End of life care - Public Accounts Committee Contents

2  The capacity and capability of staff

13. Much of end of life care is provided by a wide variety of generalist staff for whom end of life care represents a varying proportion of their role. As a result, these staff may not be trained in the identification, delivery and discussion of end of life care.[25] Such skills are essential to delivery of good end of life care as once patients are identified, their wishes can be discussed and care plans can be put in place.[26] The Department estimates that it needs to train hundreds of thousands of NHS and social care staff and is currently working with Skills for Health and Skills for Care to develop the competencies these staff will need. It is also developing an e-learning programme and a training programme which will focus on the improvement of communication skills.[27]

14. 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. In addition, only 39% of doctors and 15% of nurses who responded to the survey stated that they had received pre-registration training in communicating with patients approaching the end of their life.[28] Evidence to the Committee by the Council of Deans of Health indicated that the level of pre-registration training provided to nurses (and other allied health professionals) who qualified in the last five years has improved and that all universities now provide some dedicated pre-registration training in end of life care. However, the proportion of respondents who had qualified in the last five years was small and a key issue is the need for post-registration training.[29]

15. The Department has taken steps to improve the capability of NHS staff. In 2003, it allocated £12 million over three years to an NHS End of Life Care Programme. The Programme aimed to improve the quality of end of life care by working with Strategic Health Authorities to identify and spread good practice across the country. This included encouraging uptake of the Gold Standards Framework, Preferred Priorities for Care and Liverpool Care Pathway tools recommended by the National Institute for Health and Clinical Excellence.[30] These end of life care tools respectively seek to aid the identification of end of life care patients, record patients' preferences over the care they wish to receive and empower generalist clinicians to care for the dying and manage pain in the last days and hours of life.[31]

16. These tools are well regarded by a range of users and the limited research carried out has shown that they can lead to reductions in unnecessary hospital admissions and increase the likelihood of people dying in the place of their choice.[32] A third of doctors and 54% of nurses who responded to the National Audit Office surveys reported being trained in at least one of the three tools and that this training had led to an increase in their confidence in delivering end of life care. Uptake of the tools by GP practices, however, varied with Primary Care Trusts reporting an average uptake by practices of 48% for the Liverpool Care Pathway and 60% for the Gold Standards Framework.[33]

17. Little is known, however, about the direct patient benefits associated with their use due to difficulties in measuring outcomes for deceased patients. The Department is therefore seeking to measure the impact of the tools on patient care through the development of a programme of surveys of bereaved relatives, known as VOICES, which will be launched in 2009. Bereaved relatives will act as a proxy for the patient, providing detailed feedback on aspects of the quality of health and social care across the different care settings.[34]

18. Primary Care Trusts rate education and training in care homes as the biggest challenge in delivering good quality end of life care.[35] There has been little end of life care training provided to staff working in care homes, and few staff have qualifications relevant to caring for people approaching the end of their life. Where training is provided, the nature of this training can vary widely. High staff turnover rates also mean that care homes are training fewer staff than they lose on an annual basis.[36]

19. The Department, through its End of Life Care Programme, has also sought to address the lack of training in care homes and has worked with 1,300 care homes over the last three years to develop and implement e-learning programmes and to increase use of the Gold Standards Framework and Liverpool Care Pathway.[37] The Department have encountered little resistance to their staff being trained amongst the care homes it has worked with, but the homes often lacked the capacity to release staff to attend training courses or to develop in-house training materials themselves.[38] Although many care homes provide good quality care, there is still a significant amount of work to be done to develop the skills and training of staff in the 18,000 remaining care homes across England who have not yet had the benefit of the Department's training.[39]

20. The care homes viewed e-learning as a flexible and cost-effective way of delivering training to their staff and reported that providing effective training can also have a positive impact on staff retention.[40]

21. The Department does not propose to set a national target for increasing the number of care home staff with qualifications relevant to caring for people at the end of their life, but stated that Strategic Health Authorities or Primary Care Trusts may set themselves local targets.[41] The Department also stated that over time it would expect to see an increase in the number of care home residents able to die in care homes and that the levels identified by the review of patient records carried out in Sheffield for the National Audit Office, where the proportion of residents dying in care homes could have been increased from 61% to 80% was the sort of improvement that, it would like to see over time.[42]

22. The Department considers that residents in care homes should have the same level of access to nursing and medical care as a person living in their own home and so is seeking to increase the level of support provided to care homes by specialist palliative care nurses.[43] Hospices can play a key role in providing this support through outreach services such as those developed for people with advanced dementia in care homes by St Christopher's Hospice. The Department considered that the work at St Christopher's provided a good example of partnership working where skills were being utilised across settings, thereby avoiding the need for patients to be transferred between institutions. In addition to disease specific approaches, the Department is also looking at ways in which the skills within the hospice movement can be used to improve patient care in different settings irrespective of the patient's diagnosis.[44]

25   C&AG's Report, para 2.24 Back

26   Qq 10, 70 Back

27   Qq 10, 26 Back

28   C&AG's Report, para 2.25 Back

29   Q 10; Ev 15-16 Back

30   Qq 4, 20; C&AG's Report, para 1.7 Back

31   Qq 10, 20, 55, 61 Back

32   C&AG's Report, paras 16, 3.4 Back

33   C&AG's Report, paras 3.7-3.9 Back

34   Qq 43; 61-64 Back

35   Q 103 Back

36   Qq 40, 47-50, 102 Back

37   Qq 40, 49-50, 54-55, 104 Back

38   Qq 49-51 Back

39   Qq 40, 45 Back

40   Qq 49, 54, 104 Back

41   Q 56 Back

42   Q 40 Back

43   Qq 40-41 Back

44   Qq 11, 20, 25, 41; C&AG's Report; Appendix 6; Example 2 Back

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