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20 May 2009 : Column 416WH—continued
Mr. O'Brien: My hon. Friend’s question helps to make this point clear. We must ensure that the emphasis is right. Early discharge should occur only on clinical grounds—in that sense, it is not early, but appropriate. Early discharge is never really justified because, if it is early, it is happening before it would be considered appropriate on clinical grounds. Perhaps her intervention will help me to clarify that I am arguing not for early discharge, but for a process of discharge planning that starts as soon as a patient arrives in a bed. That is good clinical practice, because part of getting patients as well as possible is looking at how that can be achieved in the shortest possible time with the maximum possible care and dignity. That is especially important where there is high capacity utilisation of beds, the numbers of which are reducing, particularly for elderly patients in acute and hospital settings.
Not only are bed numbers reducing, but there is a real lack of intermediate care beds, as has been debated by Front Benchers before. In Winsford, in my constituency, a former care home was converted into Elmhurst intermediate care centre, which opened recently. That NHS asset had been lying redundant for far too long—many of us campaigned and argued about it—and eventually the local NHS hospitals trust, which covers Leyton hospital and the Victoria infirmary in Northwich, decided to convert it into a 30-bed intermediate and rehabilitation care centre to provide around-the-clock NHS care outside the hospital setting. I have visited it, of course, and met the staff, management and patients, and it was encouraging to see the progress that patients were making, and that they were receiving great care and were very enthusiastic about the centre.
Such an approach is appropriate for rehabilitation, mainly for elderly people, not all of whom will go home. It provides an opportunity to avoid what seems to happen most of the time, when there is an emergency of trying to find a bed for continuing or later care, but the family are not ready. It gives people time to prepare and offers the patient a chance not only to recover medically, but to regain some of the confidence that is often lost as a result of a medical procedure. That work among Mid Cheshire Hospitals NHS foundation trust, the Central and Eastern Cheshire primary care trust—my hon. Friend made a key point about PCT involvement and who has true accountability—and Cheshire East Community Health shows how powerful it can be to work outside silos. We need much more of that kind of provision through the allocation of resources across the NHS. However, there must be a consideration of accountability and the question about who should ultimately take decisions on provision and allocation.
The elderly who are allocated beds are often receiving palliation. I am in no way suggesting that the state should try to usurp the fantastic work done by volunteers and professionals throughout the country in the hospice sector—no doubt the Minister will discuss the actions that the Government have taken on end-of-life care. The “End of Life Care Strategy” was published last July, although it was twice delayed. The headlines were about moving care away from hospices and into homes, and about various initiatives on the quality and continuity of care. That is an appropriate trend. St. Luke’s hospice in Winsford, with which I am very familiar, has a limited number of beds, but an awful lot of the best care can be given by finding ways of extending the great
expertise within the hospice into homes and communities and into supporting the families and volunteers who can give people the dignity and, above all, care that they need.
There have been missed opportunities on moving towards an outcome-focused model of care in relation to what is described as a “good death”. Progress is demonstrated by the fact that we now talk about “good death” in Westminster debates. One has to track back only a few years to see when politicians were not using such phrases, in the same way that they sought never to be photographed when visiting prisons because they were concerned about the image that might be created. We are now talking openly about this, which shows important progress on debates about this sector, and we are refusing to withdraw from the issues that need to be tackled.
We need to continue to press the Government to consider delivering a tariff for palliative care, which has formed part of the debate about the future funding of hospices. In his previous role, the Prime Minister promised that, by April 2006, charities would not be subsidised by the taxpayer, yet that continues to happen in hospices across the length and breadth of the country, which is why the tariff would be a great step forward.
It is telling that the Darzi review, out of which the final iteration of the “End of Life Care Strategy” arose, mentioned palliative care only once. My hon. Friend made some important points that we need to bear in mind about not only the quality of end-of-life care, but training in it—as I said, I have a specific reason to be aware of how important that training is. Furthermore, none of the strategic health authority reports mention dignity as a key part of end-of-life care. Dignity does not just mean giving someone the option to die in a place of their choosing; it means receiving good care in that place and retaining the respect of self and others in the final days of life.
The Minister and I are unlikely to agree on my next point, which was also raised by my hon. Friend. I believe—I have been pressing this matter for a while—that the biggest scandal surrounding dignity in care has been malnutrition. Figures that I uncovered through parliamentary questions earlier this year revealed that in 2007—the last year for which figures are available—malnutrition killed 242 people in NHS hospitals. That marks a 20 per cent. increase in the number of people dying from malnutrition in hospitals since 1997. Conversely, the number of people dying in care homes from malnutrition has halved.
The regional increases were as big as 50 per cent. in the east midlands and 30 per cent. in the north-west and south-east. In fact, since 1997, 2,656 people have died from malnutrition in England, with the poorest performing regions being the west midlands, where 380 people have died from malnutrition in hospital, and the south-east, where 348 people have died. That is simply not good enough. I urge the Minister not to dispute the statistics, which is what happened during one of our first exchanges about the situation, but to recognise that, whatever his understanding of the statistical base, we need to get to grips with the problem. Such things are avoidable and can be corrected by giving nurses the chance to continue to offer the type of care that they would like to deliver, rather than deflecting them away from ensuring that nourishment is given.
Moreover, it is important to pick up my hon. Friend’s point about the care context of anybody who is moving towards the end of life or is in a very vulnerable and disabled state. It is important that care professionals encourage family members and other supporters to help with nutrition arrangements, because delivering nutrition is often quite boring and takes an awful lot of time. Nutrition is absolutely vital. It is ultimately one of the great tests of care for any trained nurse—they are, above all, motivated to care.
Finally, I shall mention continuing care, which has been a continuous bugbear for the Government. It is a complex issue because it sits at the interface between health and social care. Countless councils will testify that it is in relation to continuing care that PCTs first shed responsibilities in times of financial difficulties, because they know that the means-tested social care system might pick up the person and the tab. In June 2007, London Councils revealed that 13 boroughs had to provide £15 million to cover services heretofore provided by PCTs.
I hope that the Minister will address the serious concerns raised—I am sure that he will try to do so—particularly in relation to the number of beds in the NHS, and the issues of palliative care and dignity within that. It is increasingly clear that the failures of local health chiefs are not primarily to blame; it is the systemic failure of an ill-thought policy. We need to rethink that and show some leadership. Above all, we need to present patients—particularly as they approach the end of life—their families and those who really care the chance not only to make choices, but to get the care and dignity that they need. There should be accountability for the decisions made and those decisions should be taken on the basis of providing the best care, and according to clinical criteria, instead of people simply being offered what can be afforded because, at a time when someone needs to focus on care and dignity, they least wish to be confronted with purely financial choices.
10.35 am
The Minister of State, Department of Health (Mr. Ben Bradshaw): I congratulate the hon. Member for Vale of York (Miss McIntosh) on securing the debate. Care for the elderly and for people at the end of life affects us all—whether it is for ourselves or the ones we love. I express my deepest sympathy, and that of the Secretary of State, to the hon. Lady on the recent loss of her mother. I am grateful not only for the general comments she made about the excellent work being done by NHS staff up and down the country, but for her praise for the doctors and nurses at Darlington Memorial hospital and at Richardson hospital. I add my thanks to them and to the thousands of others who work tirelessly to give their patients the best possible health care in an atmosphere of dignity and respect—especially for those who have reached the end of their lives.
I would also like to say—the hon. Lady might have already done this and I hope she will forgive me if she has done so—that if she would like to discuss her case with her primary care trust in more detail, I would be happy to facilitate that. I would also be happy to ensure that such a meeting is facilitated in relation to the case of one of her constituents that she mentioned. From
what she says, her constituent has been having trouble getting to the bottom of some of the decisions made about the care of her relative.
The hon. Lady raised a number of issues that I will come to in turn: the criteria for allocating beds by PCTs; the funds available for that purpose; how the NHS deals with elderly patients, and the issue of community hospital beds. Decisions about overall service provision for all aspects of health care are made locally by the PCTs that work with the local community and clinicians. PCTs commission the services that they think they need to improve the health care of their populations. With local authorities, PCTs undertake regular local strategic assessments to understand their current and future health needs. They then commission the most appropriate services from a range of providers to meet those needs. As we have heard, those providers might be a hospital, care home, hospice or any other appropriate provider. They are then responsible for delivering the agreed level of service. Specific decisions, for example about bed numbers, will be made to best fulfil contractual obligations and provide the highest possible quality of care.
The hon. Lady raised the overall national decline in geriatric beds. Yes, that has been the case, but there are many more places for older people that are funded by the NHS—both in care homes and in their own homes supported by care home packages. I am sure that she will appreciate that individual decisions about the discharge of a patient can be complex and can involve a range of clinical and social factors. There will always be some difficult borderline cases, and a judgment needs to be made about the best way forward. The patient might return home with a care package, such as regular nursing care, or there might be a move into full-time residential care. Whatever the decision, it should be made in consultation with the patient and their family. Decisions also need to be kept under review, because people’s circumstances and condition can quickly change.
Individual decisions about treatment and discharge must be taken in the best medical interests of the patient by clinical professionals and for no other reason or by any other person. Although the PCT commissions services, including beds, it should play no part in the individual allocation of those beds. The hon. Lady asked a number of questions about what sort of criteria are considered when such decisions are made, and she had a list in relation to her own case. A few issues—they might seem obvious to hon. Members, but they are important—are behaviour, cognition, nutrition, psychological needs, mobility, drugs and medication, skin condition and any other significant needs.
The hon. Lady also asked to what extent patients’ or relatives’ views are taken into account. The national framework for continuing health care sets out the expectation that patients should be at the centre of decision making. They should be supported so that they can be actively involved in those decisions and relatives should be involved, too. She asked who makes the final decision on discharge. If there is some sort of dispute or disagreement, the final decision is made by the multidisciplinary team and the consultant in discussion with the family.
The hon. Lady did not ask this question, but thinking about this debate, I asked my officials whether there might be circumstances in which the wishes of a patient
or a relative could be overridden. The answer I received is that the patient’s wishes are at the centre of the decision-making process, but the clinical well-being and needs of the patient may mean that it is not possible to meet them. For example, a patient might desperately want to go home, but the clinicians may decide that they would not be able to look after themselves, and do not have the necessary support at home to do so. In some exceptional circumstances, there will be a need for a clinical override.
Bob Spink: I know that systems are in place and that guidance has been given, but they are simply not working. I cite a case that arose a week ago. A constituent from Canvey island was taken to Southend hospital, then discharged to a nursing home in Southend without the family’s permission or knowledge. She was not cared for properly at the nursing home, she did not take food, and she ended up back in Southend hospital. The family wanted very much for her to be moved back to Canvey island, where there are places in residential and nursing homes where she could receive care. I hope that that will now take place, but the system is not working.
Mr. Bradshaw: The hon. Gentleman raises an individual case. As I indicated in my remarks, some decisions are difficult and some are borderline. In a service as big as the NHS, which deals with many people every day of the year, decisions will, unfortunately, occasionally be made which perhaps are not correct.
What is important is that if patients or their relatives believe that a decision is wrong, they come forward and make that clear to the people who made the decision. They need to appeal and take the matter up with the PCT. I would invite the hon. Gentleman, if he has not already done so, to raise the case with the PCT.
Mr. Bradshaw: The problem has been sorted, perhaps with the hon. Gentleman’s help. His help should not have been required to sort it, but we are all human beings, and mistakes can be made. What is important is that if they are made, they are rectified as quickly as possible to the satisfaction of patients and their families.
Miss McIntosh: I am grateful for the thoroughness with which the Minister is responding. He mentioned the number of beds, but has not yet touched on the change in the role of community hospitals and the length of time that patients can stay in them, or the point, which was touched on by the hon. Member for Leeds, North-West (Greg Mulholland), about patients who are taken out of hospital, put into a care home or their own home, then readmitted in a short time as an emergency case. The Minister has also not dealt with my remarks about the thrust of Government policy to close council-run care homes. There was a consultation, which I believe has concluded. The perverse effect will be less patient choice, because there will be fewer care home beds in local authority control.
Mr. Bradshaw: I was about to address those points, and I still have a bit of time to do so. However, if at the end of my remarks the hon. Lady feels that there are questions that I have not addressed, I would be happy to write to her about them.
The hon. Lady specifically asked how rapidly equipment could be put into someone’s home to facilitate their return home. I am advised that it can take several days, and that it depends on how long the occupational therapist takes to do the assessment. If specialist equipment is required, it could take longer.
The hon. Lady highlighted what she believes to be possible differences in policies and quality of care between PCTs. The national continuing health care framework is designed to ensure consistency across all PCTs. However, we recognise that there are still variations, and my Department is working hard to try to remove them. The national service framework for older people sets out the standard of care that all PCTs should provide, and therefore quality should be more consistent across all PCTs. We are working hard to ensure that that is the case.
The hon. Lady asked why general practitioners were not routinely informed. GPs are not normally involved or informed when a patient is in hospital. However, they should be informed as part of the normal discharge process, and they should also be invited to become involved in continuing care decision making, although attendance may depend on the GP’s availability at any given time.
The hon. Lady asked about training for NHS staff in end-of-life care. Additional funding has been found for training the work force in end-of-life needs and has been given to all strategic health authorities for the financial year 2009-10. She made a point about the rules changing in her community hospitals. I hope that she will forgive me, but I have not been able to get an answer on that in the time that we have had available during the debate, but I will write to her and hopefully provide the answer that she requires.
Miss McIntosh: I am grateful to the Minister for allowing me to make this point. My understanding is that the Government changed the role of community hospitals across the piece, not just in the Vale of York. It used to be possible to receive long-term end-of-life care in community hospitals, particularly in areas that had hospice facilities in such hospitals or did not have hospice facilities. My understanding is that it was Government policy that made the change nationally, not just in one specific constituency.
Mr. Bradshaw: If the hon. Lady will forgive me, I will have to write to her with clarification. My understanding is that the policy in the particular hospital where her mother was staying is not to keep patients long term. I will have to write with clarification, if she will allow me to do so.
The hon. Member for Leeds, North-West (Greg Mulholland) raised the issue of delayed transfers. We acknowledge that they have been a problem in the past and still are a problem, but the number of delayed transfers has fallen dramatically since 2001. In 2007-08, there were 2,235 delayed discharges from 85,119 acute care beds, equating to 2.6 per cent. of all occupied acute care beds. That was down from more than 7,000 in 2001, so there has been a dramatic fall. However, I accept that we still have more to do, and we will work hard to ensure that we build on the progress that has been made in recent years.
I would like to make a few more general remarks about issues that have been raised by hon. Members, and explain what the Government are doing to improve the quality of care generally for older people. The transforming community services programme supports the NHS in delivering the commitment that we made in “NHS Next Stage Review: Our vision for primary and community care” to create modern, responsive community services of a consistently high standard. The programme seeks to improve the amount of information available about services, patient outcomes, quality and the overall patient experience. It also supports new models of service delivery as PCT provision is separated from PCT commissioning.
Many elderly people enjoy good health in their later years, but that is not always the case. A central objective for all NHS providers is to build care around the needs of each individual. That personalised care planning approach is the same for everyone, including the elderly. For a patient with a long-term condition, personalised care planning that is tailored around their lifestyle and aspirations provides them and their carers with information and self-management advice to help them to learn about their condition, and find out how best to manage it and how it will affect their life.
Most hon. Members will acknowledge that many people die well. At the end of their lives, they are cared for with dignity and respect, surrounded by their family and friends in an environment in which they feel comfortable and safe. They experience care that is well co-ordinated, holistic and ethical with regard to their personal beliefs and preferences.
Miss McIntosh: I spoke about nutrition, and my hon. Friend the Member for Eddisbury spoke eloquently about malnutrition, which is a concern for those who provide personal and health care. People go into nursing and the caring professions—I include carers in this as well—because they want to care for patients, regardless of their age. I was shocked by the figures that my hon. Friend gave: there is obviously an increasing problem with malnutrition. I hope that the Minister will take that on board. I was staggered by the fact that the Secretary of State was not aware of initiatives such as those undertaken by the National Patient Safety Agency, as well as the nutrition now programme, which incorporates hydration. This is obviously an area of policy on which the Government must focus.
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