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Lord Lyell of Markyate: My Lords, I start with a sincere apology to your Lordships for not being in my place at the beginning of the debate; I was walking across London. I was very sorry to miss the speeches of the noble Baroness, Lady Finlay of Llandaff, whom I congratulate most warmly on introducing the debate, and the noble Lord, Lord MacKenzie. None the less, it is a great honour to be a Member of your Lordships' House and I am delighted to have the opportunity to make my maiden speech on the very important subject of palliative care.

Like many Members of your Lordships' House, I have been a strong supporter of the hospice movement ever since I came into Parliament—and, indeed, shortly before. I have been a supporter of St Frances Hospice in Berkhamsted, then for many years of St John's Hospice in Moggerhanger and currently of the Grove House Hospice in St Albans.

Any insights that I may have are not my own but are due to the fact that I was lucky enough to marry into a medical family. Under the inspiration of my father-in-law, the late Professor Charles Fletcher—a great expert on emphysema, which so injures old people—both our elder children are doctors in the NHS. Our elder daughter is a registrar in care of the elderly in Southmead Hospital in Bristol and our son and his wife are both general practitioners in south-east London. So if there is any merit in this speech, it comes not from me.

The hospice movement is one of the shining constellations in the firmament of the voluntary and charitable sectors. All governments are wise to cherish it and to work with it closely. As many noble Lords have said, it has developed a great deal over the past 30 years.

The first important development, which I strongly encourage, is that in addition to the wonderful work that it does in relation to cancer—both for in-patient residents in the hospices themselves and out in the community—it now treats other conditions that so often afflict those in the later stages of their lives. I refer particularly to heart failure, which can affect people for many years, angina, chronic emphysema and other conditions which obstruct patients' airways. In both these areas the medical profession is rightly seeking to work out how best to give palliative care to those who may never get better but who can none the less, with proper help, enjoy a valuable quality of life—largely at home—for whatever period is left to them.

As I understand it, it tends to be the very frail and the very old who are let down by our system, and those who are fading often find themselves forced to fade in hospital for lack of an adequate structure to give help at home.
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Nursing care at home is immensely valuable. Families can be very good at caring for their loved ones. Indeed, old and frail people can be very good at caring for themselves at home if they can have, in particular, the advantage of three-times-a-day help, but they often have to wait many weeks, and perhaps months, before such help can be provided—if, indeed, it can be provided at all. Great efforts are rightly made to tie in the work of the National Health Service with local authority social services and, when available, the work of the hospices, both residential and out in the community. This is hugely to be encouraged.

An extra problem to be overcome is the fact that general practitioners, who are wonderful and often find the greatest satisfaction in helping their long-term patients in the last years of their lives, cannot necessarily be present out of hours—the out of hours service has to cope—and the systems of the hospice service and the NHS have to meet that particular problem.

St Christopher's Hospice in south-east London was one of the earliest hospices, started by Dame Cicely Saunders herself. It is once again showing the way by providing an excellent palliative care system for elderly patients in their own homes. They are looked after by the hospice team during the day and those hospices work closely with district nurses. In doing so, importantly, they are also able to provide cover by night.

However, the work is expensive. It is not, as I understand it—the Minister will correct me if I am wrong—at present supported by any extra funding from the NHS and the continuation of that service is under great pressure.

For all their wonderful work, once the need for medical intervention to a patient has ceased and the patient is stable but eventually dying, the hospital is not the ideal place to be. The nurses are inevitably busy. When the family are around the bed, it is all too likely that the patient in the next bed may need to use the commode or another confused patient may be wandering in the ward. Side rooms are at a premium and may be needed for a patient with an infection, so as an elderly patient one is lucky to get a side room.

I turn to costs. The costs of nursing care at home at its most intense are probably close to hospital costs, but that usually takes place for only a short period and a hospital bed is freed up. On a cost-benefit analysis, the benefits to a patient and the family are huge compared with the misery that can be suffered when one has to die in hospital, wonderful though the hospital services are.

The overall costs of hospice and specialist palliative care services are estimated to total some £450 million, of which 35 per cent is contributed by the NHS. One hundred and seventy million pounds is a modest figure compared to the total NHS spending today of around £60 billion. Professor David Taylor of the School of Pharmacy at the University of London estimates that every pound invested in hospice and home care can release some £2 worth of hospital services.

So may the message go forth from this debate that this work by hospices of caring for the very old and the very frail in their own homes deserves the Government's
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strongest support. It is not only excellent value for the NHS, above all, at a critical point in our lives; it is of enormous benefit to all our fellow citizens.

3.23 pm

Baroness Greengross: My Lords, it is a great privilege for me to congratulate the noble and learned Lord, Lord Lyell of Markyate, on his splendid maiden speech. I expected him, with his background as a former Solicitor-General and Attorney-General to speak with immense clarity and confidence, but I did not know that he was also going to speak in such a moving way. It was particularly moving for me because he emphasised so much the plight of very old and frail people. The noble and learned Lord will make an important contribution to this House. We will all be aware of the huge experience and the contribution he will make to all our deliberations. I wish him well and congratulate him again.

I also thank the noble Baroness, Lady Finlay, for having secured this debate, which is critically important. I congratulate the other speakers, because it is obvious that all of us are proud of the UK's record. We have a superb record of palliative care and world leadership in the hospice movement, which has spread to many countries all around the world. We know that people who are dying do not just need general care; they need personal, humane, gentle, loving care, right up and until they take their last breath. We also know that, unfortunately, with the best will in the world, the tight resources of the NHS mean that does not always happen. I agree with the noble Baroness, Lady Finlay, that sometimes that is because we do not get the integration of health and social care right. When people are suffering form a terminal illness, it is hard to separate one need from another. That is where our systems fall down sadly for many people.

I was angered when I read an article in the Guardian on 1 July which said that,

That is absolutely unacceptable in a country such as ours that has such high standards in its health and social care. The Guardian article also said that that happens despite the huge advances in drugs and technological systems for care over the past 30 or 40 years.

This debate is so important because we need to talk more openly about dying and the process of dying. It is something that we will all face, and have already faced with our friends and families. So often, it is a taboo subject; one of the last taboo subjects. They are really dangerous subjects, because they often have dreadful results because of being taboo, so we have a result of poor treatment and bad care that remains hidden from the scrutiny that people deserve and the standards that should be available to everyone to protect us all.

Many people are ignorant, particularly, as the noble Lord, Lord Patel, has emphasised, people from ethnic minorities and older people from the general population. People are sometimes denied the excellent palliative care or hospice care that could be available
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to them if they knew how to make it available. We know that most people want to die at home because they believe that they will get more personal and loving care there than in hospital. Yet the majority of all people die in hospital. We must ask why that is and why only a minority benefit from hospice care or palliative care.

I agree with the noble Lord, Lord Patel, that hospice-type care must be available in multiple settings today. To spend your last days in a hospital ward is often to die badly. We have heard so many horror stories of neglect. We have heard of discrimination on the grounds of age. We have heard of very inappropriate settings and lack of privacy, among other problems. Care in a hospital could and should be as good as that in a hospice. One area of all general hospitals could be made into a hospice environment. After all, we have managed to ensure that most maternity units in the NHS incorporate an area that is gentle and friendly, which is a suitable environment, so crucial for when a child is born. When someone is dying is no less significant an event. We should have the same standards of environment suitable for that event too.

As the noble Baroness, Lady Finlay, said, since the Shipman case there is a big problem, which has been reported in a medics' survey recently, that doctors are more nervous and less willing to prescribe adequate pain relief to dying people since that tragedy. For some we know that pain relief is just not possible. Most of us want to be in control of pain at the end of our lives. One of the reasons why I supported the Bill proposed by the noble Lord, Lord Joffe, on assisted dying is partly because the safeguards built into it mean that palliative care must be delivered to anyone in that position. Therefore, we would have to have more palliative care available, and that must be a good thing. You cannot offer a service unless it exists. So, in my view, the amount of palliative care available has to increase.

I strongly support the efforts of Marie Curie Cancer Care and other organisations that are trying to ensure that everybody who wants to die at home can do so. There are gross inequalities in the distribution of palliative and hospice care. Although I congratulate the Government on their investment in this type of care, all noble Lords have outlined that it is not enough, and we need more resources if we are to get it right.

There also has to be a big cultural shift in attitude within the Department of Health and the NHS, especially about older people who often suffer from multiple conditions—not always cancer. We know that older people with cancer are far less likely to die in a hospice. The figure is 8.5 per cent of those who are 85 or over, compared with 20 per cent of all cancer deaths. We know that older people with dementia do not usually benefit from palliative care at all because it is not recognised as a terminal illness, although, of course, it is in its later stages. Even for those dying of cancer, NICE has concluded that the resources are inadequate, so there is a big demand.
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My first experience of somebody close to me dying was a very young woman with a husband and two young children. Tragic though it was, her death was beautiful. Her experience and that of others in the same position should be the standard for us all, regardless of age, ethnicity, disability or cause of death. Dying is a part of our lives.

3.31 pm

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