Westminster Hall
Wednesday 20 May 2009
[Frank Cook in the Chair]
Elderly Patients (Bed Allocation)
Motion made, and Question proposed, That the sitting be now adjourned.—(Mr. Blizzard.)
9.30 am
Miss Anne McIntosh (Vale of York) (Con): I am delighted to have secured this debate on the provision of primary care trust beds and the criteria relating to that. I am also delighted to appear under your chairmanship, Mr. Cook; you take a keen interest in these matters, so it is particularly appropriate that you are here today. I also welcome my Front-Bench colleague, my hon. Friend the Member for Eddisbury (Mr. O’Brien), the Minister and other hon. Members.
I have had a number of constituency cases concerning elderly and end-of-life care, but a recent personal interest has cast a different light on the subject. Some 1.3 million people are employed by the NHS, and I recognise the excellent care provided by staff, not just in Vale of York, but across the country. They deserve praise and recognition at every turn. Their level of care, commitment and dedication is outstanding; they are the true angels of the health service. Having said that, however, not all is well. Considerable changes have been brought in since 1997: the number of hospital beds has fallen; the role of community hospitals has been revised; and there is confusion about who is responsible for each bed, for agreeing the criteria for their allocation and for deciding who occupies them and for how long.
I shall explain my reasons for seeking this debate. I was fortunate enough to have a question on the provision of elderly care beds answered by the Minister of State, Department of Health, the hon. Member for Corby (Phil Hope). However, I had great difficulty understanding the purport of the response. It began:
“Primary care trusts work with local authority partners to commission high-quality care services from appropriate providers to meet local patient needs”.
However, it did not say who those providers are, so it would be helpful to hear today who is involved at each turn in securing that decision.
I then put it to that Minister that, in my view, PCTs have too much power and responsibility and that many of their members are not clinically qualified and yet are taking key decisions about a patient with a terminal illness, which can cause great distress to them, their family and their loved ones. He replied that the Government have
“an appropriate process for commissioning high-quality services locally. It is the responsibility of primary care trusts to undertake that function and, in the case of the care of elderly people, to do so, through beds in hospitals, beds in residential care and so on, in partnership with their local authorities.”—[Official Report, 12 May 2009; Vol. 492, c. 675.]
I shall address not the least of the changes to which I referred earlier. Since 1997-98, there has been a dramatic drop in the number of hospital beds, from 138,000, in 1997-98, to 121,780, in 2007-08. If people are spending less time in hospital after an operation, it can be a good thing, but within those statistics is a sub-figure for geriatric beds, the number of which has fallen from 30,200 to 20,700. That rings alarm bells. I hope that the Minister here today will explain where those beds have gone.
The Government want more people to end their lives in their own homes, and North Yorkshire is no exception. I support that, but many local authorities are reducing the number of places in council-provided care homes, which removes an element of choice, especially for those who cannot remain in their own homes, because, perhaps, they lack support or live in a very rural area where the provision of care is challenging. Over the next five, 10 or 15 years, sufficient care home places will not be available.
The role of community hospital has been revised. I understand that one change came in 2000 and another—possibly—in 2006-08. When I was first elected, it was generally understood that someone who was very seriously ill and likely to deteriorate and enter the end-of-life stage could end their days, over a prolonged period, in a community hospital. That understanding is no longer there. The confusion over the past eight years over the changing role of community hospitals is causing an element of concern and distress. Will the Minister explain how community hospitals fit into that?
On continuing healthcare, it was also my understanding that, once assessed, a patient would remain on that assessment for a prolonged period. That changed in September 2008: following six weeks on continuing health care, that category is now reassessed. Who makes those assessments? I understand that there is an assessor from the PCT and a social worker, but it is not clear who has the final say in each case and who can appeal. I hope to return to that point.
There is a lack of transparency and a clear understanding about the criteria for the allocation by PCTs of beds for the elderly, especially when a patient moves from an acute to a community hospital and when trying to vacate places in the latter over the long term. The way in which the criteria are applied is causing anxiety for patients and distress for families. This month, the Public Accounts Committee, dealing with terminally ill patients, reported:
“People who die in hospital are not always afforded the end of life care they deserve”.
It also concluded that patients are not always treated with “dignity” and “respect”. Patients sometimes have difficulty eating and drinking, which I found hurtful in my own experience. When a close member of the family makes themselves available to hydrate and feed the patient, that needs to be handled very sensitively. Those with such difficulties need particular care, and surely it is in the interests of the Government, the health service and the wider community that family members be encouraged to assist the patient in eating and drinking—hydrating and taking the right nutrition.
Over the past 10 years, the Government have engaged in various reorganisations of health care, but, somewhere along the line, have lost sight of the plight of elderly
patients, in the view of the PAC. Clearly, this problem will not go away, but will increase, given that we are all living longer, owing to improved health care and scientific and medical advances, which obviously we all welcome. However, as part of the Government’s approach of meddling, the criteria for caring for the elderly in community hospitals have changed. I am finding it very difficult to get to the bottom of that change, and I would be very grateful if the Minister were to elaborate .
Mr. Stephen O'Brien (Eddisbury) (Con): In addition to wanting to understand the process, both retrospectively and for the future, is the thrust of my hon. Friend’s anxiety that, in the absence of knowing who ultimately takes a decision, there is no sense of accountability or, indeed, opportunity to negotiate or review a decision, when it does not appear to have been taken on primarily clinical grounds?
Miss McIntosh: There is a problem with both accountability and transparency. We need to know what the criteria are, who takes the decision and what the appeal mechanism is. A second concern is that decisions should be taken primarily on clinical need. I will elaborate on what I think about continuing health care assessment and why it is flawed. Thirdly, and perhaps most importantly, the system seems to be driven on a cost-efficiency basis. I do not think that we can put a price on health care. Someone who has had a good life and lived to a good age deserves to be given by the health service and the community both dignity and a “good death”. I am most grateful to my hon. Friend for allowing me to elaborate on those three points.
Let me expand on the continuing health care assessment, which is the nub of the problem. In my mother’s case, 12 boxes had to be filled in. Even to a lay person, it was evident that she ticked a sufficient number of boxes, yet she was deemed to have failed the assessment. That obviously caused distress, but as I am capable of standing up for myself, I was able to argue our corner. However, that is not the case for a constituent of mine—I will not disclose her name, because I do not have permission—about whom I have been corresponding with the Department. The health care assessment form that she had to fill in ran to 23 boxes—23 different criteria that had to be met, many of which were obscure and opaque. It is very difficult for a lay person, particularly someone who is a close relative of the patient, to understand the assessment system. If someone is unable to eat, drink, take their medication and is in danger of falling, I would have thought that their condition was so transparent that they would tick all the boxes for continuing health care assessment. It is bewildering for a patient to have to tick 23 boxes for a primary care trust. Often, the options are not sufficiently well explained to the patient. If the case involves an elderly relative, the family need to understand the system to be able to explain it. If the patient is registered blind, profoundly deaf or is not able to read the form themselves, relatives will not make much progress in explaining to them the purport and the importance of the assessment.
Will the Minister explain who sets the criteria, who owns or has responsibility for the beds, and who, in each case, delivers the health care? Obviously, part of
that is evident in the location of the bed—whether it is in an acute hospital, a community hospital or another place. Moreover, will the Minister explain who supervises the delivery of the treatment under the continuing health care assessment and does he think that supervision is adequate? I fear that there is evidence of systemic failure in the way in which the criteria of continuing health care assessment are defined. Where does one find the definition? Having seen two or three assessments from different primary care trusts, I understand that there is some fluidity in interpretation.
Community hospitals provide an excellent service. I am fortunate to have two in my constituency—Lambert hospital in Thirsk and St. Monica’s hospital in Easingwold—which provide excellent services close to the homes of local people. Many of the staff live locally and are well integrated in the community. Families, friends and loved ones are easily able to visit the hospitals and the patient can remain close to their own home in fairly familiar surroundings.
My understanding is that there have been significant changes to the role of community hospitals for patients over a six-week period—that arbitrary criterion seems to have been introduced in the past eight or nine years. I want to know why the changes have occurred, highlight the difficulties created by the new criteria and draw attention to the unfortunate results that they are producing locally in the care for the elderly.
It is true that funding for the NHS has risen consistently under both Labour and Conservative Governments since it was founded in 1948. Yet, while the Government have nearly doubled spending over the past few years, the number of beds has reduced overall. In particular, the number of beds available for the elderly has reduced by a larger proportion than any other beds. It looks as though money is being spent on management, bureaucracy, form-filling and pointless and endless reorganisations. We now have strategic health authorities. We had a primary care trust for the whole county—York and North Yorkshire—then four separate PCTs and now we have just one to cover the whole county. I am referring only to the PCTs. If we consider the ambulance service as well, we will see that the number of reorganisations throughout the NHS is bewildering. Surely it is the Government’s hope to ease the distress of elderly patients and restore their dignity by drawing attention to such issues.
In the time that I have been preparing for this debate—I am sure that the Minister is aware of this—the Public Accounts Committee has published a report on end-of-life care. Paragraph 2 is striking:
“People who die in hospital are not always afforded the end of life care they deserve, including effective pain management and being treated with dignity and respect.”
The report goes on to say that when
“someone is approaching the end of life it should not mean we abandon concern for their quality of life”.
“Lack of co-ordination between health and social care services mean that peoples’ preferences for care are not always communicated effectively.”
That confirms the thrust of my earlier remarks. The report continues:
“People nearing the end of their life should be allocated a single health or social care professional contact to improve the co-ordination of care between services and providers.”
I know that it is the intention of the Government and the NHS to have a welcoming nurse for the patient when they are admitted to hospital. In my experience, and in the experiences of my constituents, that is not happening. Often even simple things are not done properly. For example, handovers at the beginning and end of each round are not as full as they should be, particularly when all beds are occupied. When a patient is admitted to hospital and given a terminal diagnosis, the GP should be informed of their condition. When that patient is discharged, a package on the continuing health care assessment is then given to their GP, but for the weeks or months that a patient is in hospital, GPs are kept out of the picture.
It is also wrong that an individual should see seven doctors in as many weeks. Continuity of care should mean, as far as possible, that a patient has a dedicated nurse and doctor—unless the doctor is on holiday or otherwise absent. I take some comfort from the PAC report.
“There is a lack of education and training in basic end of life care.”
That is staggering. In the body of the report—paragraph 14 —the PAC states:
“A survey of doctors and nurses carried out by the National Audit Office found that only 29% of doctors and 18% of nurses had received any pre-registration training in end of life care.”
It is perhaps a good moment to pause and say that I am heavily related to the medical profession: my father was a GP; my brother is a practising GP; my uncle was a consultant surgeon; and we had two or three pharmacists in the family as well—I was never going to go into medical practice, because I do not do very well with the sight of blood. I have always understood that a good bedside manner is important for medical practitioners, and I am sure that for previous generations end-of-life care training was a priority, so what has changed? Staggeringly, less than 30 per cent. of doctors and 20 per cent. of nurses receive any pre-registration training, and they are the people to whom families and patients look to guide them through what is the most traumatic stage of life.
The PAC report goes on to state:
“Primary Care Trusts have limited understanding of the local demand for and the cost-effectiveness of their commissioning of end of life care services. Trusts should use the commissioning guidance provided...and benchmarking information provided by the National Audit Office, to assist them in allocating resources more effectively.”
I am sure that the Minister will want to consider that in the context of my earlier remarks.
“There is a risk that the additional”
money that the Government have
“committed to improving end of life care will not be used as intended.”
How does the Minister expect PCTs to account for how the additional money will be spent and how will information be fed back to the trusts to allow them to benchmark their performance in improving service quality?
“There has been limited formal evaluation of the patient benefits associated with approaches intended to improve end of life care such as the Gold Standards Framework. The Department should”—
“commission clinical evaluations to determine whether use of such approaches results directly in higher quality care.”
Will the Minister take this opportunity to comment on that?
“Some 70% of independent hospices have only one year contracts with the NHS and for 97% the funding they receive does not cover fully the costs of the NHS services they provide.”
That we are so dependent on hospices, as voluntary organisations, to provide end-of-life care will set many alarm bells ringing.
“More people could be supported to die in their homes or in a care home if there was a more responsive system for providing the equipment and support services needed.”
On that, I return to the continuing health care assessment. Will the Minister explain how rapidly the equipment can be put in someone’s home? How close are we to the provision of 24-hour care in the home and are there big differences between the level of care that can be provided by two adjoining PCTs, for example, between the North Yorkshire and York PCT and the County Durham PCT? The report states:
“The Department should review how requests for equipment and other assistance that support people to remain in their homes are handled, and identify ways of improving the speed and flexibility of the provision of such services.”
I welcome this opportunity to set out my concerns. I hope that the Minister realises that my constituent’s mother died in January, and that now, in May, she is still chasing the PCT, which does not cover my constituency. That situation has caused enormous human distress. I hope the Minister elaborates, so that I can go back and explain to my constituents how the continuing health care assessment works, who in the PCT is responsible for taking such decisions and what the appeal mechanism is. Will he satisfy me that when the PCT takes such decisions, it does so on the basis of clinical need, and that the matter should not be seen, as it currently is, as a tick-box exercise for those who are approaching their final days?
| Next Section | Index | Home Page |