Health CommitteeWritten evidence from Help the Hospices (ETWP 81)

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. Introduction

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 In addition to this submission, we highlight some examples of the contribution that local hospices make to the delivery of education, training and workforce planning in an appendix. We would be pleased to provide further examples and information if it is needed.

3. Summary of Key Points

The constitution of both provider-led networks and Health Education England (HEE) should include hospice and palliative care representation. (Paragraph 4.3)

The Department of Health should work with the relevant professional bodies to ensure that all trainee doctors, nurses, allied health professionals, and registered social care staff receive an appropriate level of training in the delivery of end of life care. (Paragraph 4.5)

There must be a clear link between the role of HEE and the NHS Commissioning Board. (Paragraph 4.7)

The contribution of hospices to education and training should be recognised and supported. (Paragraph 5.2)

The DH should clarify how the commissioning of social care education and training will interact with the proposed healthcare education and training system. (Paragraph 7.1)

The transitional arrangements for the new education and training system must be carefully monitored. (Paragraph 8.1)

The DH should clarify the powers that HEE will have over local skills networks. (Paragraph 8.2)

The DH should develop specific guidance on healthcare provider “skills networks” and areas of collaboration between networks, which recognises the importance of palliative and end of life care. (Paragraph 8.3)

The DH should clarify the expected number of skills networks and the implications for smaller education providers such as hospices. (Paragraph 8.4)

CPD should continue to be funded through the central education and training budget. (Paragraph 9.3)

HEE should have a role in monitoring and reviewing the CPD of the NHS workforce as part of its remit. (Paragraph 9.5)

HEE should ensure provider quality and monitoring systems, for example staff appraisal systems, are responsive to and form the basis of the development of education and training. (Paragraph 9.6)

The DH should strengthen the existing standards against which care homes are assessed to include a requirement to demonstrate that staff have received such training. (Paragraph 9.7)

placements should be managed multi-professionally across a network of healthcare providers, not by individual providers (Paragraph 10.1)

4. The right numbers of appropriately qualified and trained healthcare staff (as well as clinical academics and researchers) at national, regional and local levels

4.1 Every year, independent charitable hospices care for more than 360,000 people affected by terminal illness, including carers and families. Specialist palliative care nurses and other professionals are vital to the quality care and support that hospices provide.

4.2 Education and training in the new system should recognise the integral role that hospices can play in helping to shape the workforce of the future, and the importance of taking a long-term view of workforce and education and training. As the population ages and people approach the end of life with ever more complex care needs, flexible and adaptive hospice and palliative care services, with an appropriately trained workforce to support this care, will need to be available.

4.3 We strongly recommend that the constitution of both provider-led networks and Health Education England (HEE) includes hospice and palliative care representation. If properly professionally integrated, these structures should direct and enable workforce planning to be centred on patients’ care, including palliative and end of life care.

4.4 The hospice and palliative care workforce is ageing, particularly in nursing, and a new workforce needs to begin training as soon as possible. The recently published National Council of Palliative Care Specialist Palliative Care Workforce Survey highlights that 39.2% of all nurses working in the specialism are recorded as being aged over 50, as are 44.7% of social workers, 36.3% of physiotherapists and 25.3% of occupational therapists.1 27.5% of specialist palliative care consultants are aged over 50, higher than the national average.2 There are also significant staff shortages, with an average vacancy rate amongst the specialist palliative care nursing workforce of 8.7% and consultants of 7.8%.3 Given many senior staff are reaching retirement age, in the context of already high vacancy rates, there is an urgent need to address the training of less senior staff.

4.5 The new education and training system must ensure that the wider healthcare workforce, from healthcare assistants to doctors, appreciate the importance and principles of end of life care and are better equipped to deal with patients as a whole in a much more sensitive way. The continued failure of health and care professionals to effectively engage with patients, their carers and families about their end of life choices limits choice and control. Hospices are challenging this through their work with the health and social care workforce to develop their knowledge and confidence to support people’s preferences at the end of life, enabling them to make appropriate referrals and to access appropriate support for their patients and service users. The experience of the hospice movement suggests that providing additional education and training for the health and social care workforce can help to improve the quality of care for people. We recommend that the Department of Health work with the relevant professional bodies to ensure that all trainee doctors, nurses, allied health professionals, and registered social care staff receive an appropriate level of training in the delivery of end of life care.

4.6 All hospice and palliative care providers, including hospices, will need to be more proactive in their recruitment and training of staff to meet the changing and often complex needs of patients and their families.

4.7 It is vital the new education and training system is in line with the wider system design for the commissioning and provision of services. Furthermore, the system should be appropriately integrated with the approaches to planning and developing the public health and social care workforce. In addition to the relationship between local provider led networks and clinical commissioning groups, we recommend that there must be a clear link between the role of HEE and the Commissioning Board.

5. All providers and commissioners of healthcare (both NHS and non-NHS) play an appropriate part in developing the future workforce

5.1 Proposals currently focus on education and training provided by academic institutions at the cost of community-based education providers such as hospices. Hospices are co-producers and co-providers of education and training with the NHS; if they are integrated more closely into the healthcare system, they are better placed to share their knowledge and expertise with others.

5.2 Hospices play a vital role in developing and supporting the health and social care workforce through education and training. This contributes significantly to the development of a high quality, flexible, palliative care workforce in both their organisation and in the wider care community. Local hospices have developed education and training programmes for the staff of providers of other types of care, such as care homes. We recommend that the Government recognises supports and invests in the expertise of hospices in training and education to support staff in other care settings. For example, hospices could help support the training of care assistants, particularly those working in care homes, or people’s own homes.

6. Training curricula reflect the changing nature of healthcare delivery, including the medico-legal context

6.1 As recognised in the National Audit Office’s report on End of life care, there are significant gaps in the education and training curricula for health and social care professionals. End of life care must be integrated and embedded in training curricula for health professionals. We recommend that the Department of Health work with the relevant professional bodies to ensure that all trainee doctors, nurses, allied health professionals, and registered social care staff receive an appropriate level of training in the delivery of end of life care.

7. Multi-professional and multidisciplinary leadership and accountability (encompassing the full range of healthcare professions, specialties and grades) at all levels

7.1 Hospice education and training is generally inter-professional, recognising the service model of multi-professional hospice and palliative care. Hospices are dependent on development of both the health and social care workforce to deliver quality care, and hospice education and training activity reflects the activity of hospices as providers of integrated health and social care, for example end of life e-learning through e-learning for Healthcare, and competences through Skills for Health and Skills for Care. Hospices have highlighted concern that there is not more joined up development between the health and social care workforce, and that there is no reference within the proposed changes to the interaction with social care education and training arrangements. We recommend that the Department of Health provides further clarification of how the commissioning of social care education and training will interact with the proposed healthcare education and training system.

7.2 The governance arrangements and structures of HEE should ensure equitable representation of all the professionals; to achieve this, HEE can build upon existing expertise in the nursing, midwifery and allied health professions professional advisory bodies as well as Medical Education England. However, HEE should look to ensure a new and multi-professional approach to workforce training.

8. High and consistent standards of education and training

8.1 The current timetable put forward to have new systems and processes in place by 2012 does not allow enough time to pilot and evaluate changes to the provision of education and training. It is imperative that any changes to education and training commissioning ensure advances made in end of life care in recent years through the End of Life Care Strategy are not lost, and do not further destabilise the system. Going forward it will be important to “lock in” the knowledge and experience of those who are currently commissioning education and training. Previous reports of the Health Select Committee reflected on the lack of knowledge on education commissioning prior to strategic health authorities taking a leading role and this should not be lost going forward. We strongly recommend that transitional arrangements for the new education and training system are carefully monitored.

8.2 Consistency and quality need to be supported by clear lines of accountability and strong principles of good governance in the new system for education and training. The proposed relationship between HEE and local skills networks is still unclear. If HEE is to have a medium to long-term view of workforce planning, there could be a tension between the short to medium-term priorities that provider skills networks would see as their responsibility, and the perspective and oversight that HEE should take. We recommend that the Department of Health provides greater clarification over the powers that HEE will have over local skills networks.

8.3 We remain concerned at the continued lack of clarity on the constitution of skills networks and how their success will be measured and evaluated. The Department of Health has a responsibility to ensure that skills networks are properly governed and performance is managed to ensure the best quality healthcare workforce is developed. We recommend that the Department of Health develops specific guidance on healthcare provider “skills networks” and areas of collaboration between networks, which recognises the importance of palliative and end of life care.

8.4 The fact that skills networks will not be coterminous with clinical commissioning groups will have implications for the bureaucracy and transparency of the new system. The DH must make sure that the right checks are in place so that the number of new skills networks does not create extra bureaucracy in the new education and training system, especially for smaller providers such as hospices. We recommend that the Department of Health clarify the expected number of skills networks and the implications for smaller education providers such as hospices.

9. The existing workforce can be developed and re-skilled for the future (through means including post-registration training and continuing professional development)

9.1 Continuing professional development (CPD) is critical for enabling health professionals to take greater ownership of their education and training and to continue to develop to meet the health and social care challenges of the future. Hospices play a crucial role in delivering cost-effective professional development in their organisations, alongside developing education and training programmes for those working in the public and private sector, such as in care homes. This contributes significantly to the continuing professional development of a high quality, flexible palliative care workforce—both now and for the future.

9.2 CPD in the NHS must be sustained and protected. In the past CPD budgets have often been cut first and, given the current financial climate, there is a real risk to the development of the existing workforce. In a recent survey of Royal College of Nursing members, by sector, 29% of respondents in the NHS had received no continuous professional development and training in the last 12 months, compared to 23% of those working in the independent and voluntary sectors and 19% of those working in other sectors.4

9.3 There should also be greater transparency about the overall level of investment across the system. We recommend that CPD continues to be funded through the central education and training budget.

9.4 We recommend that the Department of Health should also investigate how current professional requirements, for example the NHS constitution and standards for professional regulation could be strengthened with regards to education and training. For example, the NHS constitution pledges to provide all staff with personal development, access to appropriate training for their jobs and line management support to succeed, and staff have responsibility to “aim to take up training and development opportunities provided over and above those legally required of your post”.5

9.5 As the Government’s response to the NHS Future Forum report acknowledges, HEE will have national oversight of education and training and so be best placed to ensure that providers are operating effectively within a wider context. We recommend that HEE should have a role in monitoring and reviewing the CPD of the NHS workforce as part of its remit.

9.6 Professional ownership of education and training that meets the need of employers is also dependent on good employer engagement. We recommend that HEE ensures provider quality and monitoring systems, for example staff appraisal systems, are responsive to and form the basis of the development of education and training.

9.7 For example, few care home staff have sufficient training in providing end of life care. We recommend that the Department of Health strengthen the existing standards against which care homes are assessed to include a requirement to demonstrate that staff have received such training.

10. Open and equitable access to all careers in healthcare for all sections of society (by means including flexible career paths)

10.1 Student placements play an important role in both encouraging healthcare professionals to undertake a career in palliative care and supporting the work of hospices. We recommend that placements are best managed multi-professionally across a network of healthcare providers, not by individual providers, as smaller providers such as hospices may have capacity issues in providing opportunities.

10.2 Financial support is vital for ensuring placements at hospices continue. We recommend that the funding arrangements of undergraduate clinical placements (both medical and non-medical) be established as soon as possible to support placements in hospice and palliative care, and to ensure a level playing field between providers.

December 2011

APPENDIX

CASE STUDIES

West Cumbria Hospice at Home—educating care homes

Hospice at Home West Cumbria has appointed a facilitator to instigate a programme of education in local care homes. This project grew out of discussions with the End of Life Network which agreed to fund an education programme for care homes that is managed by the hospice.

The facilitator will work with champions appointed by care homes. Through the education programme champions will take on responsibility for implementing the “six steps for success”.

These include identifying where people are in their disease trajectory, how to talk to engage in end of life conversations, advance care planning, co-ordinations of care, use of end of life care pathways and hot to achieve quality care for people at the end of life.

The facilitator is an ongoing resource to support champions to deliver the plan, and to spread what they have learnt among their colleagues in order for the care home to better meet the needs of people at the end of life.

St. Luke’s Hospice, Basildon—improvements through education and training

St. Luke’s Hospice won a tender from Essex County Council through Essex Works Brokerage to provide a 2 day End of Life Care training course for social care staff including, social care practitioners and facilitators and social carers.

The course will be repeated six times across the area and reach a minimum of 150 people. The principles of good end of life care for all out lined in the End of Life Care Strategy will be threaded throughout each session, allowing delegates to recognise key principles within care delivery.

The aim is for delegates to gain knowledge, understanding and confidence about the principles of palliative and end of life care and how these can be applied in their roles. It will include identifying end of life situations, ensuring holistic assessment, initiating discussions and documentation about planning and choice at end of life and supporting clients and carers in those choices.

The course is delivered by hospice staff from the inpatient and hospice at home settings, who have sound clinical and hands on experience. Plans are currently in place to put on a further module for those with additional interest over four days.

The course evaluation is proving positive:

“The course has up skilled the EOLC confidence to raise awareness, engage people before, during and at end of life etc, and most importantly having the knowledge of local services available.” Course delegate

1 National Council for Palliative Care (2011) NCPC Specialist Palliative Care Workforce Survey. (accessed 7 December 2011).

2 Ibid.

3 Ibid.

4 Royal College of Nursing (2011) Views from the frontline: RCN Employment Survey 2011.
http://www.rcn.org.uk/__data/assets/pdf_file/0019/407242/004184.pdf (accessed 15 December 2011),

5 NHS Choices (2009) NHS Constitution.
www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution/Pages/Overview.aspx (accessed 18 May 2011).

Prepared 22nd May 2012