Health and Social Care Bill

Memorandum submitted by Help the Hospices (HS 97)

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 three key issues: commissioning, competition, and the transitional arrangements.

3. Summary of key points

· It is essential that the reform of commissioning promotes and encourages partnership working between providers. (4.3.1)

· The commissioning reforms should recognise the ‘co-commissioning’ role played by local charitable hospices. (4.3.3)

· There should be penalties for GPs who fail to make appropriate referrals for patients, or fail to deliver improved patient outcomes. (4.4.3)

· The quality of care commissioned should be included as a specific duty of GP consortia. (4.4.5)

· The Department of Health (DH) should provide further clarification on its approach to the tendering of integrated care services. (5.2.5)

· Regulation of the healthcare market must not increase bureaucracy for charitable providers such as local hospices. (5.3.1, 6.4.3)

· The momentum in palliative and end of life care must not be lost during the transitional period. (6.4.1)

· There should be robust accountability mechanisms to make sure that patient outcomes are improved in the new system. (6.11)

4. Commissioning

4.1. Help the Hospices has previously drawn attention to the deficiencies of the current commissioning system, which supports the uneven provision and funding arrangements across the country [1] . The existing commissioning arrangements hamper the development of new services, reduce efficiency and act as a disincentive to service integration and were recognised in the End of Life Care Strategy (2008) as significant barriers to meeting the increased demand of the country’s ageing population.

4.2. We continue to support the End of Life Care Strategy but are aware that its impact has often been blunted by current commissioning practice. For this reason Help the Hospices welcomes the Coalition Government’s commitment to reform commissioning in England, although we have some concerns about the mechanisms being established through the health and social care bill.

4.3. Partnership in commissioning with the voluntary sector

4.3.1. We are concerned that the content of the bill that covers commissioning does not take into account the specific circumstances and contributions of independent charitable hospices to the health economy. Nor do we believe that it will sufficiently support the development of a vibrant health provider market in which partnership working is encouraged, as set out in part 3, chapter 1.

4.3.2. The independent charitable hospice sector provides two-thirds of specialist inpatient palliative care in the UK [2] . However, the majority of the care provided by hospices is provided in the community; in the past five years there has been a 58% increase in the services provided by hospices to people in their own home [3] .

4.3.3. Not only are hospices substantial providers of hospice and palliative care they are also significant funders of such care; in 2009 hospices spent £686.9 million. In short, for every £1 the state invests in local charitable hospices, those hospices deliver £3 worth of care [4] . Hospices are unique among providers of healthcare because they contribute so significantly to the funding and provision of hospice and palliative care. We are concerned that this ‘co-commissioning’ role played by the voluntary sector is not recognised in the proposed commissioning reforms.

4.4. GP consortia

4.4.1. Help the Hospices supports the application of the principle of subsidiarity in NHS commissioning, but we are concerned about some of the practical considerations in the move towards GP commissioning.

4.4.2. Historical evidence with regards to past GP commissioning activities alongside international experience suggests it will take several years for GP consortia to become effective at commissioning across the full range of health services [5] . For the commissioning of hospice and palliative care this may be exacerbated by a deficit in end of life expertise among GPs.

4.4.3. A recent survey by Help the Hospices uncovered that one in four GPs are not confident in their ability to provide information to a patient with less than six months to live. This is despite GPs seeing on average more than four patients a month with a terminal illness [6] . For GP commissioning to work there is an urgent need for GPs to work closely with local hospices to build expertise around the delivery of hospice and palliative care in their communities. Consortia will need support to develop capacity and capability and to make sure they have access to the management and strategic skills required of effective commissioning, and individual GPs will need support and incentives to deliver quality outcomes for their patients. One way to achieve this would be to introduce penalties for GPs that fail to make referrals to appropriate services.

4.4.4. Many hospices have already begun to cultivate relationships with local GP leaders. However, this process alone is not sufficient to make sure that the knowledge and confidence of GPs is increased sufficiently to end the problems associated with the current commissioning system and deliver effective outcomes for patients.

4.4.5. While there is potential in the Government’s commitment to ‘aligning the clinical and financial aspects of commissioning’ to generate efficiency savings by ‘enabling clinicians to prioritise the best and most appropriate care for local populations’ this is dependent upon GPs developing their knowledge and confidence of end of life care [7] . A structural change to the mechanics of commissioning is not enough, on its own, to ensure better outcomes for patients. Help the Hospices recommends that the quality of care being commissioned is specifically included as a responsibility of GP consortia.

4.4.6. Research conducted by the Commission for the Compact and Help the Hospices has highlighted the critical importance of personal relationships in the commissioning of hospice care, and the wide variation in the approaches taken by commissioners [8] . Lessons should be learned from areas where relationships between hospices and commissioners are strong and where the planning of care is more effective than others.

4.5. NHS Commissioning Board

4.5.1. While the bill outlines a system that divides responsibilities between local GP consortia and the national NHS Commissioning Board, we question whether consortia will always be of a sufficient size to commission hospice and palliative care as a relatively low volume and specialised service. In our view, the NHS Commissioning Board should have the power to require consortia to collaborate on the commissioning of such services, to maximise efficiency and to help minimise the transactional costs associated with local hospices needing to forge relationships with multiple consortia. It would help to ensure that commissioning of such services operated at a population size that would enable effective commissioning. We would strongly support consortia being required to collaborate in the commissioning of hospice and palliative care services.

5. Competition

5.1. Help the Hospices supports a mixed economy in the healthcare market. Independent charitable hospices, as major providers of palliative care, are themselves outside of the immediate NHS family. However, we believe that further consideration needs to be given to the potential destabilising effect of a rapid expansion of providers on existing established services.

5.2. Any willing provider

5.2.1. In his letter to the NHS in February 2011 concerning the transitional arrangements [1] , Sir David Nicholson indicates that the principles of ‘any willing provider’ set out in the bill would not apply to complex integrated services, such as end of life care. Help the Hospices has also had discussions with the DH that have reinforced this proposal. Instead, the commissioning of such services would operate on the basis of a local tender, with long-term contracts awarded to encourage investment and development of services locally.

5.2.2. While in principle we believe that this approach makes more sense for the commissioning of complex palliative care services, we are concerned that there is limited information on how such a system would work in practice, and believe that any tendering process should provide tangible incentives for partnership working, service improvement and integration.

5.2.3. This proposal begs further questions, not least in relation to the population that would be included within such a tendering arrangement. In our response to the DH consultation on commissioning for patients [2] , we highlighted our view that consortia should be required to collaborate on the commissioning of hospice and palliative care services, and in our view, the mechanics of how such collaboration would be mandated are even more important if commissioning will be undertaken on the basis of tendering arrangements. Help the Hospices believes that it does not make any practical sense to commission complex yet relatively low volume services such as hospice care at an ultra-local level.

5.2.4. Clarification is also needed on the potential impact of such tendering on the ‘joint strategic needs assessments’ that will become the responsibility of upper-tier local authorities, particularly where the population for which services are being put out to tender might cross local authority boundaries.

5.2.5. Help the Hospices therefore encourages the Committee to seek further clarification on the arrangements for such integrated services, and the circumstances in which ‘any willing provider’ might be replaced by a tendering arrangement.

5.3. Regulating the healthcare market

5.3.1. We are concerned that the new role for Monitor as the economic regulator for healthcare runs the risk of creating an additional layer of bureaucracy for independent charitable hospices, and that there is potential for duplication of information required by Monitor and the Charity Commission.

5.3.2. In the current system, hospices, as charities in their own right, are required to provide the Charity Commission with information relating to their financial management, governance and viability. Help the Hospices is concerned that in licensing providers, Monitor is likely to be requesting similar information. We are concerned that this runs counter to the Coalition Government’s commitment to reduce the regulatory burden on charities. We recommend that wherever possible, information be shared between the Charity Commission and Monitor to reduce the risk of duplication for local charitable providers.

6. The transitional arrangements

6.1. Help the Hospices is concerned about how the scale, pace and cost of the reforms may affect those receiving hospice and palliative care and, in particular, the continuity and quality of care.

6.2. Alongside providing health and social care services, hospices play a crucial role in delivering the healthcare workforce through their expertise in the local provision of education about palliative care needs. This contributes significantly to the continuing professional development of a high quality, flexible palliative care workforce in their organisations and in the wider community – both now and for the future. Help the Hospices is seeking assurances that education and training will be appropriately safeguarded during the transitional period and in the new system.

6.3. It is vital that transition arrangements, in particular the transitional process for changes to the commissioning of hospice and palliative services, do not destabilise existing provision.

6.4. Maintaining the momentum

6.4.1. Progress and momentum in end of life care enabled by the 2008 End of Life Care Strategy and the inclusion of end of life care as one of the eight high-level priorities in the NHS Next Stage Review [1] programme must not be lost during the transition period. While we have welcomed the Coalition Government’s commitment to end of life care, the proposals outlined in the white paper include end of life care as only one discrete priority among many other competing priorities. Within a forthcoming challenging period of transition, we have concerns that this could lead to a weakening profile of hospice and palliative care in the NHS agenda, at a time when our population is ageing, and more people will be living and dying with complex comorbidities.

6.4.2. In July 2010, the Economist Intelligence Unit identified the UK as having the best-developed palliative care services out of the 40 countries surveyed. The ranking was attributed, in part, to the ‘well-established hospice movement’ [2] . It is vital that transition arrangements, in particular the transitional process for changes to the commissioning of hospice and palliative services, do not further destabilise this valuable provision.

6.4.3. We are concerned that the transitional process of devolving commissioning to GP consortia will increase the complexity of the relationships between hospices and commissioners without adding value to the commissioning of hospice and palliative care, adding significantly to the transactional costs for independent charitable hospices. In the present system, many hospices provide services on behalf of two or more PCTs. This is particularly true for children’s hospices, which cover much larger populations. Under the proposed system, local hospices are likely to need to negotiate with significantly larger numbers of GP consortia. If hospice and palliative care services are to be put out to tender, we believe that there is an opportunity to make sure that individual consortia collaborate on the commissioning of such services, as described above.

6.5. Promoting stability in hospice provision

6.6. We are also concerned that the timetable for the introduction of GP consortia as set out in the white paper will lead to a confusing fragmentation of commissioning decisions during the next two financial years, at a time when statutory income streams for hospices are uncertain [3] . During this period, different GP consortia will be at different stages in their development, resulting in a situation where our member hospices who work with more than one PCT in the current system could find themselves working with multiple commissioners within multiple systems. If the resources the NHS currently provides to hospices are devolved, there is a danger running costs will increase and efficiency will be threatened by increasing the number of commissioning relationships that an individual hospice will need to negotiate, thereby increasing costs, rather than promoting greater efficiency.

6.7. The Government’s reforms propose substantial change and will require significant expertise to be implemented smoothly. Our members have expressed concern that PCT management and commissioning expertise and ‘institutional memory’ are already being lost in the rapid shift to GP commissioning. While we support the view that commissioning by PCTs requires reform, further consideration needs to be given to how to sustain and safeguard commissioning capacity and capability during the transitional period.

6.8. We would support recommendations that shadow GP consortia should be expected to meet explicit performance markers before proceeding to fully fledged consortia status [4] . Similar to the authorisation regime for foundation trusts outlined in part 3, chapter 101, GP consortia should have a process that enables them to commission good quality care across a progressively wider range of services, as well as handle increasing amounts of NHS funds effectively. 

6.9. We have concerns regarding that decisions on the transitional arrangements for the new commissioning system are being taken before a decision on the funding of hospice and palliative care. The Palliative Care Funding Review currently underway is due to report in summer 2011. While we have welcomed the review, we believe significant risk is presented by the fact that the decisions on the transitional arrangements for the new commissioning system will be taken before a decision is made on hospice and palliative care and how it should be funded, and therefore commissioned, in the future.

6.10. In complex areas of care such as hospice and palliative care, there is strong evidence to suggest that there should be emphasis on collaboration and integration between health and social care. Recognising the activity of hospices as providers of integrated health and social care, we have concerns that although ministers have stressed the need for integration, there are no powers within the bill (part 3, chapter 1) for Monitor to promote such integration. Decisions on the transitional arrangements for the new commissioning system will also be taken before the reforms in social care are agreed. Indeed, as with the Palliative Care Funding Review, the Commission on Social Care is not expected to report until summer 2011.

6.11. The transition period for reform will only work if new and existing structures within the system are supported by strong accountability mechanisms. As the NHS is also expected to deliver £20 billion of efficiency savings by 2014 and the financial environment is pressured, accountability needs to be strong enough to ensure the system achieves improved outcomes and greater responsiveness to patient need. We are pleased the bill goes some way in explaining how consortia, the NHS Commissioning Board and regulators will be held to account, although much of the detail is left to regulation. The key test will be how the new system and proposed accountability arrangements deal with issues that emerge. For example, the bill does not explain how the board’s mandate is passed down to consortia, how their performance will be measured or published, or how failure will be determined.

March 2011


[1] Help the Hospices. Submission to the Health Select Committee inquiry into commissioning , 2010.

[2] Help the Hospices. Hospice and p alliative c are d irectory . London : Help the Hospices, 2009 .

[3] Unpublished analysis of the Minimum Data Set for Palliative Care, Help the Hospices, 2009 .

[4] Help the Hospices. Hospice a ccounts . London : Help the Hospices, 2010 .

[5] Thorlby R , Rosen R, Smith J. GP commissioning: insights from medical groups in the United States . London : The Nuffield Trust, 2011.

[5] http://www.nuffieldtrust.org.uk/publications/detail.aspx?id=145&prID=756

[6] Primary Healthcare Professionals Monitor, September 2010, nfpSynergy.

[7] Paragraph 23, g overnment r esponse to the House of Commons Health Select Committee t hird r eport of s ession 2010- 2011: c ommissioning, January 2011 . www.official-documents.gov.uk/document/cm80/8009/8009.pdf

[8] Commission for the Compact and Help the Hospices . Positive engagement, future practice: learning for end of life care . Commission for the Compact , 2008.

[1] Department of Health. Equity and excellence: liberating the NHS – Managing the transition . www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_124479.pdf (accessed 10 March 2011).

[2] Help the Hospices. Liberating the NHS: commissioning for patients – a response from Help the Hospices , 2010 .

[1] Department of Health (DH). High quality care for all – NHS Next Stage Review final report . London : DH, 2008 .

[2] The Economist . Grim reapings – An attempt to rank end of life care in different countries . www.economist.com/node/16591106 (accessed 10 March 2011) .

[3] A Help the Hospices/National Council for Palliative Care (NCPC) survey undertaken in October 2010 found that 30% of hospices had already seen an in-year reduction in PCT funding, and a third of respondents were aware of care staff cuts in local palliative and end of life care services. Help the Hospices/NCPC . National survey of adult palliative care providers , 2010.

[4] The Nuffield Trust . The Nuffield Trust’s response to the publication of the health and social care bill . www.nuffieldtrust.org.uk/pressarea/index.aspx?id=1144 ( accessed 10 March 2011 ).