Health and Social Care Bill

Memorandum submitted by Help the Hospices (HSR 55)

1. About Help the Hospices

1.1 Help the Hospices is the leading charity supporting hospice care throughout the UK. We want the very best care for everyone facing the end of life.

1.2 The majority of hospice care in the UK is provided by our member hospices – local charities rooted in the communities they serve. Care is given free of charge to the patient and their friends and family. It can be at home, in the hospice and in the community and can be for days, months or years. We are here to represent and support our members. We work with our members and other organisations as they strive to grow and improve hospice and palliative care throughout the UK and across the world.

1.3 Our services are here to support hospice people and champion the voice of hospice care. They include a wide range of training and education programmes, informative and practical resources for hospice staff, work to influence government policy and support for quality care and good practice.

2. About this memorandum

2.1 This memorandum draws on the experience of independent charitable hospices around England, and is supplemented by references to research conducted by Help the Hospices and others.

2.2 We have limited our comments to key issues: overall accountability, clinical advice and leadership, public accountability and patient involvement, choice and competition and the timetable for change.

3 Summary of key points

Overall accountability

· A temporary framework should be developed to allow intervention during the transition period to prevent ‘significant failure’. (4.4)

· The meaning of ‘significant failure’ should be clarified. (4.5)

Clinical advice and leadership

· Provisions should be considered that would make sure the expertise of hospice and palliative care providers be reflected in the composition of clinical networks and clinical senates. (5.2)

· Provisions should be made to ensure that the NHS Commissioning Board and clinical commissioning groups obtain advice from social care practitioners. (5.3)

· The NHS Commissioning Board and clinical commissioning groups should be required to report annually on the outcomes that have been made based on the advice they have obtained. (5.4)

Public accountability and patient leadership

· We recommend that consideration be given to setting out arrangements, including the composition of, Health and Wellbeing Boards to make sure that joint strategic needs assessments reflect local expertise and the full range of services local populations require including hospice and palliative care. (6.1)

· Commissioners should be assessed on the regard that they give to advice provided by clinical networks and clinical senates, which would make sure that the expertise of health and social care professionals impacts on commissioning decisions. (5.2 and 5.3). (6.2)

Choice and competition

· A commitment should be made to develop a measure of a providers’ wider ‘social value’. (7.2)

· The NHS Commissioning Board and clinical commissioning groups should consider how hospice and palliative care providers will be supported to improve their ability to collect and present data. (7.3)

· We recommend that a duty be introduced on clinical commissioning groups to make sure that providers have access to NHS systems to underpin more integrated care. (7.4)

· We recommend that a duty be introduced that would provide Monitor with the means to incentivise integration in strategic areas of care. (7.5)

· We recommend that in the annual mandate of the Secretary of State clarification is made about the commissioning of complex care such as hospice care. (7.6)

· Monitor should be given powers to intervene to make sure that patients are referred to services at an appropriate time. (7.7)

· All commissioners should be required to make an annual report to Health and Wellbeing Boards that details expenditure on hospice and palliative care. (7.9)

· The regulatory implications of the Bill should be assessed and appropriate action should be taken to reduce overlapping or inappropriate regulatory requirements. (7.10)

The timetable for change

· We recommend that the current funding of independent charitable hospices and other providers of palliative care is protected during the long transition to a new system. (8.3)

4. Overall accountability

4.1 We support the government’s changes to the Bill in pursuit of improving overall accountability for the health service. However, we remain concerned by the focus on intervention only in the event of ‘significant failure’.

4.2 Recent research by the Economist Intelligence Unit identified the UK as having the best-developed palliative care services out of 40 countries surveyed. The ranking was attributed, in part, to the ‘well-established hospice movement’. Our members provide the majority of hospice care and are often the only provider of hospice and palliative care in many areas of the country.

4.3 Our members will respond to changes in demand; they face a number of challenges, including a transition to a new funding system, a transition to new commissioning arrangements and the need to develop a wide number of relationships, often from scratch. Many other providers, although facing a number of challenges, are perhaps not facing the same number as our hospices.

4.4 We do not expect our members to experience ‘significant failure’ during the transition period but we believe it would be sensible to adopt a more flexible approach to intervention. During the transition interventions should be allowed to make sure that service provision is protected especially in areas expecting substantial growth in demand and broad changes such as the hospice and palliative care. We recommend that a temporary framework should be developed to allow intervention during the transition period to prevent ‘significant failure’.

4.5 Recent failings such as those by the Care Quality Commission to act on reports of abuse at a private provider in Bristol caused widespread public outrage. As we currently understand the Bill, the Secretary of State would not be able to intervene because it is an individual case. We consider the focus on ‘widespread failure’ overlooks the fact that multiple ‘individual’ failings can be symptomatic of the former. We recommend the meaning of ‘significant failure’ is clarified to make sure interventions that will support continuity of services are possible.

5. Clinical advice and leadership

5.1 Help the Hospices welcomes new and strengthened duties to make sure that the expertise of clinicians is embedded in the new NHS structures. Clinical networks and clinical senates have the potential to help commissioners understand services better and improve commissioning decisions. However, we can see that there are two challenges to their effectiveness.

5.2 Firstly, the Bill does not make any specific recommendations about the composition of clinical networks or clinical senates. The NHS Future Forum recognised the need to develop and support a multiprofessional approach to care. For example, hospice and palliative care was identified in the End of Life Care Strategy as a key area that would benefit from changes to commissioning; however, few changes have occurred. To make sure that people have access to high quality hospice and palliative care, professionals with experience of such care should be involved in commissioning processes too. We recommend that provisions be considered that would ensure the expertise of hospice and palliative care providers be reflected in the composition of clinical networks and clinical senates.

5.3 The focus on the advice of clinicians is also of concern and appears to be at odds with the government’s commitment to develop care that is of a more integrated nature. The success of the hospice sector in delivering high quality care is often attributed to its holistic approach that goes beyond meeting patients’ clinical needs to their social needs. We recommend that provision be made to make sure that the NHS Commissioning Board and clinical commissioning groups obtain advice from social care practitioners.

5.4 Secondly, the role of clinical networks and clinical senates will be determined by the degree to which commissioners consider the advice that they have obtained. Commissioners currently have access to specialist advice and data but it is questionable whether their decisions on commissioning hospice and palliative care are informed by either. While it is important to hold providers and commissioners accountable for collating and obtaining appropriate data, this does not guarantee that it will be considered. We recommend that the NHS Commissioning Board and clinical commissioning groups be required to report annually on the outcomes that have been made based on the advice they have obtained.

6. Public accountability and patient involvement

6.1 In its amendments the government has introduced provisions which establish a regulation-making power that sets out arrangements of clinical commissioning groups. We recommend that consideration be given to setting out arrangements, including the composition of Health and Wellbeing Boards, to make sure that joint strategic needs assessments reflect local expertise and the full range of services local populations require including hospice and palliative care.

6.2 We welcome the government’s new provision to make sure that an assessment is made of how well clinical commissioning groups discharge their duty to have regard for joint health and wellbeing strategies. We recommend that commissioners should also be assessed on the regard that they give to clinical networks and clinical senates, which would make sure that the expertise of health and social care professionals impacts on commissioning decisions. (5.2 and 5.3).

7. Choice and competition

7.1 Help the Hospices supports the outcome of the government’s reconsideration of the role of competition in the Bill. We have been a supporter of greater patient choice and competition as our members extend patient choice as independent providers.

7.2 We are concerned that the Bill continues to make reference to other policy initiatives such as the Big Society agenda, which calls for charities and voluntary sector organisations to play a greater role in providing public services. This would be a new approach to public services and its development would require some support. We recommend that the Bill include a commitment to develop a measure of a provider’s wider ‘social value’.

7.3 Similarly, we support the revised duties of Monitor but have concerns about the impact of making the duty to promote economic, efficient and effective provision of services part of Monitor’s main duty. Our members’ historical experience of commissioning and of regulation has meant that, unlike other providers, they have not been able to collect data that would enable them to demonstrate their efficiency and effectiveness. Nevertheless, our members have been cited in research as a significant contributor to the UK’s number one ranking among 40 other wealthy nations for its palliative care. We recommend that the NHS Commissioning Board and clinical commissioning groups consider how hospice and palliative care providers will be supported to improve their ability to collect and present data.

7.4 We also recommend that a duty be introduced on clinical commissioning groups to make sure that providers have access to NHS systems to underpin more integrated care.

7.5 Help the Hospices supports the promotion of integrated care over competition but we believe that this could be strengthened. The development of integrated care is further developed in some areas of health and social care than in other areas; demand will also vary and change in different areas. We recommend that a duty be introduced that would provide Monitor with the means to incentivise integration in strategic areas of care, eg hospice and palliative care, to make sure that providers across the care spectrum can meet increased demand.

7.6 We are also concerned that the revised Bill fails to address concerns that we raised in previous submissions. The principle of any qualified provider has been suggested as the guiding principle for the future commissioning of services. However, Help the Hospices has heard from the Department of Health that complex services such as palliative care would be subject to a procurement model of commissioning, which we would welcome. We recommend that in the annual mandate of the Secretary of State clarification is made about the commissioning of complex care such as hospice care.

7.7 The new clause that requires Monitor to include standard conditions in the licence requiring providers to act transparently in determining patient eligibility is to be welcomed. The clause reflects concerns that have been raised about the recommendations of the Palliative Care Funding Review. We recommend that this requirement is made stronger and that Monitor be given powers to intervene to make sure that referrals are made at an appropriate time.

7.8 Similarly, the focus on the roles of Monitor and the NHS Commissioning Board on pricing and national tariffs means that the Bill largely neglects services for which a national tariff does not currently exist. The Palliative Care Funding Review makes a number of recommendations, which over time would see the development of a national tariff.

7.9 The government is expected to outline its vision for the future of palliative care funding later in 2011 but there is the possibility that a national tariff will take years to introduce. There are also challenges to establishing a national currency for services without a national currency. We recommend that commissioners make an annual report to Health and Wellbeing Boards which details expenditure on hospice and palliative care.

7.10 Lastly, the amendments put forward by the government have failed to address the issue of regulation. In our previous submission we highlighted the burden that regulation places on hospices, yet the revised Bill is likely to increase this burden on our members. We recommend that the regulatory implications of the Bill on all providers are assessed and appropriate action is taken either to reduce overlapping or inappropriate regulatory requirements introduce ‘passporting’ to reduce the regulatory burden on hospices.

8. The timetable for change

8.1 Despite amendments to the timetable for reform, Help the Hospices remains concerned about its scale, pace and cost and its effect on those receiving hospice and palliative care and, in particular, the continuity and quality of care.

8.2 We have already highlighted the many changes and challenges that hospice and palliative providers face because of other reforms. The most significant is the overhaul of the funding system, which the Palliative Care Funding Review published recommendations for on 1 July 2011. The government is expected to publish its vision of palliative care funding later this year.

8.3 We are concerned that as any transition to a new system is likely to be lengthy, the current provision of hospice and palliative care is at risk of being destabilised, which would have serious implications for people facing the end of life and their friends and family. We recommend that the current funding of indepen dent charitable hospices and other providers of palliative care is protected during the long transition to a new system.

July 2011

Prepared 19th July 2011