HC 1048-III Health CommitteeWritten evidence from Help the Hospices (PH 140)

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 Meorandum

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 the following areas:

the creation of Health England within the Department of Health;

the future role of local government in public health;

arrangements for public health involvement in the commissioning of NHS services;

arrangements for funding public health services; and

the future of the public health workforce.

3. Summary of Key Points

There is a need to develop standards to benchmark local authority and GP commissioning consortia performance and progress (4.6).

Hospice care should be used as a model for the integration of health and social care (5.3).

The Government should provide incentives to partnership working, and encourage local authorities and commissioning consortia to engage other key local government departments regarding areas such as housing, transport and planning (5.4).

The Department of Health should consider how to support open, appropriate sharing of information for joint strategic needs assessments in a market place where such information may become increasingly commercially sensitive’ (5.6).

The Government should monitor local authorities to make sure they do not simply redesignate many of their existing activities as public health, because of existing pressure on their budgets (7.1).

4. The Creation of Public Health England within the Department of Health

4.1 Getting end of life and bereavement care right can not only vastly improve people’s individual experience of care, but also the experience of carers, friends and family. As Dame Cicely Saunders, founder of the modern hospice movement, noted: “How people die remains in the memory of those who live on”.

4.2 The number of people who will die each year is expected to rise over the next decade. While people may have an increased life expectancy, there are growing numbers of people living with, and dying with, complex health and social care needs. However, alongside two-thirds of us being uncomfortable discussing dying, there is also currently a disconnect between where people say they want to die, and where they actually die. About 70% of people say they want to die at home, but at present most deaths in England occur in NHS hospitals.

4.3 We welcome the creation of Public Health England, as public health has a vital role to play in improving people’s experience of care at the end of life, both individually and collectively, and in increasing their confidence and ability in discussing dying, death and bereavement. We support the Government’s commitment in the public health white paper to continue to promote the implementation of the End of Life Care Strategy, and the reference to the Dying Matters national coalition.

4.4 Currently more than 200 independent charitable hospices across the UK provide expert advice, support and health and social care to about 360,000 patients, carers and family members. They are rooted in the communities they serve and as well as direct care, hospices offer public health benefits through education, advice and support for health and social care professionals. They also offer employment and volunteering opportunities within their local communities.

4.5 A recent study by the Economist Intelligence Unit identified the UK as having the best-developed end of life care among 40 countries surveyed. The ranking was attributed, in part, to the “well-established hospice movement”. It is vital to make sure that the progress in end of life care enabled by the 2008 End of Life Care Strategy is sustained and that the future public health system enables hospices to continue their valuable work in partnership with GPs, GP consortia and local authorities, alongside the new Public Health England—contributing to the improvement of health outcomes and the public health both nationally and locally.

4.6 The transition period for reform will only work if new and existing structures within the system are supported by strong accountability mechanisms. To ensure the quality of services, we recommend standards should be set to benchmark local authority and GP commissioning consortia performance and progress. Without a formal performance management mechanism, it may be difficult for local communities and Public Health England to monitor progress. Transition and benchmarking will be helped by making sure local authorities and GP consortia have access to timely and appropriate data and analysis to make informed decisions.

5. The Future Role of Local Government in Public Health

5.1 We welcome the direction towards the integration of health and social care through the enhanced role for local government proposed in “Healthy lives, healthy people”. To make sure that health and wellbeing boards are able to engage effectively with local people and neighbourhoods, we have welcomed the suggestion that local authorities may also choose to invite local representatives of the voluntary sector and other relevant public service officials to participate in the board.

5.2 We are working to support hospices to strengthen their relationship with local authorities and to develop their skills in engaging with local authorities.

5.3 Hospices are unique among providers of health and social care because they contribute so significantly to the funding and provision of palliative and end of life care. In 2009, hospices spent £686.9 million. In short, for every £1 the state invests in local charitable hospices, hospices deliver £3 worth of care. We are anxious to make sure that this “co-commissioning” role played by the voluntary sector is not lost in the proposed new public health system. We recommend that hospice care be used as a model for the integration of health and social care.

5.4 We support the white paper’s recognition that the “embedding of public health within local government…will enable joint approaches to be taken with other areas of local government’s work”. There is strong evidence to suggest that there should be emphasis on collaboration and integration between public health and areas such as housing, transport and planning, as well as health providers, when making commissioning decisions, redesigning care pathways and integrating services. We recommend that the Government provides incentives to partnership working, and that local authorities and commissioning consortia engage other key local government departments regarding areas such as housing, transport and planning.

5.5 Hospices can contribute valuable local intelligence to help shape local authorities’ and commissioning consortia’s understanding of need, gaps in service and the quality of services, and we believe must they be supported to do so. Data and intelligence can also be used by commissioners and providers such as hospices to support care, for example with regards to epidemiology—deaths, causes, ages and gender.

5.6 To be truly effective, it is essential that joint strategic needs assessments are supported by a systematic collection and analysis of information and proper engagement with hospices, alongside local people, businesses and other charities, to become genuinely cross-sector exercises which effectively inform commissioning. We recommend that the Department of Health should consider how to support open, appropriate sharing of information for joint strategic needs assessments in a market place where such information may become increasingly “commercially sensitive”.

6. Arrangements for Public Health Involvement in the Commissioning of NHS Services

6.1 We welcome the recognition of the need for close partnership working between the NHS and Public Health England.

6.2 Significant engagement from commissioning consortia leadership with the health and wellbeing boards will be essential to joining up public health and healthcare. In some areas, commissioning consortia will have a different geographical area to the health and wellbeing board. This will make it difficult for the consortia to commission on a population-wide basis in collaboration with local authority colleagues.

6.3 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 clinical commissioning. We support the proposals to strengthen the public health role of GPs; these proposals must support and strengthen the role of GPs in end of life care.

6.4 Good primary care is critical to public health and tackling inequalities, and GPs have a valuable role in both the provision and signposting of palliative and end of life care. However, a recent survey by Help the Hospices revealed 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. For clinical 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. 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.

6.5 Many hospices have already begun to cultivate relationships with local GP leaders. However, a structural change to the mechanics of commissioning is not enough, on its own, to ensure better outcomes for patients.

7. Arrangements for Funding Public Health Services

7.1 We welcome the Government’s commitment to improving the health of the population and are pleased that funding for public health will be ring fenced. However, we recommend that the Government should monitor local authorities and make sure that they do not simply redesignate many of their existing activities as public health, because of existing pressure on their budgets.

8. The Future of the Public Health Workforce

8.1 We support the vision for an expert, professional, committed and flexible public health workforce outlined in “Healthy lives, healthy people” and welcome the commitment to developing a more detailed workforce strategy for public health.

8.2 The reforms must enable the current and future workforce to respond to patient need, changing service models and the complex challenges of 21st century healthcare. To achieve this, palliative and end of life care must be integrated and embedded in the workforce, including public health professionals, to make sure all agencies and staff appreciate the importance and principles of end of life care and are better equipped to meet people’s needs.

June 2011

Prepared 28th November 2011