Select Committee on Health Written Evidence


Memorandum by The Prince of Wales Hospice, Pontefract (PC 22)


  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.


  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.


  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.


  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.


  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.


  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.


  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.


  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.


  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.


  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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