the Hospice are
subject to close contract management to ensure value-for-money.
8. WORKFORCE
ISSUES INCLUDING
THE SUPPLY
AND RETENTION
OF STAFF
AND THE
QUALITY AND
ADEQUACY OF
TRAINING PROGRAMMES.
Response: the supply of trained doctors
in palliative medicine is poor at consultant level and below.
Urgent measures need to be taken to make palliative medicine a
more attractive option for trainee doctors and for those wishing
to become consultants and to increase the number of training places
available at both levels. Moreover, assistance—financial
and otherwise—should be available to those hospices that
employ doctors part-time and support them in obtaining a qualification
in palliative medicine.
Similarly, there is a finite number of suitably
trained, qualified and experienced trained nurses in palliative
care and the recruitment of them is therefore problematic, especially
at a more senior level. Again there need to be incentives to hospices
to take on those nurses without the necessary qualifications etc.
and to train them. It remains to be seen whether these recruitment
difficulties are exacerbated by "Agenda for Change":
this is highly probable as not all hospices will be able to afford
the significant increase to the wages bill that will be the inevitable
consequence of introducing that particular initiative (this one
included).
Once recruited, retention is not a significant
issue as at 15% staff turnover is relatively low.
9. FINANCING,
INCLUDING THE
ADEQUACY OF
NHS AND CHARITABLE
FUNDING AND
THEIR RESPECTIVE
CONTRIBUTIONS AND
BOUNDARIES.
Response: to break even in 2003/04 The Prince
of Wales Hospice, Pontefract will require an income just over
£1.5million but is unlikely to achieve that and will therefore
return a deficit of £70,000. The Hospice's limited reserves
will allow it to absorb that deficit but it is not a situation
that could be sustained in the medium-to-long term. Indeed, should
"Agenda for Change" have to be introduced so that staff
can be recruited and retained and so as to maintain staff morale
(see immediately above) even the short-to-medium-term financial
situation becomes precarious.
About 24% of the Hospice's income this year
will come by way of a grant from the Eastern Wakefield Primary
Care Trust (EWPCT). The service level agreement between the Hospice
and the EWPCT categorically states that it cannot guarantee that
level of funding every year, although it has stated that its ultimate
aim is to fund 50% of the cost of running a 9 bed incare ward
because of its key position in the provision of the local palliative
care services. This year it will cost about £900,000 a year
to run the afore-mentioned ward, of which the EWPCT's current
grant will provide only 39%. Moreover, the cost of providing this
service will increase significantly if or when "Agenda for
Change" is introduced so the paucity of the NHS's contribution
to it will be exacerbated.
It could be equally argued that the daycare
service provided by the Hospice is also intrinsically woven into
the fabric of local palliative care, to which by exception the
NHS makes no financial contribution. The total cost of providing
this service this year will be £190,000 and it would be reasonable
for the NHS to contribute to this expenditure.
The remaining income is generated through fundraising
activities (50%) and the Hospice's charity shops (26%). Given
the socio-economic conditions in which both take place, sustained
growth is challenging and cannot be assured.
If the Hospice is to continue to provide first
class services to communities that will undoubtedly continue to
need them and if it is to extend the range of its services to
better meet the needs of its population and to contribute to Government
objectives (eg hospice care at home), the NHS will have to increase
its funding at a faster pace than hitherto so that it at least
contributes the proportion of care costs that it has indicated
it will in financial year 2004/05. Regardless of whether or not
that is achieved, all future NHS funding should reflect the effects
of NHS pay initiatives on the Hospice's costs so as not to further
worsen its financial position.
10. THE IMPACT
AND EFFECTIVENESS
OF GOVERNMENT
POLICY INCLUDING
THE NATIONAL
SERVICE FRAMEWORKS,
THE CANCER
PLAN AND
NICE RECOMMENDATIONS.
Response: all changes to government policy
are reviewed to determine their relevance to Hospice policies,
procedures and protocols and, if it would be beneficial to patient
care, necessary changes are made to the last three. And, of course,
government policy informs negotiations with the Eastern Wakefield
Primary Care Trust over the service level agreement and provides
a backcloth to other dealings the Hospice has with the NHS. The
impact of recent policy changes has been minimal and, of course,
the NICE recommendations are still in draft form.
17 February 2004
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