Memorandum by Dr Ann Morris (PC 28)
North Lincolnshire PCT serves a population of
approximately 157,000 and is part of the Humber & Yorkshire
Coast Cancer Network. Within North Lincolnshire there are 22 GP
practices, 1 adult hospice and 1 Acute Trust supported by 5 Macmillan
Clinical Nurse Specialists2 in the acute trust and 3 in
ChoiceThe provision of Palliative Care
Services in respect of location, timeliness and support to people
in their own homes:
Palliative care services are provided
by the PCT, the Acute Trust and an independent Hospice
District Nurses provide generalist
palliative care as do General Practitioners and are both supported
by the Macmillan Clinical Nurse Specialist (CNS).
Access to Macmillan Clinical Nurse
Specialists is mainly via General Practitioners and the acute
trust; the method of referral varies across our network. There
is evidence to suggest that formal referral guidelines need to
be developed to avoid delayed, duplicated or missed referrals.
In addition to the above mentioned
professionals, patients/carers/family are supported by the PCT
Home Healthcare Team and Marie Curie services
The Macmillan CNSs are able to provide
some level of support in respect of social/psychosocial issues
but the level of advice given is subject to the depth of available
knowledge and the amount of time available to spend with the patients/carers/family
Social Services provide some level
of intervention but this does not replace the need for a palliative
care social worker
The hospice provides specialist advice
to patients/carers and family members both as part of the day-care
and in-patient facility. It provides symptom control combined
with other therapies as well as brief respite.
A recent Macmillan survey of local
GP practices confirmed that some practices recorded the patients'
preferred place of death. However it was noticed that patients
and relatives were subject to changing their minds as situations
changed, eg deterioration of illness, family unit breakdown, inability
In order to facilitate patient/family/carer
choice when this relates to remaining at home, support needs to
be virtually instantaneous as this category of patient does not
have the luxury of time to wait for bureaucratic processes to
take due course
24hr District Nursing Service is
not available in North Lincolnshire, Provision of this would go
some way to providing the support and confidence patients/carers/family
need in order to remain at home.
Work in respect of anticipatory care
is ongoing eg hand-over-forms for out of hours staff but more
GP education is needed.
Time and resources (financial/professional)
are limited in financially constrained organisations.
The discharge of patients from hospital
who wish to go home or to the hospice for the last days of life
is hindered by the lack of flexibility of transport arrangements.
A group will be convened to discuss
and explore possibilities for initiating a rapid discharge policy
for terminally ill patients who wish to be transferred from hospital
to home/hospice for the last days of their life.
The ambulance service does not see
terminal patients as a priority to discharge as they are "secure"
in hospital and therefore the priority is given to attending someone
needing to be admitted to hospital.
EquityDistribution of provision, geographical
and between different age groups:
Cancer patients have the cancer plan,
NICE guidance etc,. Other palliative patients including those
with Motor Neurone Disease, cardiac failure, chronic respiratory
disease and renal failure and others do not,. This can lead to
potential inequalities in relation to patients requiring palliative
care but are not suffering from cancer
North Lincolnshire has access to
Children's hospices in neighbouring areas.
North Lincolnshire covers a wide
geographical rural area which can impact on patients'/family/carers'
access to services.
Consideration needs to be given to
staffing levels in the above circumstances. The distance/time
travelled should inform staffing numbers, which should therefore
not be formula based.
Communicationbetween clinicians and patients;
The balance between people's wishes and those of Carers, Families
Local education programmes are addressing
the need for better communications between all parties
The needs of different cultures and beliefs:
A local assessment of ethnicity has
been undertaken locally and will inform future service planning
Support Servicesincluding Domiciliary Support
and Personal Care:
The limitation of resources (financial
and manpower) impact greatly on the ability to achieve a timely
and robust service, therefore the provision of appropriate and
timely support services requires further investment in relation
to both personnel and finance.
Patients can undergo numerous assessments,
which can delay the actual delivery of services required. Need
to develop single assessment mechanisms.
Qualityof services and quality assurance:
The local hospice is regarded highly
for the services it provides
Needsof different age groups and different
Where possible local services take
cognisance of the differing needs of the various age groups and
multi cultural community we live in.
Governanceof charitable providers, standards
of organisation, links to the NHS and specialist services:
Comply with and conform to recommendations
by CHI, National Care Standards, Cancer Network Peer Review process.
Local independent hospice has well
established links with NHS health organisations.
WorkforceSupply and retention of staff
and adequacy of training programmes:
National shortage of consultants
in palliative medicine impacts on ability to recruit locally.
Unattractive to newly qualified consultants
to be working outside of an established professional centre.
Consideration should be given to
the accreditation of professional staff who have provided "long"
service in palliative medicine (in line with accreditation process
up to 1997).
Nurses are taking on more senior
roles with added responsibility, which adds to the shortfall in
the already depressed "hands-on" nursing service.
Financingincluding the adequacy of NHS
and charitable funding and their respective contributions and
The NHS should provide funding to
charitable hospices equal to the level of costs that would be
incurred by the NHS, should the hospice not exist.
Core Funding (clinical costs/admin/cleaning/general
wear-and tear) should be considered for hospices as baseline funding
is being erodedpercentage uplifts do not equal staffing
Allocations should be made to PCTs
in a timely way to enable the appropriate planning of services.
The release of the Specialist Palliative
Care Funding could have been more timelyto coincide with
the definitive NICE Guidance for Supportive and Palliative Care.
Government Policythe impact and effectiveness
of National Service Frameworks, the Cancer Plan and NICE Recommendation
The delay in releasing the definitive
NICE Guidance on Supportive and Palliative care has not been helpful
to the recent formal planning process (LDP refresh).
The NSFs highlight the need to provide
Palliative Care services to other patient groups.
Recommendations to the Government:
Review hospice funding allocations
to include core services.
Planning can only be truly informed
by the full funding envelope being available at the commencement
of the planning roundno surprises mid-year with additional
dictates/targets with no additional resources because "its
included in the baseline".
Address the shortfall of consultants
in palliative medicine