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20 May 2009 : Column 410WH—continued
The most worrying thing that emerges from the debate is the lack of education and training of professionals in basic end-of-life care, and the fact that people who die in hospital are not always afforded the end-of-life care, dignity and respect, effective management, hydration and nutrition that they deserve. If I achieve anything through this debate, I want to see a single professional contact and perhaps a review of the system for the allocation of beds by PCTs. I am most grateful to have had the opportunity to discuss this matter today.
9.55 am
Bob Spink (Castle Point) (Ind): I am grateful to you, Mr. Cook, for allowing me to say a few words, and I congratulate the hon. Member for Vale of York (Miss McIntosh), both on bringing to the House a subject of growing importance, and on dealing with it in a sensitive and thoughtful way.
Care of the elderly is a measure of the civilisation of our society. When people are at the end of their lives, it is a stressful time for them and their families, and they require a lot of dignity and respect. I declare an interest: my son is a consultant neurosurgeon who
treats some of the hon. Lady’s constituents at the neurosurgical centre in Hull and he often allocates beds for elderly people.
In January this year, Help the Aged, which is merging with Age Concern to make a single charity that will lobby on behalf of elderly people, and the British Geriatrics Society, produced a report in which they highlighted the fact that almost half the doctors who specialise in health care for the elderly think that the NHS is institutionally ageist. That is a worrying statistic, and I will say more about it.
First, we should put this debate in context. In the past decade, the Government have increased by a phenomenal amount the resources going into health care, on which they are to be warmly congratulated and for which they should be thanked. I am sure that whoever forms the next Government will continue that process but, unfortunately, the outcomes in the health service are not perceived to have increased or improved at the same rate, never more so than in relation to this matter, probably because people are living longer, which is a blessing. The average life span is about 83 years for ladies, and 78 years for men—I am hoping that the next Government will allow sex changes on the NHS because when I am 77, I intend to go for a sex change. More seriously, the demands for care are growing consistently and will continue to do so.
The hon. Lady made the valid point that there are insufficient beds, but the really important point is patient choice. It is not so much a matter of how many beds there are in any one part of the system, but of ensuring that there is the right number of beds in each part of the system, however many that is. There are different ways of caring for people when they are elderly or terminally ill, and it is important to ensure that there are sufficient beds in each part of the system to care for them, and to enable them to have choice between acute hospitals, community hospitals, the hospice service, nursing homes and family care at home. Different people will make different choices as to how they want to spend their last weeks, months and years.
I will focus on hospices, because the number of hospice beds determines how many beds will be needed in the NHS. I am grateful to the Government for the funding of the adult hospice sector—much more so than for the funding of the children’s hospice sector, which is a different matter. The Government are funding the sector generously, but we must ensure that hospices remain essentially voluntary organisations funded by charitable donations, as that is their ethos and character, which is a good thing. However, we must also ensure that any care given by hospices that displaces care that would otherwise have to be given by the national health care service, and would thus involve providing beds, is properly funded. The NHS and the Government must continue to work with hospice centres to develop a proper service agreement under which the care provided by hospices is funded by the NHS, so that hospices can continue to provide service and increase service to meet demand. I know that the Minister is sympathetic.
The right hon. Lady—excuse me, the hon. Lady; she should be a right hon. Lady—made some excellent points on nursing homes, but the problem with nursing homes is the formula for deciding how much a family must pay in top-up fees for the bed provided. I am
aware of one case involving a lady who had a stroke eight years ago and has not said a word since. She is doubly incontinent and cannot speak, stand, eat or support herself sitting up, yet her family must pay several hundred pounds a month in top-up fees for what is obviously nursing care, which traditionally would have been provided in a long-term hospital bed. Eight years after the stroke, the family is having great difficulty paying the top-up fee. The lady was reassessed recently, but the family must still pay just over £106 a week in top-up fees. That is not good enough.
The Government are short-changing not only families but themselves, as the situation means that people stay in hospitals because they are not happy to move to homes. The Government are missing a trick. If they were a little more generous, and ensured that social services were more generous in assessing the nursing care element, we could get more people into residential homes where they would have society and a better quality of life and would be nearer their families. All in all, that would be a good deal for the individual and for the public purse.
On care at home by the family, there are some wonderful, heroic families who care for loved ones at the end of their life. They can do so only because of the fantastic support that they are given by Macmillan nurses, who take a lot of pressure off the NHS to provide beds in hospitals. We must never lose an opportunity both to congratulate Macmillan nurses on what they do and to promote their activities.
I have probably said enough, so I will end by quoting Help the Aged and the British Geriatrics Society, which said that the NHS must
“stop being service-led and become people-centred”,
and must do it soon. I know that the Minister is doing all that he can to move in that direction.
Frank Cook (in the Chair): Right hon. and hon. Members will see that there are 57 minutes left before we must move on to our next topic for debate. As we have three Members who wish to make winding-up speeches, I expect each speaker to take no more than 18 minutes.
10.4 am
Greg Mulholland (Leeds, North-West) (LD): Thank you, Mr. Cook. I will take nothing like 18 minutes, to the relief of right hon. and hon. Members. I congratulate the hon. Member for Vale of York (Miss McIntosh) on securing this debate, and on her persistence on the issue. At the end of last week, I had the pleasure of walking through her constituency, which was enjoyable. I did the Ebor way as part of my training for the 126-mile challenge that I am supposed to be finishing this weekend. When I got to my own constituency, the weather changed somewhat, and it became rather less pleasurable. I am sporting an enormous blister on my left foot, which is something of a challenge.
The issue that we are debating is enormously important, and the hon. Lady is right to raise it. To echo the comments that have already been made, I think that all of us appreciate the wonderful work done in the NHS and in many care homes to look after our older people and ensure that they have the care and dignity that they deserve. That is not always the case, but a lot of wonderful work goes on, and it is important to recognise that.
Older people are the largest single demographic using NHS services. Despite that fact, the NHS is all too often not geared to the needs of older people. That lies at the heart of some of the problems that we often discuss in debates attended by the right hon. and hon. Members here today, who have a particular interest in the needs and rights of older people in health and community care.
The age of 60 is no longer old. People of 60 are still running marathons; I ran one a few weeks ago alongside people in their 60s, their 70s and even, amazingly, their 80s. Yet in the health service, people who reach 60 are suddenly regarded as older, or “elderly”, to use the term in the title of this debate. We must face the fact that despite attempts to counter the problem with measures such as the Equality Bill, which is going through Parliament, institutional ageism still exists within our health services, to echo the point made by the hon. Member for Castle Point (Bob Spink). That is simply not acceptable. All too often, older people’s needs are not met in hospital. Adequate provision is not made for conditions that are particularly, although not exclusively, related to older people, such as incontinence. That is a huge part of the problem.
We are all aware that funding for the NHS is a concern. The simple reality is that savings will have to be made in this difficult economic climate. The Budget estimates that those savings need to be about 3 per cent., or £10.5 billion, and that £500 million of savings have already been made. My first point to the Minister—and I am sure that we would all agree—is that the needs of older people, which I am afraid are not always met, as we heard from the hon. Member for Vale of York, must not be seen as an easy place to make further efficiency savings.
The Budget says that savings will be made partly by reducing the length of stay of people in hospital. Where clinically appropriate, that is something that we all support, but there is a concern about older people who are not necessarily so ill that they need to be in hospital but whose communities lack the facilities to deal with their needs. They may be simply too weak to live at home and cope alone, and I am afraid that they do not get the care that they need through local authorities to be able to do so. All too often, an unfortunate cycle arises. Older people are discharged from hospital back to their home, yet without the care and support that they need, they simply deteriorate, become ill again and are readmitted. The situation costs the health service huge amounts of money, because we are not dealing with people in a way that enables them to carry on without the need to go into hospital.
Primary care trusts’ funding is weighted by the number of older people in their area. We would therefore expect areas with more elderly people to have better care provision, but I do not think that the figures bear that out. One problem—this is a debate that we have had on many subjects—is that there is no ring-fencing. Surely, if there is a failure across the country to address the problem of dealing with older people who are not ill enough to be in hospital but clearly need a higher level of support, there must be some way to ensure that money is spent where it is needed.
Although this debate is about older people, my simple point is that whether or not people should be in a hospital or community hospital should be judged on
their individual needs, regardless of age. Having said that, account must be taken of the particular situation that older people are in. Clinical judgments must take account of what will happen if the person is discharged from hospital. Too often, older people do not receive sufficient care in the community to prevent them from becoming ill again and returning to hospital. Although they are important, PCT criteria will continue to mask the problem until we break that cycle. There must be a principle of providing proper support in the community.
Emergency admissions of older people have risen in recent years, and that costs money. It is not ideal to keep older people in hospital for any length of time. They face particular problem such as being more susceptible to health care-acquired infections, and that will continue until there is more investment in community care and a better system of care funding up and down the country. That is what it boils down to.
On the other side of coin, we must look at the problem of bed blocking. Department of Health figures show that during one week in March 2008, some 2,232 people across the country suffered a delayed discharge from hospital. Beds are being used that need not be used if care in the community was adequate. The issue is not only about cost, but about people of all ages being unable to get the hospital beds that they need.
The hon. Member for Vale of York mentioned the end-of-life strategy, but that does not wholly relate to the subject of this debate, because many older people who go in and out of hospital are not at the end of their lives. We can and should enable such people to carry on living full lives for many years. However, end-of-life care is a particular issue for older people. As the hon. Lady said, about 40 per cent. of people who die in hospital do not have medical needs and therefore do not need to be there. A strong preference for dying at home was shown in the Public Accounts Committee report that she quoted. Despite that, 60 per cent. of deaths occur in acute hospitals. In many cases, the person has no clinical need to be there. Only 18 per cent. of people die at home.
Interestingly, the figures on the proportion of people who die in acute hospitals across different PCTs range from 46 to 77 per cent. In some parts of the country, more than three quarters of people die in hospital. As I have said, 40 per cent. of people who die in hospital do not have medical needs and so do not have to be there. We are therefore failing on both counts.
To echo the hon. Member for Castle Point, it is impossible not to mention the fact that the Government have invested heavily in the NHS. They are to be commended on that investment. At the end of the Government’s life, which is approaching, they will be able to say that they have put a lot of emphasis on the NHS. They can present that as a success. Nevertheless, the system of care for older people in this country is an acute and abject failure for this Government. Tony Blair infamously said that he did not want to live in a country in which people had to sell their homes to pay for care. Despite that, the Government have done precious little to address the system of care funding.
People have no idea what they are entitled to. In fact, they are entitled to very little unless they sell their house and drain a large amount from their savings, or they already live in poverty and so qualify for certain benefits. We do not have the national system of entitlement for
older people that we need. I wait with interest to hear both the Conservative and Government policies for the next election. We have stuck our neck above the parapet with the Liberal Democrat minimum care entitlement policy, which states that every older person in this country should have some entitlement to care. I look forward to the debate on how much people should be entitled to if we go down that road. It pretty much follows the Wanless model. If people know that they have an entitlement, they can plan and have some security in older age.
We believe that our policy would go a long way towards stopping the cycle of people being discharged from hospital without adequate provision, getting ill again and blocking hospital beds unnecessarily. In the limited time that remains for them, how do the Government propose to deal with that problem, which they have not dealt with so far? There is a dual challenge and it is not easy to solve. Will the Minister give us some idea of how the Government intend to deal with it? Until this important challenge is addressed, we will not meet the needs of older people in our country, and everyone would agree that that is not acceptable.
10.17 am
Mr. Stephen O'Brien (Eddisbury) (Con): In this House, we often speak of our constituents’ experiences and of our professional experiences. It is rare that hon. Members draw on their personal experiences when advocating for others. I congratulate my hon. Friend the Member for Vale of York (Miss McIntosh) on securing this important debate. By speaking up for her constituents, she has spoken for all our constituents. I pay tribute to her candour and courage in relating her recent experiences as a caring daughter to her mother.
My hon. Friend’s speech was shot through with a sense of the quality of our NHS. She stated that our focus on care and what we mean by care defines how civilised we are as a society. I agree that whenever we discuss these matters, we must repeat our admiration and support for all the care workers and professionals in the NHS. That is a personal matter for me because my wife is an NHS-trained nurse—she has specialised in caring for the elderly and more recently has become a hospice nurse. My hon. Friend’s comments are apposite to the aim we all share of providing the best possible care for people throughout their lives, and particularly as they approach the end of their lives. She is right that nurses tend to be the apex of that consideration.
The case that my hon. Friend described raises serious questions about the reality of local policies. The complexity of allocating beds to elderly patients reflects the complexities of morbidity and mortality as age progresses. Allocation is linked to issues such as cancer, palliative care, and intermediate and continuing care policies. Issues of quality are also linked to the bed, once it has been allocated, particularly in relation to the Government’s dignity in care agenda.
In the wake of the Staffordshire general hospital case, we must discuss bed provision in hospitals. One of the Healthcare Commission’s criticisms was about insufficient beds. In 2007-08, the number of NHS beds was cut by 4 per cent.—6,722 beds—and in the past three years, as
the NHS has struggled to recover from deficits, the number of beds has been cut by 11 per cent., or 20,699. It is important to emphasise the point that my hon. Friend made, citing a further statistic, about the disproportionately negative effect that that has had on geriatric beds and elderly people. Bed occupancy is still too high, running at more than 95 per cent. in some trusts.
I recognise, however, that bed cuts are a crude measure. Better care should lead to a reduction in beds, but it is not clear that the relationship is organic, as is testified by the Government’s recent failure to bring superbugs adequately under control, to deliver on single-sex wards, to provide isolation beds or to prevent the tragedy at Stafford. Sir George Alberti makes telling comments in his review of Stafford, noting that there are serious problems around bed management. Of the emergency admissions unit, he says:
“There are officially 37 beds in the unit but this has been increased to 49. The layout is poor and there are insufficient nurses, particularly to manage the extra number of beds.”
That point emphasises that there must be proper staff resources for the number of beds in place. It also has ramifications for the dignity agenda. Will the Minister confirm how many hospitals are operating beds, or wards with beds, in excess of their official capacity? If he cannot do that immediately, will he ask his officials to grant that information by writing letters to hon. Members who have attended the debate?
Alberti also recommended that patients should be reviewed at 11 o’clock every morning, seven days a week, to see whether they could be discharged. It is important that bed blocking is avoided, but the reverse is also true, and patients must not be turfed out of their bed for anything other than clinical reasons—my hon. Friend the Member for Vale of York argued that point emphatically. Will the Minister explain what safeguards are in place? If it cannot be demonstrated that the only criterion, or the overwhelming priority criterion, is clinical, the only other default position, which might be addressed under the term “administration” or “efficiency”, would, at the end of the day, be a cost consideration. That seems completely inappropriate if we want to give people the best possible care, particularly as they approach the end of their life.
There is a more important issue, and I thought it rather strange that the Alberti report did not address this. It is clinically critical, particularly for good nursing—it has certainly been proven to be best practice since time immemorial—to start discharge planning the moment a patient arrives in a bed. That applies even when the patient appears to be moving towards the end of their life, or when it is too early to determine whether there will be an opportunity to discharge them or whether they are approaching the end of their life, in which case consideration should be given to whether that will be in hospital or whether the patient will be given a choice about where to die.
Miss McIntosh: My hon. Friend is examining this issue very thoroughly, but the concept of early discharge when a patient has been in a new situation for only one day or one week causes the most distress. How can we handle that more sensitively, rather than making the patient feel unwelcome when they have been there for only a short time?
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